Faculty Bibliography

The purpose is to identify risk factors of functional outcome following proximal humerus open reduction and internal fixation. Patients treated for proximal humerus fractures with open reduction and internal fixation were enrolled in a prospective data registry. Patients were evaluated for function using the Disability of the Arm, Shoulder and Hand score for 12 months and as available beyond 12 months. Univariate analyses were conducted to identify variables associated with functional outcome. Significant variables were included in a multivariate regression predicting functional outcome. Demographics and minimum of 12 month follow-up were available for 129 patients (75%). Multiple regression demonstrated postoperative complication (B=8.515 p=0.045), education level (B=-6.269p<0.0005), age (B=0.241p=0.049) and Charlson Comorbidity Index (B=6.578, p=0.001) were all significant predictors of functional outcome. Orthopaedic surgeons can use education level, comorbidities, age, and postoperative complication information to screen patients for worse outcomes, establish expectations, and guide care.

BACKGROUND: With an expected doubling of the geriatric population within the next thirty years it is becoming increasingly important to determine who among the elderly population benefit from orthopaedic interventions. This study assesses post-operative outcomes in patients aged seventy or greater who sustained a proximal humerus fracture and were treated surgically as compared to a younger geriatric cohort to determine if there is a chronologic age after which post-operative outcomes significantly decline. METHODS: A retrospective chart review was conducted for 201 patients who sustained fractures of the proximal humerus (OTA 11A-C) and were treated operatively by open reduction and internal fixation. Data from 132 independent, active patients aged fifty-five or older was identified and analyzed. Forty-seven patients age 70 or older were compared to 78 patients aged 55-69. Average length of follow-up was 19.5 months. All complications were recorded. Univariate and multivariate analysis was conducted to assess for differences between groups. RESULTS: 95% of patients achieved fracture union within 6 months. No significant differences were found between cohorts with regard to gender, fracture severity, or CCI (p = 0.197, p = 0.276, p = 0.084, respectively). Functional outcome scores, shoulder range of motion, and complications rates for patients aged 70 and older were not significantly different from patients aged 55-69. There were 10 complications in the older elderly cohort (21%), 6 of which required re-operation and 13 complications in the young elderly cohort (17%), 8 of which required re-operation. CONCLUSIONS: Operative fracture repair using locked plating of the proximal humerus in septuagenarians and octogenarians can provide for excellent long-term outcomes in appropriately selected patients. These patients tend to have long term functional outcome scores, post-operative range of motion, and complication rates that are comparable to younger geriatric patients. Physicians should not exclude patients for repair of proximal humerus fractures based on chronological age cutoffs.

AIMS: To evaluate whether an ultra-low-dose CT protocol can diagnose selected limb fractures as well as conventional CT (C-CT). PATIENTS AND METHODS: We prospectively studied 40 consecutive patients with a limb fracture in whom a CT scan was indicated. These were scanned using an ultra-low-dose CT Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) protocol. Studies from 16 selected cases were compared with 16 C-CT scans matched for age, gender and type of fracture. Studies were assessed for diagnosis and image quality. Descriptive and reliability statistics were calculated. The total effective radiation dose for each scanned site was compared. RESULTS: The mean estimated effective dose (ED) for the REDUCTION protocol was 0.03 milliSieverts (mSv) and 0.43 mSv (p < 0.005) for C-CT. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of the REDUCTION protocol to detect fractures were 0.98, 0.89, 0.98 and 0.89 respectively when two occult fractures were excluded. Inter- and intra-observer reliability for diagnosis using the REDUCTION protocol (kappa = 0.75, kappa = 0.71) were similar to those of C-CT (kappa = 0.85, kappa = 0.82). Using the REDUCTION protocol, 3D CT reconstructions were equivalent in quality and diagnostic information to those generated by C-CT (kappa = 0.87, kappa = 0.94). CONCLUSION: With a near 14-fold reduction in estimated ED compared with C-CT, the REDUCTION protocol reduces the amount of CT radiation substantially without significant diagnostic decay. It produces images that appear to be comparable with those of C-CT for evaluating fractures of the limbs. Cite this article: Bone Joint J 2016;98-B:1668-73.

