Faculty Bibliography

OBJECTIVES/OBJECTIVE:To assess the role self-reported treatment for a psychiatric diagnosis may play in long-term functional outcomes after operatively managed tibial plateau fractures. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Over an 11-year period, patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an IRB-approved registry. A total of 245 patients were included in the study. Twenty-one patients reported treatment for a psychiatric diagnosis. INTERVENTION/METHODS:Surgical repair of tibial plateau fractures. MAIN OUTCOME MEASURE/METHODS:Patients were divided into 2 cohorts; 1 cohort being those who self-reported receiving treatment of a psychiatric diagnosis (PI); the other group being those who did not self-report receiving treatment of a psychiatric diagnosis (NPI). Three-month, 6-month, and long-term outcomes (mean = 18 months) were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, and postoperative complications (infection, VTE, nonunion, and necessity for secondary operations). RESULTS:Pain scores were higher in patients who self-reported receiving treatment for a psychiatric diagnosis (P = 0.012). Long-term functional outcomes as measured by the SFMA were demonstrated to be worse in patients who self-reported treatment for a psychiatric diagnosis (P = 0.034). No differences existed between groups in regards to postoperative complications. Multiple linear regression analysis revealed that being treated for diagnosis of a mental health illness was an independent predictor of worse functional outcomes at long-term follow-up [B = 8.874, 95% confidence interval (CI) = 0.354-17.394, P = 0.041]. CONCLUSIONS:Mental health plays a crucial role in long-term outcomes after operative fixation of tibial plateau fractures. Patients who have been diagnosed with a mental health illness have significantly worse outcomes at long-term follow-up. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Clinician-scientist numbers have been stagnant over the past few decades despite awareness of this trend. Interventions attempting to change this problem have been seemingly ineffective, but research residency positions have shown potential benefit. OBJECTIVE:We sought to evaluate the effectiveness of a clinician-scientist training program (CSTP) in an academic orthopedic residency in improving academic productivity and increasing interest in academic careers. METHODS:Resident training records were identified and reviewed for all residents who completed training between 1976 and 2014 (n = 329). There were no designated research residents prior to 1984 (pre-CSTP). Between 1984 and 2005, residents self-selected for the program (CSTP-SS). In 2005, residents were selected by program before residency (CSTP-PS). Residents were also grouped by program participation, research vs. clinical residents (RR vs. CR). Data were collected on academic positions and productivity through Internet-based and PubMed search, as well as direct e-mail or phone contact. Variables were then compared based on the time duration and designation. RESULTS:Comparing all RR with CR, RR residents were more likely to enter academic practice after training (RR, 34%; CR, 20%; p = 0.0001) and were 4 times more productive based on median publications (RR, 14; CR, 4; p < 0.0001). Furthermore, 42% of RR are still active in research compared to 29% of CR (p = 0.04), but no statistical difference in postgraduate academic productivity identified. CONCLUSIONS:The CSTP increased academic productivity during residency for the residents and the program. However, this program did not lead to a clear increase in academic productivity after residency and did not result in more trainees choosing a career as clinician-scientists.

INTRODUCTION: Much has been studied with reference to methicillin resistant Staphylococcus aureus (MRSA) and methicillin sensitive S. aureus (MSSA) colonization and associated outcomes and comorbidities. In the area of Orthopedic surgery, literature predominantly comes from the field of arthroplasty. Little is known about outcomes of fracture and Orthopedic trauma patients in the setting of S. aureus colonization. We believe that MRSA/MSSA colonization in and of itself may be a weak marker for generally poor protoplasm, potentially with complex medical history including previous hospitalization or rehab placement. This milieu of risk factors may or may not contribute to poorer outcomes after fracture and fracture nonunion surgery. The purpose of this study is to determine if nasal swabbing for S. aureus (MRSA or MSSA) carriage can predict operative culture, complications, or outcomes following fracture nonunion surgery. METHODS: Sixty-two consecutive patients undergoing surgery for fracture nonunion were prospectively followed. Data analyses were performed using grouped MRSA and MSSA carriers (Staphylococcus carriers: SC). Outcomes analyzed included time to healing, need for additional surgery, and persistent nonunion. RESULTS: Twenty-six percent of patients (16/62) were identified as MSSA carriers, an additional 6.5% (4/62) carried MRSA. Follow-up of at least 12-months was obtained on 90% (56/62) of patients. White blood cell counts, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values did not differ between SCs and non-carriers pre-operatively. Carriers were just as likely as non-carriers to culture positively for any pathogen at the time of surgery. Although SC's were three times as likely as non-carriers to grow S. aureus (15% vs. 5%), this difference did not reach statistical significance (p=0.3). Post-operative wound complications, antibiotic use, pain at follow-up and progression to healing did not differ between groups. CONCLUSIONS: Ultimately, pre-operative nasal swabbing for S. aureus is a simple and non-invasive diagnostic tool with prognostic implications in patients undergoing fracture nonunion surgery. This study found that MRSA and MSSA colonized patients with fracture nonunion of long bones do not have an increased association with positive cultures or a predisposition towards greater post-operative infectious complications.

