Faculty Bibliography

BACKGROUND: Rotational injuries are the most common and usually classified as per the Lauge Hansen classification; with the most common subgroup being the supination external rotation (SER) mechanism. Isolated fractures of the distal fibula (SE2) without associated ligamentous injury are usually treated with a splint or brace and the patient may be allowed to weight bear as tolerated. This study reports the functional outcomes following a stable, low energy, rotational ankle fracture supination external rotation (SER2) when compared to unstable SER4 fractures treated operatively. MATERIALS AND METHODS: 64 patients who were diagnosed and treated nonoperatively for a stable SER2 ankle fracture were followed prospectively. In the comparison group, 93 operatively treated fibular fractures were extracted from a prospectively collected database and evaluated comparison. Baseline characteristics obtained by trained interviewers at the time of injury included: Patient demographics, short form-36, short musculoskeletal functional assessment (SMFA) and American Orthopedic Foot and Ankle Society (AOFAS) questionnaires. Patients were followed at 3, 6 and 12 months postsurgery. Additional information obtained at each followup point included any complications or evidence on fracture healing. Data were analyzed by the Student's t-test and theFisher's Exact Test to compare demographic and functional outcomes between the two cohorts. P < 0.05 was considered to be significant. RESULTS: The average of patients' age in the stable fracture cohort was 43 versus 45 in the SER4 group. Nearly 64% of the patient population was female when compared with 37% in the operative group. In the SER2 by 6 months all patients had returned to baseline functional status. There were 18 delayed unions (all healed by 6 months). Based on the functional outcome scores all patients had returned to preoperative level. In comparison, SE4 patients had less functional recovery at 3 and 6 months (P < 0.05) based on the SMFA scores and at 3, 6 and 12 months based on the AOFAS (P < 0.001) scores. There was no difference in pain levels between the two groups at all time points. There were three nonunions in the SE4 group and six delayed unions. CONCLUSIONS: An SER2 ankle fracture is a relatively benign injury with functional limitations resolving by 3 months while the need for surgical fixation in SER ankle fractures appears to affect lower extremity function to a greater degree for a longer time period. Patients should be counseled as to these expected outcomes.

Mechanical failure of the femoral component following total hip arthroplasty is a relatively uncommon complication that has been previously well-described in the literature. Modular, cementless implants have become a popular op - tion in revision total hip arthroplasty. They offer the distinct advantage of optimizing joint kinematics through varying the degree of version, offset, and leg length. We report the case of early fatigue fracture of the Restoration (Stryker, Mahwah, NJ) femoral prosthesis. The following is a detailed description of this case. This report details the events sur - rounding stem failure, and the technique of reconstruction used to deal with this failure.

OBJECTIVE:: The purpose of this study was to investigate the nonoperative treatment strategies for Mason-Johnson Type-I radial head fractures. DESIGN AND SETTING:: Retrospective review of every patient with a closed radial head/neck fracture who presented to our tertiary care specialty institution in the past two years.Patients/Participants: A search of ICD-9 code 813.05, closed fracture of the radial head/neck, in our electronic record system yielded 82 consecutive patients. MAIN OUTCOME MEASUREMENTS:: Complications and treatment interventions were recorded. Demographic, radiographic, and physical exam data were collected for all patients treated nonoperatively and analyzed for association with recommendation for continued follow-up and radiographic assessment. RESULTS:: 54 patients (68%) had 56 nondisplaced or minimally displaced (< 2mm) radial head or neck fractures without additional injury to the affected limb. All patients were treated nonoperatively and no patients in this cohort developed a complication or had any medical or surgical intervention other than physical therapy. No radiographic or physical exam measure was significantly associated with recommendation for a second outpatient follow-up, third outpatient follow-up, or with the number of additional radiographs ordered beyond the initial exam. An average of 4.4 (SD 3.3) additional x-rays were taken of each affected elbow after initial outpatient presentation. CONCLUSIONS:: Orthopaedic surgeons are likely over treating patients with Mason-Johnson Type-I radial head fractures by recommending frequent radiographic follow-up without modifying treatment, leading to unnecessary patient visits, radiation exposure, and increased costs. LEVEL OF EVIDENCE:: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE: To describe the features of displaced intra-articular fractures confined to the volar rim of the distal radius and compare outcomes after their operative fixation to complete intra-articular and extra-articular fractures treated with operative fixation. METHODS: A total of 627 distal radius fractures were treated over a 6-year period. Twenty-eight patients had volar rim fractures (type 23-B3, as classified by the Orthopaedic Trauma Association [OTA]), all treated with operative reduction and fixation using a volar buttress plate. Clinical outcome information including radiographs, Short Form-36 health survey, and Disabilities of the Arm, Shoulder, and Hand questionnaire were collected at regular postoperative intervals. Patients with volar rim fractures were compared with patients who sustained other types of operatively managed distal radius fractures (OTA types 23-A, 23-B1/B2, and 23-C). RESULTS: The most common type of volar rim fracture consisted of a single large fragment (OTA 23-B3.2; 46%), followed by comminuted fractures (OTA 23-B3.3; 36%). Restoration of radiographic parameters was similar between groups except for an increased volar tilt in volar rim fractures compared with group 23-B1/B2. Active wrist and finger motion improved in all groups except for wrist extension, which was less in the 23-B1/B2 groups. The 23-B1/B2 group had the greatest pain and worst Short Form-36 scores. Disabilities of the Arm, Shoulder, and Hand questionnaire scores were similar and without differences between groups. CONCLUSIONS: Our data suggest that patients with volar rim distal radius fractures can expect a rapid return to function with minimal risk for complications and have outcomes similar to other types of operatively treated distal radius fractures. Further investigation of type 23-B fractures (23-B1/B2) is warranted owing to evidence of diminished outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

