Faculty Bibliography

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.

BACKGROUND: This video presents the digitized, original, reel-to-reel footage of Victor Frankel's groundbreaking 1960s experiments demonstrating the viscoelastic properties and fracture mechanics of loaded bone. As can be seen, novel instrumentation was used that resulted in an easily reproducible method of controlling bone loading rates. The innovation, and associated experiments, radically advanced our understanding of the mechanisms of acute fractures and bone's response to energy. METHODS: Using the "Standard Torsion Testing Machine" that he helped design, the author explains how the mechanical and functional properties of bone are affected by various defects. Examples used include an intact dog femur, a femur with a hole in the cortex, and a femur with an open section defect. Slow motion depiction allows the viewer to appreciate the potential soft tissue damage associated with bone fragmentation and how this varies with energy input. The video concludes with a demonstration of the effect of torsional motion on the vasculature. RESULTS: Graphs produced by the torsion tester display torque versus angular deformation plots for each experiment. These illustrate the relationship between bone structure, fracture, and energy. The x-ray contrast segment provides an example of associated arterial damage secondary to a fracture. CONCLUSION: This previously unreleased piece of orthopaedic history provides viewers with perspective on the early days of biomechanical study and an easy-to-understand tutorial on acute fracture mechanics and the role of energy in injury.

Background Isolated medial tibial plateau injuries are uncommon and underdescribed in the literature. As such, the range of fracture severity and outcomes in comparison to more frequently described tibial plateau fractures are lacking. Method To assess outcomes of this rare injury, we compared two cohorts of patients. Overall, 27 patients who sustained 27 isolated medial plateau (Schatzker type IV) fractures and 81 patients with 81 split depression lateral plateau (Schatzker type II) fractures were compared. The outcomes were stratified by injury mechanism energy and assessed with radiographs, clinical and arthroscopic examinations, and functional status with the short musculoskeletal function assessment questionnaire (SMFA). Results Overall, 52% of Schatzker type IV fractures versus 71% of Schatzker type II were associated with high-energy injuries. Schatzker type IV fractures were more often nondisplaced and amenable to being managed, nonoperatively, 22 versus 6%, with excellent results. Schatzker type II fractures had a corresponding higher proportion of postoperative articular step off greater than 12 mm and poorer 12-month SMFA scores. Schatzker type IV fractures were more often treated with an external fixator than Schatzker type II fractures (22 vs. 1%). Within Schatzker type IV fractures, high- versus low-energy injuries did not differ significantly with regards to initial articular step off (4.2 vs. 5.1 mm), ligamentous and meniscal injury, or SMFA outcomes. Conclusions Isolated medial plateau fractures had low- and high-energy patterns with differing management and outcomes. Schatzker type IV fractures overall were associated with lower energy mechanisms, less initial articular step off, and better functional outcomes than Schatzker II comparisons in this cohort. Level of Evidence: The level of evidence is 4.

PURPOSE: The purpose of this study was to summarize the recent developments in the field of tissue engineering as they relate to multilayer scaffold designs in musculoskeletal regeneration. METHODS: Clinical and basic research studies that highlight the current knowledge and potential future applications of the multilayer scaffolds in orthopaedic tissue engineering were evaluated and the best evidence collected. Studies were divided into three main categories based on tissue types and interfaces for which multilayer scaffolds were used to regenerate: bone, osteochondral junction and tendon-to-bone interfaces. RESULTS: In vitro and in vivo studies indicate that the use of stratified scaffolds composed of multiple layers with distinct compositions for regeneration of distinct tissue types within the same scaffold and anatomic location is feasible. This emerging tissue engineering approach has potential applications in regeneration of bone defects, osteochondral lesions and tendon-to-bone interfaces with successful basic research findings that encourage clinical applications. CONCLUSIONS: Present data supporting the advantages of the use of multilayer scaffolds as an emerging strategy in musculoskeletal tissue engineering are promising, however, still limited. Positive impacts of the use of next generation scaffolds in orthopaedic tissue engineering can be expected in terms of decreasing the invasiveness of current grafting techniques used for reconstruction of bone and osteochondral defects, and tendon-to-bone interfaces in near future.