Faculty Bibliography

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.

BACKGROUND:Cost effective implant selection in orthopedic trauma is essential in the current era of managed healthcare delivery. Both locking and non-locking plates have been utilized in the treatment of displaced fractures of the olecranon. However, locking plates are often more costly and may not provide superior clinical outcomes. The primary aim of the present study is to assess the clinical and functional outcomes of olecranon fractures treated with locked and non-locking plate and screw constructs while providing insight into the cost of various implants. METHODS:We performed a retrospective chart review of a single institution database identifying Mayo IIB type olecranon fractures treated surgically from 2003 to 2012. All fractures were treated with either a locked plate or a one-third tubular hook plate construct. Clinical and radiographic outcomes were evaluated. Minimum 6-month follow-up was required. Outcomes were compared between fixation constructs, including rate of union, early failure, postoperative range of motion, and complication rates. Statistical analysis included Pearson's Chi-squared and Fisher's exact test for categorical variables, and the Student's ttest for continuous variables. RESULTS:The one-third tubular construct was equivalent to locking plate constructs with respect to union, post-operative range of motion, and rates of complications. There were no early or late failures. Locking plates were associated with a relative cost increase of $1,263.50 compared to the one-third tubular hook plate per case. CONCLUSION:Surgeons should consider the cost of implants when treating Mayo IIB olecranon fracture. In this cohort, one-third tubular plates provided equivalent outcomes to locked plates with a notable decrease in cost.

BACKGROUND: To compare 30-day outcomes in patients treated for a distal femur (DF) fracture with plate fixation (PF) or intramedullary nail (IMN). METHODS: Differences in rates of any adverse events (AAE), serious adverse events (SAE), infectious complications, and mortality were explored between groups in the ACS-NSQIP database. RESULTS: There were 511 PF and 44 IMN patients. The PF group and IMN groups had similar rates of AAEs (p = 0.35), SAEs (p = 0.46), infectious complications (p = 1.00), and mortality (p = 0.39). CONCLUSIONS: DF fractures treated with IMN have equivalent short-term outcomes compared to those treated with PF.

PURPOSE: To compare and contrast postoperative complications in the geriatric population following open reduction and internal fixation (ORIF) for (DF) fractures relative to femoral neck (FN) fractures. METHODS: Patients aged 65 years and older in the American College of Surgeons National Surgical Quality Improvement Program database who underwent ORIF for FN fractures or DF fractures from 2005 to 2012 were identified. Differences in rates of any adverse events (AAEs), serious adverse events (SAEs), infectious complications, and mortality between groups were explored using univariate and multivariate analyses. RESULTS: The DF cohort had a higher proportion of females (81.95% vs 71.35%, P < .001), were younger (79.41 +/- 7.93 vs 82.11 +/- 7.26 years old, P < .001), and had a lower age adjusted modified Charlson comorbidity index score (4.22 +/- 1.32 vs 4.49 +/- 1.35, P = .02). Cases with DF and FN did not differ in AAE (20.05% vs 20.20%, P = .94), SAE (12.03% vs 13.19%, P = .51), infectious complication (4.26% vs 4.22%, P = .97), hospital length of stay (7.32 +/- 6.73 days vs 7.02 +/- 10.67 days, P = .59), or mortality rates (4.51% vs 5.99%, P = .23). Multivariate analyses revealed that fracture type did not impact AAE (P = .28), SAE (P = .58), infectious complications (P = .83), or mortality (P = .85) rates. CONCLUSION: Postoperative morbidity and mortality of geriatric patients who sustain DF and FN fractures treated operatively were comparable. This information can be used when risk stratifying and prognosticating for elderly patients undergoing these procedures.

Application of the correct fixation construct is critical for fracture healing and long-term stability; however, it is a complex issue with numerous significant factors. This review describes a number of common fracture types and evaluates their currently available fracture fixation constructs. In the setting of complex elbow instability, stable fixation or radial head replacement with an appropriately sized implant in conjunction with ligamentous repair is required to restore stability. For unstable sacral fractures with vertical or multiplanar instabilities, "standard" iliosacral screw fixation is not sufficient. Periprosthetic femur fractures, in particular Vancouver B1 fractures, have increased stability when using 90/90 fixation versus a single locking plate. Far cortical locking combines the concept of dynamization with locked plating to achieve superior healing of a distal femur fracture. Finally, there is no ideal construct for syndesmotic fracture stabilization; however, these fractures should be fixed using a device that allows for sufficient motion in the syndesmosis. In general, orthopaedic surgeons should select a fracture fixation construct that restores stability and promotes healing at the fracture site, while reducing the potential for fixation failure.