BACKGROUND: Lower extremity injuries secondary to low-energy gunshot wounds are frequently seen in the civilian populations of urban areas. Although these wounds have fewer complications than high-energy gunshot injuries, the functional and psychological damage is still significant making appropriate timely orthopaedic treatment and follow-up imperative. PURPOSE: The purpose of this study is to present our outcomes in the treatment of low-energy gunshot wounds in a civilian population at an urban, level one trauma center in patients treated by a standard protocol. METHODS: One hundred and thirty three patients who sustained 148 gunshot wound injuries were treated at our level one trauma center between January 1(st), 2009 and October 1(st), 2011. Following IRB approval, we extracted information from medical records regarding hospital course, length of stay and type of operative or non-operative treatment. If available, injury and post-operative radiographs were also reviewed. Patients were contacted by telephone to obtain Short Musculoskeletal Function Assessment (SMFA) surveys, pain on a scale of 0-10 and for the determination of any adverse events related to their shooting. RESULTS: There were 125 men (94.0%) and 8 women (6.0%) with an average age of 27.1 years (range 15.2-56.3). Seventy-six patients (57.1%) did not have any health insurance upon admission. The average length of stay in the hospital was 4.5 days (range 0.0-88.0). Fifty-one gun shots (34.5%) resulted in fractures of the lower extremities. Patients underwent a total of 95 lower extremity-related procedures during their hospitalization. Twenty-two patients (16.5%) experienced a complication related to their gunshot wounds. 38% of the cohort was available for long-term functional assessment At a mean 23.5 months (range 8-48) of follow up, patients reported mean Functional and Bothersome SMFA scores of 19.6 (SD 15.9) and 10.9 (SD 15.6) suggesting that these patients have poorer function scores than the general population. These patients still had pain related to their gunshot injury with an average pain score of 2.16 (range 0-8). CONCLUSIONS: Gunshot injuries to the extremities may involve bone, soft tissue, and neurovascular structures. Execution of appropriate therapeutic methods in such situations is critical for treating surgeons given the potential for complications. At our level one trauma center, gunshot victims were predominantly young, uninsured adult men. Complications included infection, compartment syndrome, and arterial injuries. Functional data collected demonstrated that patients continued to have difficulties with ADL's at long-term follow-up.

Bisphosphonates are one of the most commonly prescribed medications for the treatment of osteoporosis. Their use has greatly decreased the number of osteoporosis-related vertebral and nonvertebral fractures. Recently, however, a relationship between long-term bisphosphonate use and subtrochanteric and femoral shaft fractures has been elucidated. These low-energy fractures, termed atypical femur fractures, exhibit unique characteristics in their pathophysiology, presentation, and radiographic appearance compared with more traditional high-energy femur fractures. Here we provide a review based on the most recent literature of the pathophysiology, presentation, evaluation, and management of these fractures. Despite an abundance of literature, atypical femur fractures remain difficult to treat, and surgeons must be aware of the tricks and complications associated with their management.

Today's increasingly complex health-care landscape requires that physicians take an active role in minimizing health-care costs and expenditures. Judicious choice of implants, a fracture-driven treatment algorithm, capitation models, use of generic fracture implants, and reuse of external fixation constructs all represent mechanisms that can result in substantial savings. In some health-care environments, these cost savings programs may be directly linked to physician reimbursement in the form of gainsharing plans. Evidence-based critical evaluations of implant usage patterns are necessary to help control implant-related health-care spending but are lacking in the current literature. Physicians need to acknowledge their influence and responsibility in this realm and assume an active role to help reduce costs.