Faculty Bibliography

INTRODUCTION: Acute compartment syndrome (ACS) is well known among orthopaedic surgeons. The timely diagnosis and management of ACS is crucial to avoiding its sequelae, including renal failure, ischemic contractures, and limb loss. Despite its relative importance, ACS poses a challenge to many residents and clinicians as diagnosis relies largely on clinical judgment. METHODS: Timely diagnosis and thorough compartment release are essential to optimizing outcomes in ACS. This video highlights a clinical case in which compartment syndrome of the leg was considered, diagnosed, and surgically managed. RESULTS: This video will present the indications for compartment release and a video-guided demonstration of compartment checks using an arterial line transducer, a 4-compartment fasciotomy with 2 incisions, and temporizing vessel loop closure. CONCLUSIONS: Compartment syndrome can be a devastating complication of common fractures. It is essential that orthopaedic practitioners understand the immediacy of intervention. We have a responsibility to provide timely, accurate diagnosis along with expedient surgical management.

PURPOSE: Fracture nonunion is a common problem for today's orthopaedic surgeon. However, many techniques are currently available for the treatment of long-bone nonunion. This video demonstrates the use of iliac crest bone graft and plate stabilization in the setting of a hypertrophic femoral nonunion. METHODS: Treatment of femoral nonunion after intramedullary nail fixation using compression plating and bone grafting is a reliable technique for reducing pain, improving function, and achieving radiographic union. Furthermore, the use of autologous bone graft, in particular iliac crest bone graft, has provided reliable clinical results. RESULTS: In this video, we present the case of a hypertrophic femoral nonunion treated with supplemental bone grafting in addition to plate and screw fixation. CONCLUSIONS: Although femoral nonunions are a relatively rare occurrence, they can be reasonably treated using stabilization and supplemental bone grafting. Iliac crest bone graft provides for excellent results when used for treatment of a fracture nonunion.

PURPOSE: Posttraumatic bone defects in the setting of severe open injuries of the lower extremity present a significant challenge for orthopaedic trauma surgeons. The induced membrane technique, also known as the Masquelet technique, has been shown to be generally successful in achieving bony union. This video demonstrates the use of the Masquelet technique for a large (18 cm) femoral defect. METHODS: The Masquelet technique is a 2-stage process. The first stage involves debridement of all devitalized tissue, using open reduction and internal fixation, and placement of a cement spacer with or without antibiotics. In the second stage, which is performed at least 6 weeks after the first, the spacer is removed and the resulting void is filled with bone graft. RESULTS: This surgical case video reviews the relevant patient injury presentation, initial management, and indications for the Masquelet technique. The second stage of the Masquelet technique is featured in this video. CONCLUSIONS: The Masquelet technique is a generally reliable method for treating large segmental bone defects. In addition, this relatively simple technique is suitable for both infected and noninfected cases.

PURPOSE: Operative fixation of displaced patella fractures is considered to be standard of care. However, patients with inferior pole patella fractures have limited options in terms of fixation. This video demonstrates the repair of an inferior pole patella fracture using nonabsorbable suture fixation. METHODS: Suture repair of patella fractures is a clinically acceptable technique, yielding similar functional results to patella fractures treated with K-wires or cannulated screws while reducing the rates of removal of hardware after fixation. RESULTS: This video features the repair of a displaced, comminuted inferior pole patella fracture using 5 Ethibond and Fiberwire. Postoperative radiographs confirm bony union. CONCLUSIONS: Suture fixation for pole patella fractures provides reliable fixation and reduces the risk of postoperative complications secondary to hardware irritation. This case highlights the success of this technique.

PURPOSE: Bilateral posterior fracture dislocation is a rare injury commonly associated with seizures. When the humeral head defect (reverse Hill-Sachs lesion) is between 20% and 45%, operative fixation using a modified McLaughlin procedure is recommended. This video demonstrates a case of bilateral posterior fracture dislocation after a drug-induced seizure treated with a modified McLaughlin procedure. METHODS: The original McLaughlin procedure involved transfer of the subscapularis tendon from the lesser tuberosity to the reverse Hill-Sachs defect. However, the modified McLaughlin procedure is more commonly described in the literature as of late and involved the transfer of the lesser tuberosity along with the subscapularis. RESULTS: This video demonstrates the modified McLaughlin technique for a posterior fracture dislocation. Computerized tomography confirms the articular impression fractures of the proximal humerus. Through a deltopectoral approach, the lesser tuberosity along with the subscapularis tendon was transferred into the defect. CONCLUSIONS: The modified McLaughlin procedure demonstrates excellent clinical and radiographic results after posterior fracture dislocation of the shoulder with a reverse Hill-Sachs lesion between 25% and 45%.

