Faculty Bibliography

Dead space is defined as the residual tissue void after tissue loss. This may occur due to tissue necrosis following high-energy trauma, infection or surgical debridement of non-viable tissue. This review provides an update on the state of the art and recent advances in management of osseous and soft tissue defects. Specifically, our focus will be on the initial dead space assessment, provisional management of osseous and soft tissue defects, techniques for definitive reconstruction, as well as dead space management in the setting of infection. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE: To investigate the impact of post-traumatic humeral shaft malalignment on the ability to position the hand in space. METHODS: Two unique models were created: a cadaver model and a computerized 3-dimensional model. In the cadaveric model, a midshaft transverse osteotomy of the humerus was created to simulate fracture. The osteotomy was fixed in varying degrees of coronal and sagittal malalignment. The hand's ability to reach six different bony landmarks was assessed as a surrogate measure of function. Subsequently, a healthy male volunteer underwent full body magnetic resonance imaging with subsequent 3D skeletal recreation. A 'virtual' midshaft transverse osteotomy was created. The osteotomy was angulated in various degrees of coronal and sagittal malalignment and the hand's ability to reach the same six bony landmarks was measured. RESULTS: In the cadaver model, varus angulation was better tolerated than valgus and sagittal deformity. Varus deformity less than 25 degrees did not have a negative influence. Valgus angulation of 20 degrees resulted in a more severe deficit. Estimated function of the upper extremity was most sensitive to sagittal deformity. These trends were confirmed in the 3D model. CONCLUSIONS: The direction and magnitude of post-traumatic humeral shaft malalignment independently affect the ability to position the hand in space, a surrogate measure of function. Upper extremity function may be more sensitive to post-traumatic humeral shaft malalignment than previously reported. Clinical studies investigating the impact of humeral shaft malalignment on functional use of the upper extremity are warranted to clinically confirm these findings.

PURPOSE: This study compares clinical and functional outcomes of patients with displaced olecranon fractures treated with either tension band wiring (TBW) or a hook plate construct. METHODS: We performed a retrospective review of olecranon fractures operatively treated with either TBW or plate fixation (PF) using a hook plate over a 7-year period. Patient demographics, injury information, and surgical management were recorded. Fractures were classified according to the Mayo system. Measured outcomes included range of elbow motion, time to union, and development of postoperative complications. Mayo Elbow Performance Index (MEPI) scores were obtained for all patients. All patients were followed for a minimum of 6 months. RESULTS: A total of 48 patients were included in this study, 23 treated with TBW and 25 treated with hook PF. Groups did not differ with respect to patient demographics, Mayo fracture type, or duration of follow-up. Patients undergoing PF had less terminal extension than TBW patients (-8.6 degrees +/- 7 degrees vs. -3.5 degrees +/- 9.3 degrees , p = 0.036) and a longer time to radiographic union (19 +/- 8 vs. 12 +/- 6 weeks, p = 0.001). There were no differences in rates of symptomatic hardware, MEPI scores, or other clinical outcomes. Two patients in each group required a second surgery. CONCLUSIONS: TBW and PF of olecranon fractures had similarly excellent functional outcomes in this study. Patients undergoing PF had a longer time to union and slightly worse extension at final follow-up. TBW remains an effective treatment for appropriately selected olecranon fractures and in this cohort outperformed plate osteosynthesis.

BACKGROUND: Although most humeral nonunions are successfully treated with a single procedure, some humeral nonunions are more difficult to heal and require multiple procedures. Current literature does not provide evidence describing how the prognosis for surgical repair in patients who develop humeral diaphyseal nonunions may be affected by initial operative versus nonoperative treatment. QUESTIONS/PURPOSES: The purpose of this study was to assess whether operative versus nonoperative treatment of acute humeral shaft fractures impacts outcome of subsequent repairs of humeral nonunions (NU) including the need for additional surgery and a comparison of pain relief (Visual Analogue Scale for pain) and functional outcome (Short Musculoskeletal Functional Assessment). METHODS: Thirty-four patients with humeral shaft nonunion were evaluated of which 15 patients had been treated operatively (OF), and 19 patients had been treated nonoperatively (NO) for their initial humerus shaft fracture. All patients underwent plating with autogenous bone graft or allograft +/- bone morphogenic protein (BMP) 2 or 7 as their final NU repair surgery prior to healing. We compared functional outcome and pain for both cohorts and determined risk factors for requiring more than 1 nonunion repair surgery. RESULTS: The mean time of final follow-up was 14.7 +/- 10.4 months. Thirty-three of 34 NUs (97.1%) healed. Patients who underwent OF of their original fracture were more likely to require more than 1 NU repair surgery (66.7 vs. 0%, p < 0.01). Of the 15 patients who underwent initial OF, 33.0% required 1 NU surgery, 33.0% required 2 NU surgeries, and 33.0% required 3 NU surgeries. Patients who underwent initial OF were more likely to require >6 months to achieve union (40.0 vs. 10.5%, p = 0.04). At final follow-up, there was no difference in functional outcome or pain scores. Initial OF was the only independent predictor of needing more than 1 NU repair surgery (OR 70.1 CI 2.8-1762.3) to achieve healing. CONCLUSION: Humeral shaft nonunions following initial operative fixation of the index fracture is more resistant to achieving union when compared to nonunions forming after initial nonoperative treatment. When final healing is achieved, there is no difference in function or pain.

