Faculty Bibliography

OBJECTIVES: To assess the outcome of patients with hyperextension bicondylar tibial plateau fractures (HEBTPs) and those with other complex tibial plateau fractures. DESIGN: Retrospective cohort design. SETTING: Academic Medical Center. PATIENTS: A total of 84 patients were included in the study. There were 69 patients with 69 knees (82%) that had sustained non-HEBTPs and 15 patients with 15 knees (18%) that had HEBTPs. INTERVENTION: Surgical repair of bicondylar tibial plateau fracture. MAIN OUTCOME MEASURES: Clinical and functional outcomes included knee range of motion, postoperative alignment, numerical rating scale pain scores, and Short Musculoskeletal Functional Assessment (SMFA) scores at long-term follow-up. Complications were recorded for both cohorts including infection and posttraumatic osteoarthritis. RESULTS: There was no difference in knee range of motion at 1-year follow-up between hyperextension and nonhypertension patients. Patients with hyperextension mechanisms did however have higher functional (SMFA) scores and a trend of higher pain scores, indicating worsened functional outcomes and were more likely than their nonhyperextension mechanism counterparts to have associated soft-tissue damage and to develop posttraumatic osteoarthritis. CONCLUSIONS: Non-HEBTP and HEBTP fracture patients have similar outcomes in terms of range of motion at approximately 1 year of follow-up, however, differ significantly in terms of functional recovery and the types of complications associated with their injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE: Whether racial differences are associated with function in the long term following surgical repair of lower extremity fractures has not been investigated. The purpose of this study is to compare how race affects function at 3, 6 and 12 months post-surgery following certain lower extremity fractures. METHODS: Four hundred and eighteen patients treated operatively for a lower extremity fracture (199 tibial plateau, 39 tibial shaft, and 180 rotational ankle fractures) were prospectively followed for 1 year. Race was stratified into four groups: Caucasian, African-American, Hispanic origin, and other. Long-term outcomes were evaluated using the short musculoskeletal function assessment (SMFA) and pain scores were assessed at 3, 6 months and 1 year. RESULTS: There were 223 (53.3%) Caucasians, 72 (17.2%) African-Americans, 53 (12.4%) Hispanics, and 71 (17.0%) patients from other ethnic groups, included in our study population. Minority patients (African-American, Hispanics, etc.) were more likely to be involved in high velocity mechanisms of injury and tended to have a greater percentage of open fractures. Although there were no differences in the rate of wound complications or reoperations, long-term functional outcomes were worse in minority patients as assessed by pain scores at 6 months and functional outcome scores at 3, 6 and 12 months. Multivariate analysis revealed that only African-American and Hispanic race continued to be independent predictors of worse functional outcomes at 12 months. CONCLUSIONS: Racial minorities and those on medicaid had poorer long-term function following fractures of the lower extremity. While minority patients were involved in more high velocity accidents, this was not an independent predictor of worse outcomes. These disparities may result from multifactorial socioeconomic factors, including socioeconomic status and education levels that were not controlled in our study. LEVEL OF EVIDENCE: Prognostic Level III.