BACKGROUND: Digital templating systems have been promoted due to their ability to reduce costs, facilitate preoperative planning, and maintain surgical accuracy. The implementation of a templating system at a large institution is complicated and has not been fully described. PURPOSE: We aim to explain the requisite collaboration between orthopaedic surgery, radiology, and information technology needed to implement a successful orthopaedic templating system at a large institution. METHODS: A search of the PubMed database was performed to provide a comprehensive review of digital templating. Furthermore, we offer the organizational and technical details needed to implement an institutional templating system. RESULTS: We have provided a strategic plan to describe the collaboration between orthopaedic surgery, musculoskeletal radiology, and information technology required for a successful templating system. CONCLUSIONS: The transition to digital templating requires planning, training, and communication between multiple disciplines. Digital templating systems have the potential to foster preoperative planning, improve trainee education, and reduce departmental costs. CLINICAL SIGNIFICANCE: Preoperative digital templating is a means to reduce the risk of intraoperative fracture, decrease overall surgical time, and plan for implant size prior to surgery.

The Accreditation Council of Graduate Medical Education requires that residency programs teach and assess trainees in six core competencies. Assessments are imperative to determine trainee competence and to ensure that excellent care is provided to all patients. A structured, direct observation program is feasible for assessing nontechnical core competencies and providing trainees with immediate constructive feedback. Direct observation of residents in the outpatient setting by trained faculty allows assessment of each core competency. Checklists are used to document residents' basic communication skills, clinical reasoning, physical examination methods, and medical record keeping. Faculty concerns regarding residents' professionalism, medical knowledge, fatigue, or ability to self-assess are tracked. Serial observations allow for the reinforcement and/or monitoring of skills and attitudes identified as needing improvement. Residents who require additional coaching are identified early in training. Progress in educational milestones is recorded, allowing an individualized educational program that ensures that future orthopaedic surgeons excel across all domains of medical and surgical competence.

BACKGROUND: In order to compare open reduction and internal fixation (ORIF) with locked plating to hemiarthroplasty for the treatment of three- and four-part proximal humerus fractures, we compared two groups of patients treated during the same time period. MATERIALS AND METHODS: Sixty-five patients who underwent repair of a three- or four-part proximal humerus fracture with locked plates (Group A) were identified in a prospective database and were compared to 29 patients who underwent hemiarthroplasty for similar injuries (Group B). Data was collected for both groups. Shoulder motion was measured and functional outcomes were obtained using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: The mean length of follow-up for the ORIF group was 16 months compared to 44 months for the hemiarthroplasty group. The average postoperative forward flexion for patients in Group A was 131.1 degrees and 110.4 degrees for Group B (p < 0.047). There were no differences in DASH scores at latest follow-up (p = 0.64). Two patients in Group A had radiographic signs of osteonecrosis but had elected for no further surgery. One patient in Group A and two patients in Group B underwent a conversion to total shoulder arthroplasty. There was no difference in the rate of secondary surgery (p = 0.98). CONCLUSIONS: The results of this study suggest that ORIF using locked plates leads to similar postoperative function compared to hemiarthroplasty. Patients who underwent ORIF did achieve greater forward shoulder flexion. Neither strategy leads to a higher reoperation rate.