OBJECTIVES/OBJECTIVE:To assess clinical and hospital quality outcomes of patients receiving the previously reported Reduced Effective Dose Using Computed Tomography In Orthopaedic iNjury (REDUCTION) imaging protocol. DESIGN/METHODS:Retrospective Chart review SETTING:: Level I Trauma Center and affiliated Tertiary Care Hospital CenterPatients/Participants: fifty patients who received this protocol for acute traumatic fracture evaluation and met inclusion criteria were compared to a cohort of fifty patients matched for age and fracture type who previously received conventional CT scanning for acute traumatic fracture evaluation. INTERVENTION/METHODS:Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) protocol for diagnostic fracture evaluation. MAIN OUTCOME MEASURES/METHODS:Estimated effective radiation doses were calculated and compared using Digital Imaging and Communications in Medicine (DICOM) information from all included studies. Patient outcomes between groups were compared with time to fracture union as the primary outcome. Secondary outcome measures included: presence of complication defined as infection, malunion, nonunion, failure of non-operative treatment, painful implants, and implant failure. Other secondary quality outcomes that were recorded included readmission within 30 days and hospital length of stay. Functional quality measures included joint range of motion. Statistical analyses were conducted to identify significant differences between cohorts (significance designated as p<0.05). RESULTS:Patient characteristics between cohorts were not significantly different with respect to age, gender, body mass index, comorbidities, injury mechanism or injury location. Fractures of the elbow, hip, knee, and foot/ankle were evaluated. Mean clinical follow-up was 9.5 ± 4.9 months for the REDUCTION cohort and 12.4 ± 5.3 months for conventional CT cohort. Mean estimated effective dose for all REDUCTION scans was 0.15 milliSieverts (mSv) as compared to 1.50 mSv for the conventional CT cohort (p=0.037). Pre-operative diagnosis was confirmed intra-operatively in 49/50 cases in the REDUCTION cohort compared to 48/50 cases in the conventional CT cohort (p=0.79). Outcomes including time to union, range of motion, complications, readmission, treatment failure, reoperation, and length of stay were not significantly different between groups. CONCLUSIONS:The REDUCTION protocol represents an ultra low dose CT scan developed for minimizing radiation exposure to patients presenting with traumatic fractures. This protocol resulted in a ten-fold reduction in radiation exposure. No difference in clinical or hospital quality outcomes was detected between patients who received this protocol as compared to those receiving automated dose CT scans. The REDUCTION protocol is a safe and effective method of performing CT scans for extremity fractures with significantly reduced radiation risk. LEVEL OF EVIDENCE/METHODS:Retrospective Case-Control Study, Level III Evidence.