OBJECTIVES: To determine whether racial or economic disparities are associated with short-term complications and outcomes in tibial plateau fracture care. DESIGN: Retrospective cohort study. SETTING: All New York State hospital admissions from 2000 to 2014, as recorded by the New York Statewide Planning and Research Cooperative System database. PATIENTS/PARTICIPANTS: Thirteen thousand five hundred eighteen inpatients with isolated tibial plateau fractures (OTA/AO 44), stratified in 4 groups: white, African American, Hispanic, and other. INTERVENTION: Closed treatment and operative fixation of the tibial plateau. MAIN OUTCOME MEASUREMENTS: Hospital length of stay (LOS, days), in-hospital complications/mortality, estimated total costs, and 30-day readmission. RESULTS: There were no significant differences regarding in-hospital mortality, infection, deep vein thrombosis/pulmonary embolism, or wound complications between races, even when controlling for income. There was a higher rate of nonoperatively treated fractures in the racial minority populations. Minority patients had on average 2 days longer LOS compared with whites (P < 0.001), costing on average $4000 more per hospitalization (P < 0.001). Multivariate logistic regression found that neither race nor estimated median family income were independent risk factors for readmission. CONCLUSIONS: Although nature of initial injury, use of external fixator, comorbidity burden, age, insurance type, and LOS were independent risk factors for readmission, race and estimated median family income were not. In patients who sustained a tibial plateau fracture, race and ethnicity seemed to affect treatment choice, but once treated racial minority groups did not demonstrate worse short-term complications, including increased mortality and postoperative readmission rates. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION: The operative management of tibial plateau fractures is challenging and post-operative complications do occur. The purpose of this study was three-fold. 1). To report complications and unplanned outcomes in patients who had sustained tibial plateau fractures and were operatively managed 2). To report predictors of these post-operative events 3). To report if differences in clinical outcomes exist in patients who sustained a post-operative event. METHODS: Over 11 years, all tibial plateau fractures were prospectively followed. Clinical outcomes were assessed using the validated Short Musculoskeletal Functional Assessment (SMFA) score. Demographics, initial injury characteristics, surgical details and post-operative events were prospectively recorded. Student's t-tests were used for continuous variables and chi-squared analysis was used for categorical variables. Binary logistic regression and multivariate linear regression were conducted for independent predictors of post-operative events and complications and functional outcomes, respectively. RESULTS: 275 patients with 279 tibial plateau fractures were included in our analysis. Ten patients (3.6%) sustained a deep infection. Six patients (2.2%) developed a superficial infection. One patient (0.4%) presented with early implant failure. Two patients (0.7%) developed a fracture nonunion. Eight patients (2.9%) developed a venous thromboembolism. Seventeen patients (6.2%) went on to re-operation for symptomatic implant removal. Nine patients (3.3%) underwent a lysis of adhesions procedure. Univariate analysis demonstrated bicondylar tibial plateau fractures (P<0.001), Moore fracture-dislocations (P=0.005), open fractures (P=0.022), and compartment syndrome (P=0.001) to be associated with post-operative complications and unplanned outcomes. Long-term functional outcomes were worse among patients who developed a post-operative complication or unplanned outcome (P=0.031). CONCLUSION: Orthopaedic trauma surgeons should be aware of complications and unplanned outcomes following operatively managed tibial plateau fractures, along with having the knowledge of factors that are associated with development of post-operative events.

OBJECTIVES: To determine the efficacy of liposomal bupivacaine compared to placebo for post-operative pain control in patients undergoing operative fixation of ankle fractures. DESIGN: Prospective single blinded randomized control trial SETTING:: Academic Medical CenterPatients/Participants: After IRB approval, seventy-six patients who sustained an acute ankle fracture (OTA 44A-C) requiring operative fixation met inclusion criteria. INTERVENTION: Patients were randomly assigned to one of two groups, control (local intra-operative sterile saline injection under general anesthesia) or interventional (local intra-operative liposomal bupivacaine and bupivacaine injection under general anesthesia). Injections were administered in a standardized fashion and included injection of a 1:1 mixture of a 40cc solution consisting of 1.3% Exparel and sterile saline (interventional) or a 40 cc injection of normal saline (control) into the surrounding periosteal, peritendinous, surrounding muscles and subcutaneous tissue of the surgical incision(s). MAIN OUTCOME MEASUREMENTS: Pain medications administered and pain according to the Visual Analogue Scale (VAS) was recorded at scheduled post-operative time points: 4, 24, 48, 72, and 336 hours (14 days). RESULTS: Thirty-nine patients were randomized to the control group and thirty-seven to the interventional group (mean age= 42 +/- 15 years), with no statistically significant differences between groups with regards to severity of injury and patient demographics. Pain scores were significantly lower in the interventional group versus control up to two weeks after surgery. Percocet ingestion at four hours was significantly lower in the interventional group (0.7 vs. 1.3, p=0.004), while it approached significance at forty-eight hours post-operatively (2.8 vs. 3.69, p=0.07). No other significant differences were noted for Percocet ingestion post-operatively at other time points assessed. The overall satisfaction with pain control was not statistically different between the two groups (p=0.93). CONCLUSION: Local intra-operative infiltration of liposomal bupivacaine administered with standard bupivacaine for ankle fractures requiring ORIF affords improved pain relief in the immediate post-operative period resulting in a reduction in Percocet ingestion, with resultant effects seen up to two days post-operatively. Continued investigation of this drug for use with extremity fractures is warranted. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE: Surgical video production is an important skill that can be of valuable use as an educational tool. However, it is important that surgical videos be filmed and edited in a methodological way to maximize its potential. In this video, we describe our preference for producing quality surgical videos. METHODS: There are many important factors to consider during the filming process, including vantage point of the videographer, lighting, and visualization of instruments. During the editing process, certain techniques can be used to make the video more stimulating and thus more engaging to the viewer. RESULTS: This video presents the filming and editing of a single case. In addition, we provide examples of acceptable and poor footage and editing techniques. CONCLUSIONS: Surgical videos can be a valuable educational tool when properly executed. In this video, we describe techniques to ensure quality production.