BACKGROUND: Operation choice is a complex decision in the surgical management of proximal humerus fractures. Recently, there has been an increase in the use of total shoulder arthroplasty (TSA) for complex fracture patterns. HYPOTHESIS: Patients with proximal humerus fractures who receive TSA are more likely to have higher hospital charges and a prolonged length of stay relative to patients receiving hemiarthroplasty (HA), open reduction with internal fixation (ORIF) or closed reduction with internal fixation (CRIF). MATERIALS AND METHODS: A statewide electronic database was used to identify 13,316 hospital admissions from 2000-2011 were a proximal humerus fracture was surgically managed in an effort to determine the effect of operation choice on cost and length of stay. A univariate analysis was preformed to examine overall trends in surgical management. Additionally, a periodic, multivariate logistic regression analysis was used to determine how operation choice affected the odds of a high cost hospital stay or a prolonged length of stay after controlling for age, comorbidity burden, gender, and insurance type. RESULTS: After controlling for confounding factors, patients receiving total shoulder arthroplasty (TSA) were 2.25 times more likely to have high total hospital charges than patients receiving HA and 3.21 times more likely than patients receiving ORIF. Additionally, TSA was found to be a significant negative predictor of prolonged length of stay (pLOS). HA, ORIF and CRIF did not significantly predict pLOS. DISCUSSION: The use of TSA for acute proximal humerus fractures is associated with increased hospital costs despite a shorter length of stay when compared to other operative choices. As reverse total shoulder arthroplasty becomes more popular for treatment of this injury, it is important that functional outcomes be interpreted in the context of relative cost trade-offs. LEVEL OF EVIDENCE: Level IV.

The orthopaedic match is one of the most competitive among medical subspecialties. Many factors are taken into account in the ranking of potential candidates. Resources are limited to guide medical students through this process. Practicing orthopaedic surgeon mentors and resident advisors often are asked to provide counseling and advice to enhance the applicant's portfolio with limited information. This paper reviews the existing quantifiable data to assist orthopaedic surgery residency applicants. A literature review of articles written in English, which were either Pubmed or non-Pubmed indexed, was performed. The authors completed the review to concisely delineate factors that are often associated with a successful matching into an orthopaedic residency. Orthopaedic surgery continues to increase in competitiveness for the medical student residency match. While there is no one specific factor associated with success in the match, studies demonstrate that institutions often look favorably on students who rotate at that particular institution; this also is reflected in clinical performance scores if those rotators become residents at that particular program. Multiple factors are considered when matching orthopaedic surgery residency applicants. The information presented in this paper can help form the groundwork for discussions between mentors and students to maximize their chances for a successful match.

The literature on the effect of ulnar styloid fractures (USFs) on concomitant distal radius fractures (DRFs) is mixed. We conducted a study to determine if associated ipsilateral USFs affect outcomes of DRFs. We retrospectively evaluated 315 DRFs treated (184 operatively, 131 nonoperatively) over a 7-year period. Concomitant USFs were identified. Mean follow-up was 12 months. Disabilities of the Arm, Shoulder, and Hand (DASH) and 36-Item Short Form Health Survey (SF-36) outcome scores, and grip strength and wrist range of motion data, were collected. Statistical analysis was performed with Student t test and analysis of variance. Incidence of concomitant USF and DRF was higher (P < .0002) in the operative group (64.6%) than in the nonoperative group (39.1%). Patients with USFs had worse mean (SD) pain score, 1.80 (2.43) versus 0.80 (1.55) (P = .0001), DASH score, 17.03 (18.94) versus 9.21 (14.06) (P = .001), and SF-36 score, 77.16 (17.69) versus 82.68 (16.10) (P = .022). In the operative group, patients with USFs had more pain and poorer DASH Functional scores than patients without USFs. Results were similar in the nonoperative group. There was no difference in healing time between intra-articular and extra-articular fractures or between presence and absence of USFs. Concomitant occurrence of USFs and DRFs-which is associated with worse pain scores and lower functioning compared with USFs without DRFs-should prompt clinicians to counsel patients about delayed recovery.