INTRODUCTION: This video demonstrates the technique of intramedullary nailing for a humeral shaft fracture. METHODS: The patient is a 30-year-old man who sustained a gunshot wound to his right arm. The patient was indicated for humeral nailing given the comminuted nature of the diaphysis and to allow for minimal skin incisions. Other relative indications include soft-tissue compromise about the arm precluding a large surgical exposure. RESULTS: This video presents a case of a comminuted humeral shaft fracture treated with an intramedullary nail. Anatomic reduction and stable fixation was obtained with this technique. CONCLUSION: This case demonstrates a soft-tissue sparing technique of humeral shaft fixation using a humeral intramedullary nail. The technique is easy to perform and has significant benefits in minimizing surgical exposure, decreasing operative time, and decreasing blood loss. In the correct clinical setting, humeral nailing provides an expeditious form of fixation that restores length, alignment, and rotation of the fracture humeral diaphysis.

OBJECTIVES:: To determine if 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 (AO/OTA 44), stratified in four groups: Caucasian, African-American, Hispanic, and Other. INTERVENTION:: Closed treatment and operative fixation of the tibial plateau MAIN OUTCOME MEASUREMENTS:: Hospital LOS (days), in-hospital complications/mortality, estimated total costs, and 30-day readmission RESULTS:: There were no significant differences with regard to in-hospital mortality, infection, deep vein thrombosis/ pulmonary embolism (DVT/PE), or wound complications between races, even when controlling for income. There was a higher rate of non-operatively treated fractures in the racial minority populations. Minority patients had on average 2 days longer length of stay (LOS) compared to Caucasians (p<0.001), costing on average $4,000 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:: While 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

BACKGROUND: The number of hip fractures is rising as life expectancy increases. As such, the number of centenarians sustaining these fractures is also increasing. The purpose of this study was to determine whether patients who are >/=100 years old and sustain a hip fracture fare worse in the hospital than those who are younger. METHODS: Using a large database, the New York Statewide Planning and Research Cooperative System (SPARCS), we identified patients who were >/=65 years old and had been treated for a hip fracture over a 12-year period. Data on demographics, comorbidities, and treatment were collected. Three cohorts were established: patients who were 65 to 80 years old, 81 to 99 years old, and >/=100 years old (centenarians). Outcome measures included hospital length of stay, estimated total costs, and in-hospital mortality rates. RESULTS: A total of 168,087 patients with a hip fracture were identified, and 1,150 (0.7%) of them had sustained the fracture when they were >/=100 years old. Centenarians incurred costs and had lengths of stay that were similar to those of younger patients. Despite the similarities, centenarians were found to have a significantly higher in-hospital mortality rate than the younger populations (7.4% compared with 4.4% for those 81 to 99 years old and 2.6% for those 65 to 80 years old; p < 0.01). Male sex and an increasing number of medical comorbidities were found to predict in-hospital mortality for centenarians sustaining extracapsular hip fractures. No significant predictors of in-hospital mortality were identified for centenarians who sustained femoral neck fractures. An increased time to surgery did not influence the odds of in-hospital mortality. CONCLUSIONS: Centenarians had increased in-hospital mortality, but the remaining short-term outcomes were comparable with those for the younger cohorts with similar fracture patterns. For this extremely elderly population, time to surgery does not appear to affect short-term mortality rates, suggesting a potential benefit to preoperative optimization. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Fracture of the metaphyseal region of the distal ulna is an uncommon injury that has been reported to occur concomitantly with distal radius fracture. We aimed to report the incidence and types of distal ulnar head and neck fractures associated with distal radius fractures and compare outcomes in operatively versus non-operatively treated patients. METHODS: Over a 5-year period a distal radius fracture registry was maintained at our institution. Eleven of 512 consecutive patients had metaphyseal distal ulna fractures in association with distal radius fractures and at least 1-year follow-up. Baseline radiographs and functional data were obtained, and patients were followed at 1-week, 2-week, 3-week, 6-week, 3-month, 6-month, 1-year, and 2-year intervals. Patients were split into two treatment groups: Group 1 consisted of five non-operatively treated patients, and Group 2 consisted of six operatively treated patients. RESULTS: Four separate fracture patterns were observed: simple transverse or oblique fracture of the ulnar neck just proximal to the ulnar head, fracture of the neck region with concomitant fracture of the tip of the ulnar styloid, simple fracture of the ulnar head, and comminuted fracture of the ulnar head. There were no statistical differences between the two groups with regard to flexion, extension, supination, pronation, and functional outcomes. CONCLUSIONS: Ulnar fracture patterns observed did not easily fall into previously described categories, and we have proposed a new classification system. Simple fractures of the ulnar neck or head often do not require operative fixation.

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.