Faculty Bibliography

INTRODUCTION: This video demonstrates the technique of posterolateral bone grafting with iliac crest bone graft for a distal tibial nonunion. METHODS: The patient is a 42-year-old man who is 6 months status post an open distal tibia-fibula fracture treated surgically, and presents complaints of persistent right ankle pain. The fracture site was tender to palpation, and 3 consecutive plain radiographs spaced 6 weeks apart demonstrated no evidence of callus formation. RESULTS: This patient was indicated for posterolateral bone grafting of his tibia and fibula nonunion with autogenous iliac crest bone graft. The plan was to create a synostosis between the fibula and tibia. Atrophic and oligotrophic nonunions have poor biology at the fracture site to promote bone growth and would therefore benefit from autogenous iliac bone graft, as this technique is osteoinductive, osteoconductive, and osteogenic stem cells. Indications for posterolateral bone grafting of the tibia include atrophic or oligotrophic nonunions, an ipsilateral same level tibia and fibula nonunion, or a tibial nonunion with a large anteromedial soft-tissue injury. CONCLUSION: The technique of posterolateral bone grafting with iliac crest bone graft for distal third tibia and fibula atrophic nonunion provides a reliable method for achieving union. If patients with injuries at high risk of nonunion are followed closely and intervention is performed in a timely manner, additional fixation or revision of fixation is not necessary if the addition of appropriate osteoinductive, osteoconductive, and osteogenic material to the nonunion is performed.

INTRODUCTION: Acute compartment syndrome (ACS) is well known among orthopaedic surgeons. The timely diagnosis and management of ACS is crucial to avoiding its sequelae, including renal failure, ischemic contractures, and limb loss. Despite its relative importance, ACS poses a challenge to many residents and clinicians as diagnosis relies largely on clinical judgment. METHODS: Timely diagnosis and thorough compartment release are essential to optimizing outcomes in ACS. This video highlights a clinical case in which compartment syndrome of the leg was considered, diagnosed, and surgically managed. RESULTS: This video will present the indications for compartment release and a video-guided demonstration of compartment checks using an arterial line transducer, a 4-compartment fasciotomy with 2 incisions, and temporizing vessel loop closure. CONCLUSIONS: Compartment syndrome can be a devastating complication of common fractures. It is essential that orthopaedic practitioners understand the immediacy of intervention. We have a responsibility to provide timely, accurate diagnosis along with expedient surgical management.

PURPOSE: Fracture nonunion is a common problem for today's orthopaedic surgeon. However, many techniques are currently available for the treatment of long-bone nonunion. This video demonstrates the use of iliac crest bone graft and plate stabilization in the setting of a hypertrophic femoral nonunion. METHODS: Treatment of femoral nonunion after intramedullary nail fixation using compression plating and bone grafting is a reliable technique for reducing pain, improving function, and achieving radiographic union. Furthermore, the use of autologous bone graft, in particular iliac crest bone graft, has provided reliable clinical results. RESULTS: In this video, we present the case of a hypertrophic femoral nonunion treated with supplemental bone grafting in addition to plate and screw fixation. CONCLUSIONS: Although femoral nonunions are a relatively rare occurrence, they can be reasonably treated using stabilization and supplemental bone grafting. Iliac crest bone graft provides for excellent results when used for treatment of a fracture nonunion.

PURPOSE: Posttraumatic bone defects in the setting of severe open injuries of the lower extremity present a significant challenge for orthopaedic trauma surgeons. The induced membrane technique, also known as the Masquelet technique, has been shown to be generally successful in achieving bony union. This video demonstrates the use of the Masquelet technique for a large (18 cm) femoral defect. METHODS: The Masquelet technique is a 2-stage process. The first stage involves debridement of all devitalized tissue, using open reduction and internal fixation, and placement of a cement spacer with or without antibiotics. In the second stage, which is performed at least 6 weeks after the first, the spacer is removed and the resulting void is filled with bone graft. RESULTS: This surgical case video reviews the relevant patient injury presentation, initial management, and indications for the Masquelet technique. The second stage of the Masquelet technique is featured in this video. CONCLUSIONS: The Masquelet technique is a generally reliable method for treating large segmental bone defects. In addition, this relatively simple technique is suitable for both infected and noninfected cases.

PURPOSE: Operative fixation of displaced patella fractures is considered to be standard of care. However, patients with inferior pole patella fractures have limited options in terms of fixation. This video demonstrates the repair of an inferior pole patella fracture using nonabsorbable suture fixation. METHODS: Suture repair of patella fractures is a clinically acceptable technique, yielding similar functional results to patella fractures treated with K-wires or cannulated screws while reducing the rates of removal of hardware after fixation. RESULTS: This video features the repair of a displaced, comminuted inferior pole patella fracture using 5 Ethibond and Fiberwire. Postoperative radiographs confirm bony union. CONCLUSIONS: Suture fixation for pole patella fractures provides reliable fixation and reduces the risk of postoperative complications secondary to hardware irritation. This case highlights the success of this technique.