PURPOSE: The Hoffa fracture is a rare fracture pattern consisting of a unicondylar posterior fracture of the distal femur. This video demonstrates a case of Hoffa fracture repair using headless screw compression. METHODS: Hoffa fractures are intra-articular in nature. Given that isolated Hoffa fractures are rare, there is little information available as to the best management of this injury. However, several small studies have demonstrated good-to-excellent functional results after anatomical reduction and rigid fixation of the Hoffa fracture, followed by early mobilization. RESULTS: This video presents a case of surgical repair of a Hoffa fracture, and contaminant meniscal repair, in a 25-year-old man. Partially threaded, headless compression screws provide for independent compression of the fracture after placement. CONCLUSIONS: The Hoffa fracture is a rare injury typically seen after high-energy trauma. The surgical technique for treatment of the Hoffa fracture as seen in this video provides good stabilization and enables for early range of motion.

PURPOSE: Tibial plateau fractures are articular fractures that sometimes prove difficult to effectively manage and treat. Although fluoroscopy is frequently used to assess the articular reduction in the surgical repair of tibial plateau fractures, this video demonstrates the additional benefit of arthroscopy in assisting with the articular reconstruction of a Schatzker III tibial plateau fracture. METHODS: The goal of operative treatment of tibial plateau is reconstruction of the articular surface followed by reestablishment of tibial alignment. Arthroscopy has been advocated as a possible supplement to the operative treatment of tibial plateau fractures. Arthroscopy-assisted fracture reduction has been shown to provide a significantly improved visualization of fracture fragment displacement when compared with traditional fluoroscopy use in select cases. RESULTS: This video demonstrates the use of arthroscopy to visualize the articular surface and aid in reduction during fixation of a tibial plateau fracture. Initially, arthroscopic visualization confirms depression of lateral tibial plateau and the elevation of the fractured segment. After fixation with 2 partially threaded cancellous screws, arthroscopy confirms articular reduction and normal relation of lateral meniscus to the articular surface. CONCLUSIONS: Arthroscopic visualization is a reliable technique for assessing articular reduction during surgical repair of a tibial plateau fracture. In addition, this technique enables the surgeon to assess for soft tissue injuries that could potentially go undiagnosed.

PURPOSE: The incidence of ankle fractures is rapidly increasing in geriatric populations. Of the 4 fracture patterns described by the Lauge-Hansen classification system, supination-external rotation (SER) accounts for most ankle fractures. This video demonstrates surgical repair of a SER type 4 ankle fracture in a geriatric patient. METHODS: SER type 4 ankle fractures are considered unstable and are generally treated with surgical fixation. After placement of plate and screws, intraoperative stress tests can be used to assess for syndesmotic widening. If necessary, the syndesmosis can be reduced open, with screw fixation placed parallel to the joint. Patients are kept non-weight-bearing for 6 weeks after surgery. RESULTS: This video, shot on an iPhone 6S, shows the case of a 66-year-old female status after a fall with twisting mechanism resulting in an unstable SER type 4 fracture requiring operative repair. Intraoperative stress test revealed medial clear space widening requiring syndesmotic reduction. CONCLUSIONS: SER type 4 ankle fractures are a common injury that must be properly managed to return patients to baseline functional status. The surgical technique described in this video provides for good stabilization and allows for early range of motion with advancement to weight-bearing as tolerated at 6 weeks postoperatively.