Purpose To determine if 3-T magnetic resonance (MR) imaging of proximal femur microarchitecture can allow discrimination of subjects with and without fragility fracture who do not have osteoporotic proximal femur bone mineral density (BMD). Materials and Methods Sixty postmenopausal women (30 with and 30 without fragility fracture) who had BMD T scores of greater than -2.5 in the hip were recruited. All subjects underwent dual-energy x-ray absorptiometry to assess BMD and 3-T MR imaging of the same hip to assess bone microarchitecture. World Health Organization Fracture Risk Assessment Tool (FRAX) scores were also computed. We used the Mann-Whitney test, receiver operating characteristics analyses, and Spearman correlation estimates to assess differences between groups, discriminatory ability with parameters, and correlations among BMD, microarchitecture, and FRAX scores. Results Patients with versus without fracture showed a lower trabecular plate-to-rod ratio (median, 2.41 vs 4.53, respectively), lower trabecular plate width (0.556 mm vs 0.630 mm, respectively), and lower trabecular thickness (0.114 mm vs 0.126 mm) within the femoral neck, and higher trabecular rod disruption (43.5 vs 19.0, respectively), higher trabecular separation (0.378 mm vs 0.323 mm, respectively), and lower trabecular number (0.158 vs 0.192, respectively), lower trabecular connectivity (0.015 vs 0.027, respectively) and lower trabecular plate-to-rod ratio (6.38 vs 8.09, respectively) in the greater trochanter (P < .05 for all). Trabecular plate-to-rod ratio, plate width, and thickness within the femoral neck (areas under the curve [AUCs], 0.654-0.683) and trabecular rod disruption, number, connectivity, plate-to-rod ratio, and separation within the greater trochanter (AUCs, 0.662-0.694) allowed discrimination of patients with fracture from control subjects. Femoral neck, total hip, and spine BMD did not differ between and did not allow discrimination between groups. FRAX scores including and not including BMD allowed discrimination between groups (AUCs, 0.681-0.773). Two-factor models (one MR imaging microarchitectural parameter plus a FRAX score without BMD) allowed discrimination between groups (AUCs, 0.702-0.806). There were no linear correlations between BMD and microarchitectural parameters (Spearman ρ, -0.198 to 0.196). Conclusion 3-T MR imaging of proximal femur microarchitecture allows discrimination between subjects with and without fragility fracture who have BMD T scores of greater than -2.5 and may provide different information about bone quality than that provided by dual-energy x-ray absorptiometry.^©RSNA, 2018.

BACKGROUND:Nondisplaced and minimally displaced fractures of the radial head and neck are common injuries, yet the role of physical therapy (PT) in their treatment is unclear. The aim of this trial was to assess the need for formal PT following a simple fracture of the radial head or neck. METHODS:Patients who had a nondisplaced or minimally displaced fracture of the radial head or neck and presented to 1 of 2 providers were enrolled prospectively between January 2014 and August 2016. Patients were randomized to receive outpatient PT or perform self-directed home exercise. The follow-up intervals were 6 weeks, 3 months, 6 months, and at least 1 year. The outcome measures were Disabilities of the Arm, Shoulder and Hand (DASH) scores; pain; time to clinical healing; and range of motion. Demographic data were analyzed using the Mann-Whitney U test and Fisher exact test. Independent-samples t tests were utilized to compare outcome measures. RESULTS:Fifty-one patients were enrolled in the study. The average follow-up was 16.6 months. Twenty-five patients were randomized to a home-exercise cohort, and 26 patients were randomized to a formal-outpatient-PT cohort. There were no significant differences in demographics between cohorts. At 6 weeks, the home-exercise cohort had better function as indicated by a significantly lower mean DASH score compared with the PT cohort (p = 0.021). At 3 months, 6 months, and final follow-up, there were no significant differences between cohorts for any outcome measure. CONCLUSIONS:Patients who performed home exercises after sustaining a nondisplaced or minimally displaced fracture of the radial head or neck demonstrated better early function at 6 weeks compared with patients who received formal PT. After 6 weeks, there were no significant differences in outcomes. These data suggest that prescribing PT for patients who have an isolated nondisplaced or minimally displaced fracture of the radial head or neck is not cost-effective and that instructing the patient to perform self-directed exercises will be followed by a similar outcome. LEVEL OF EVIDENCE/METHODS:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:The number of periprosthetic proximal femoral fractures is expected to increase with the increasing prevalence of hip arthroplasties. While native hip fractures have a well-known association with mortality, there are currently limited data on this outcome among the subset of patients with periprosthetic proximal femoral fractures. METHODS:Using the New York Statewide Planning and Research Cooperative System, we identified patients from 60 to 99 years old who were admitted to a hospital in the state with a periprosthetic proximal femoral fracture (n = 1,655) or a native hip (femoral neck or intertrochanteric) fracture (n = 97,231) between 2006 and 2014. Within the periprosthetic fracture cohort, the indication for the existing implant was not available in the data set. We used mixed-effects regression models to compare mortality at 1 and 6 months and 1 year for periprosthetic compared with native hip fractures. RESULTS:The risk of mortality for patients who sustained a periprosthetic proximal femoral fracture was no different from that for patients who sustained a native hip fracture at 1 month after injury (3.2% versus 4.6%; odds ratio [OR], 0.90; 95% confidence interval [CI], 0.68 to 1.19; p = 0.446), but was lower at 6 months (3.8% versus 6.5%; OR, 0.74; 95% CI, 0.57 to 0.95; p = 0.020) and 1 year (9.7% versus 15.9%; OR, 0.71; 95% CI, 0.60 to 0.85; p < 0.001). Among periprosthetic proximal femoral fractures, factors associated with a significantly increased risk of mortality at 1 year included advanced age, male sex, and higher Deyo comorbidity scores. CONCLUSIONS:In the acute phase, any type of hip fracture appears to confer a similar risk of death. Over the long term, however, periprosthetic proximal femoral fractures are associated with lower mortality rates than native hip fractures, even after accounting for age and comorbidities. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background /UNASSIGNED:Evaluation of resident physicians' communications skills is a challenging task and is increasingly accomplished with standardized examinations. There exists a need to identify the effective, efficient methods for assessment of communications skills. Objective /UNASSIGNED:We compared objective structured clinical examination (OSCE) and direct observation as approaches for assessing resident communications skills. Methods /UNASSIGNED:We conducted a retrospective cohort analysis of orthopaedic surgery resident physicians at a single tertiary care academic institution, using the Institute for Healthcare Communication "4 Es" model for effective communication. Data were collected between 2011 and 2015. A total of 28 residents, each with OSCE and complete direct observation assessment checklists, were included in the analysis. Residents were included if they had 1 OSCE assessment and 2 or more complete direct observation assessments. Results /UNASSIGNED: = .16), after adjusting for chance agreement. Conclusions /UNASSIGNED:Our results suggest that OSCE and direct observation tools provide different insights into resident communications skills (simulation of rare and challenging situations versus real-life daily encounters), and may provide useful perspectives on resident communications skills in different contexts.