PURPOSE: Bilateral posterior fracture dislocation is a rare injury commonly associated with seizures. When the humeral head defect (reverse Hill-Sachs lesion) is between 20% and 45%, operative fixation using a modified McLaughlin procedure is recommended. This video demonstrates a case of bilateral posterior fracture dislocation after a drug-induced seizure treated with a modified McLaughlin procedure. METHODS: The original McLaughlin procedure involved transfer of the subscapularis tendon from the lesser tuberosity to the reverse Hill-Sachs defect. However, the modified McLaughlin procedure is more commonly described in the literature as of late and involved the transfer of the lesser tuberosity along with the subscapularis. RESULTS: This video demonstrates the modified McLaughlin technique for a posterior fracture dislocation. Computerized tomography confirms the articular impression fractures of the proximal humerus. Through a deltopectoral approach, the lesser tuberosity along with the subscapularis tendon was transferred into the defect. CONCLUSIONS: The modified McLaughlin procedure demonstrates excellent clinical and radiographic results after posterior fracture dislocation of the shoulder with a reverse Hill-Sachs lesion between 25% and 45%.

INTRODUCTION: This video demonstrates the technique of intramedullary nailing for a humeral shaft fracture. METHODS: The patient is a 30-year-old man who sustained a gunshot wound to his right arm. The patient was indicated for humeral nailing given the comminuted nature of the diaphysis and to allow for minimal skin incisions. Other relative indications include soft-tissue compromise about the arm precluding a large surgical exposure. RESULTS: This video presents a case of a comminuted humeral shaft fracture treated with an intramedullary nail. Anatomic reduction and stable fixation was obtained with this technique. CONCLUSION: This case demonstrates a soft-tissue sparing technique of humeral shaft fixation using a humeral intramedullary nail. The technique is easy to perform and has significant benefits in minimizing surgical exposure, decreasing operative time, and decreasing blood loss. In the correct clinical setting, humeral nailing provides an expeditious form of fixation that restores length, alignment, and rotation of the fracture humeral diaphysis.

The internet is a popular resource for orthopedic fellowship applicants. We conducted a study to assess the accessibility of orthopedic trauma fellowship (OTF) program websites and to evaluate the content on the sites. We queried the online database of the Orthopaedic Trauma Association (OTA) and the online Fellowship and Residency Electronic Interactive Database (FREIDA) to assess available OTF program links. We used Google to assess how accessible the sites are from outside the databases. We then analyzed accessible sites for content pertinent to OTF applicants. Of the 49 OTF programs identified, 42 (86%) had their websites accessible from Google and FREIDA links. The OTA database had no OTF website links. Analysis of the 42 accessible OTF sites revealed they had an average of 40% (range, 0%-75%) of assessed content, with operative experience on 88% of sites and a program description on 93% of sites. OTF programs with >1 fellow had significantly more education content (48% vs 33%; P = .043) and total content (46% vs 37%; P = .01) on their sites than OTF programs with 1 fellow. Accessibility and content of OTF websites are highly variable and largely deficient. OTF programs should focus on improving their website accessibility and content.

BACKGROUND: The number of hip fractures is rising as life expectancy increases. As such, the number of centenarians sustaining these fractures is also increasing. The purpose of this study was to determine whether patients who are >/=100 years old and sustain a hip fracture fare worse in the hospital than those who are younger. METHODS: Using a large database, the New York Statewide Planning and Research Cooperative System (SPARCS), we identified patients who were >/=65 years old and had been treated for a hip fracture over a 12-year period. Data on demographics, comorbidities, and treatment were collected. Three cohorts were established: patients who were 65 to 80 years old, 81 to 99 years old, and >/=100 years old (centenarians). Outcome measures included hospital length of stay, estimated total costs, and in-hospital mortality rates. RESULTS: A total of 168,087 patients with a hip fracture were identified, and 1,150 (0.7%) of them had sustained the fracture when they were >/=100 years old. Centenarians incurred costs and had lengths of stay that were similar to those of younger patients. Despite the similarities, centenarians were found to have a significantly higher in-hospital mortality rate than the younger populations (7.4% compared with 4.4% for those 81 to 99 years old and 2.6% for those 65 to 80 years old; p < 0.01). Male sex and an increasing number of medical comorbidities were found to predict in-hospital mortality for centenarians sustaining extracapsular hip fractures. No significant predictors of in-hospital mortality were identified for centenarians who sustained femoral neck fractures. An increased time to surgery did not influence the odds of in-hospital mortality. CONCLUSIONS: Centenarians had increased in-hospital mortality, but the remaining short-term outcomes were comparable with those for the younger cohorts with similar fracture patterns. For this extremely elderly population, time to surgery does not appear to affect short-term mortality rates, suggesting a potential benefit to preoperative optimization. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.