Malleolar fractures, occurring predominantly following inversion injuries of the ankle or falls, are among the most common fractures treated by orthopaedic surgeons. While proper diagnosis and fixation of bony fractures is required in patients with unstable patterns, it has become apparent that injuries to the complex ligamentous structures around the ankle, including the syndesmosis, can affect patient outcomes if not treated properly. This requires proper physical and radiographic examination techniques. Controversy still remains regarding proper fixation techniques and aftercare for complex fracture patterns and syndesmotic injury. The importance of recognizing patient comorbidities has also been demonstrated, as these medical illnesses have been demonstrated to increase the risk for complications, and therefore may require modifications to standard treatment protocol. In this review we highlight the growing body of evidence on this topic to identify the current best treatment practices and areas where further analysis is needed

Background: The objective of this study was to investigate whether the total number of radiographic malalignments after distal radial fracture was associated with poor clinical outcome. Methods: Over a 7-year period, 382 patients who sustained a distal radial fracture were enrolled in a prospectively collected database and met our inclusion criteria. Patients were followed for a mean of 11 mo. Radiographs were taken and analyzed at each follow-up interval. Patients were divided in three groups, those with normal radiographic alignment (group 1), those with one abnormal measurement (group 2), and those with two or more abnormal measurements (group 3). Each patient was assessed for the Disabilities of the Arm Shoulder and Hand (DASH) and Short Form-36 (SF36) clinical outcome scores, along with functional parameters. Results: Thirty-four percent of patients had at least one abnormal radiographic measurement after initial reduction, 21% at short-term, and 24% at long-term follow-up. The long-term DASH was low (18.17 and 12.12 in groups 2 and 3, respectively) and the SF36 was correspondingly high (77.36 and 80.45 in groups 2 and 3, respectively). No individual radiographic measurement of wrist deformity or a combination of these was significantly correlated to any of the clinical outcome scores or functional parameters. Conclusions: Our data confirm reports from previous studies that no single radiographic measurement was correlated with clinical or functional outcomes. Moreover, if analyzed in combination, malalignment in multiple planes did not result in a higher association with worse outcomes

BACKGROUND: Nonunion of long bone fractures is a serious complication for many patients leading to considerable morbidity. The purpose of this study is to elucidate factors affecting continued pain following long bone nonunion surgery and offer better pain control advice to patients. METHODS: Patients presenting to our institutions for operative treatment of long bone fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months using the Short Musculoskeletal Function Assessment (SMFA), visual analog scale (VAS), physical examination, and radiographic examination. The registry was reviewed to identify patients with a tibial or femoral nonunion that went on to union with complete follow up. Univariate analyses were conducted to identify patient characteristics associated with postoperative pain. Identified patient factors with univariate p-values <0.1 were included in multivariate linear regression models in order to identify risk factors for pain 3 months, 6 months, and 12 months after nonunion surgery. RESULTS: Ninety-one patients with tibial or femoral nonunion who went on to union and had complete follow-up were identified. A Friedman test revealed mean pain score decreased significantly by 3 months postoperatively (p<0.0005). Univariate analyses demonstrated age (p=0.016), days from injury to nonunion surgery at our institution (p=0.067), smoking status (p<0.0005), wound status at time of injury (p=0.085), anesthesia (p=0.045), and nonunion location in the bone (p=0.047) were associated with postoperative pain in at least one time point postoperatively. These were included in multivariate models that revealed nonunion location (p=0.035) was predictive of pain 3 months postoperatively, smoking status was predictive of pain 3 months (p=0.012) and 6 months (p<0.0005) postoperatively, and days from injury to nonunion surgery at our institution was predictive of pain 6 months (p=0.024) and 12 months (p=0.004) postoperatively. CONCLUSION: Healed patients have improved pain levels after lower extremity nonunion surgery. Orthopedic surgeons should stress smoking cessation programs and minimize delay to nonunion surgery, in order to maximize pain relief in this patient cohort.