BACKGROUND: The objectives of this investigation were to report temporal trends in resident performed upper extremity fracture procedures and analyze case volume variability. METHODS: Orthopaedic resident case logs from the Accreditation Council for Graduate Medical Education were reviewed for graduating years 2007 to 2014. The mean number of wrist, forearm, elbow, humerus, and shoulder fracture-dislocation procedures performed by residents was analyzed. The median number of procedures reported by the top 30% and bottom 30% of residents (by case volume) was also recorded. Linear regression modeling was used to assess temporal trends. RESULTS: The mean number of wrist and forearm fracture cases performed per resident fell from 55.3 in 2007 to 46.7 in 2014 (p = 0.325) while the number of elbow and humerus fracture procedures remained relatively constant (45.6 to 45.4; p = 0.224). The mean number of shoulder fracture cases increased significantly (14.7 to 22.5; p < 0.001). Over the 8-year period, residents in the 70th percentile of caseload performed significantly more wrist and forearm (62.6 versus 39.5; p < 0.001), elbow and humerus (55 versus 34.9; p < 0.001), and shoulder (23 versus 12.9; p < 0.001) fracture procedures than residents in the 30th percentile. CONCLUSION: Resident case volume for wrist, forearm, elbow, and humerus fractures is constant or falling. However, shoulder fracture caseloads are increasing. Regardless, there is substantial disparity in upper extremity fracture case volume among residents. Further investigation is needed to assess possible educational effects of resident caseload disparity.

Background Displaced tibial plateau fractures often require surgical treatment and plate and screw constructs are the most common method of fixation. There has been increased usage of locking plate technology for both complex and simple fracture patterns without any evidence demonstrating their advantage. Purpose The purpose of this study was to compare the clinical use of locked versus nonlocked plating for repair of displaced Schatzker type-II (OTA Type 41B) tibial plateau fractures. Methods Seventy-seven consecutive patients treated operatively with one of two types of plate and screw constructs in a nonrandomized fashion for Schatzker type II tibial plateau fractures and they were prospectively followed over a 5-year period. A total of 35 (45.5%) patients were treated using a locked plate and screw construct and 42 (54.5%) patients were treated with a nonlocked plate and screw construct. All patients received the same pre- and postoperative care and there was no difference in plate morphology and length between cohorts. Clinical outcomes were assessed using Short Musculoskeletal Functional Assessment (SMFA) scores, Visual Analogue Score for pain, and knee ranges of motion. Radiographic outcome was assessed with plain radiographs at all follow-up points. Implant costs for both types of constructs were calculated from hospital purchasing records. Results Patients were assessed at a mean period of 18.5 months (range: 12-72 months). There was no difference in demographic factors, physical examination parameters, radiographic outcomes, and SMFA scores between cohorts. In terms of cost, the cost of locked construct was $905 more than the nonlocked construct. Conclusion Based on clinical outcomes and cost per implant, we found no evidence to support the routine use of locked plating for simple split depression fractures of the lateral tibial plateau. The use of standard nonlocked, precontoured implants provides adequate fixation for these fracture patterns.

BACKGROUND: Despite frequent complaints by orthopaedic trauma patients, to our knowledge there is no data regarding weather's effect on pain and function following acute and chronic fracture. The aim of our study was to investigate the influence of daily weather conditions on patient reported pain and functional status. METHODS: We retrospectively examined prospectively collected data from 2369 separate outpatient visits of patients recovering from operative management of acute tibial plateau fractures, acute distal radius fractures, and chronic fracture nonunions. Pain and functional status were assessed using a visual analogue scale (VAS) and the DASH and SMFA functional indexes. For each visit date, the mean temperature, difference between mean temperature and expected temperature, dew point, mean humidity, amount of rain, amount of snow, and barometric pressure were recorded. Statistical analysis was run to search for associations between weather data and patient reported pain and function. RESULTS: Low barometric pressure was associated with increased pain across all patient visits (p=0.007) and for patients at 1-year follow-up only (p=0.005). At 1-year follow-up, high temperature (p=0.021) and high humidity (p=0.030) were also associated with increased pain. No significant association was noted between weather data and patient reported functional status at any follow-up interval. CONCLUSIONS: Patient complaints of weather influencing pain after orthopaedic trauma are valid. While pain in the immediate postoperative period is most likely dominated by incisional and soft tissue injuries, as time progresses barometric pressure, temperature, and humidity impact patient pain levels. Affirming and counseling that pain may vary based on changing weather conditions can help manage patient expectations and improve satisfaction.