Arm wrestling places significant torque on the humeral shaft. A spiral distal humeral shaft fracture is an unusual but significant injury that can result. Of 93 patients who presented between 2009 and 2017 with closed humeral shaft fractures that were managed nonoperatively, 9 sustained the fractures while arm wrestling. Outcomes were compared with those of all other patients with nonoperatively managed humeral shaft fractures sustained through other mechanisms. The Student's t test was used to compare cohorts. All patients had spiral fractures that occurred in the distal one-third of the humerus. All patients went on to achieve radiographic union after a mean of 13.6 weeks (95% confidence interval [CI], 11.5-15.6). At fracture healing, mean angulation of the humerus seen on the anteroposterior and lateral views was 15.1° (95% CI, 12.0°-18.2°) and 8.9° (95% CI, 3.7°-14.1°), respectively. Mean elbow flexion-extension arc was 141.1° (95% CI, 134.4°-147.8°), with mean forward shoulder elevation of 168.8° (95% CI, 153.3°-184.2°). On comparison of the patients with humeral shaft fractures sustained through arm wrestling with the patients with humeral shaft fractures sustained through other mechanisms, except for earlier time to healing for the former (P=.05), no significant differences were observed. This represents the first analysis of radiographic and clinical outcomes following these types of fractures. Those who sustain these fractures secondary to the high-torque moment of arm wrestling are not different from those who sustain these fractures secondary to other mechanisms, except for an earlier time to union. This study indicates that nonoperative management of all humeral shaft fractures results in radiographic union with favorable clinical outcomes. [Orthopedics. 201x; xx(x):xx-xx.].

The purpose of this study is to evaluate incidence, preoperative laboratory markers, and outcomes of patients who positively cultured pathogens (PCP) at time of surgery for long bone fracture nonunion. Two-hundred and eighty-eight patients were enrolled in a trauma study on long bone nonunion. Two-hundred and sixteen of those 288 patients were cultured at the time of fracture nonunion surgery. Laboratory data were collected prior to intervention and infectious laboratory markers ordered on patients suspected for infection. Patients were followed for one year. Wound complications, antibiotic use, healing, function, and re-admission for further surgery were assessed. Cultures returned positive on 59 patients (representing 20.5% of the 288 patient cohort or 27.3% of the 216 patients cultured in the operative suite). More PCP's (47.5%; 28 of 59) developed wound complications, with greater mean antibiotic duration and more frequent returns to the OR averaging 1.3 procedures per patient. Twelve-month follow-up was obtained on 249 of the 288 (86.5%) and PCPs reported globally worse function. Patients who PCP at the time of operative management for long bone nonunion was a prognostic indicator of poorer long-term functional outcomes.