Faculty Bibliography

BACKGROUND: The Accreditation Council of Graduate Medical Education (ACGME) guidelines require residency programs to teach and evaluate residents in six overarching "core competencies" and document progress through educational milestones. In order to assess the progress of orthopaedic interns' skills in performing a history, physical exam, and documentation of the encounter for a standardized patient with spinal stenosis, a Structured Objective Clinical Examination (OSCE) was conducted for 13 orthopaedic intern residents, following a one month boot camp that included communications skills and curriculum in history and physical examination. Interns were objectively scored based upon their performance of the physical exam, communication skills, completeness and accuracy of their electronic medical record (EMR), and their diagnostic conclusions gleaned from the patient encounter. PURPOSE: The purpose of this study was to meaningfully assess the clinical skills of orthopaedic PGY-1 interns. The findings can be utilized to develop a standardized curriculum for documenting patient encounters and highlight common areas of weakness among orthopaedic interns with regard to the spine history and physical examination and conducting complete and accurate clinical documentation. STUDY SETTING: A major orthopaedic specialty hospital and academic medical center METHODS: 13 PGY-1 orthopaedic residents participated in the OSCE with the same standardized patient presenting with symptoms and radiographs consistent with spinal stenosis. Videos of the encounters were independently viewed and objectively evaluated by one investigator in the study. This evaluation focused on the completeness of the history and the performance and completion of the physical exam. The standardized patient evaluated the communication skills of each intern with a separate objective evaluation. Interns completed these same scoring guides to evaluate their own performance in history, physical examination and communications skills. The interns' documentation in the electronic medical record (EMR) was then scored for completeness, internal consistency, and inaccuracies. RESULTS: The independent review revealed objective deficits in both the orthopaedic interns' history and physical examination, as well as highlighted trends of inaccurate and incomplete documentation in the corresponding medical record. Communication skills with the patient did not meet expectations. Further, interns tended to over-score themselves, especially with regards to their performance on the physical exam (p<.0005). Inconsistencies, omissions, and inaccuracies were common in the corresponding medical notes when compared to the events of the patient encounter. 9/13 interns (69.2%) documented at least one finding that was not assessed or tested in the clinical encounter, and 4/13 interns (30.8%) included inaccuracies in the medical record which contradicted the information collected at the time of the encounter. CONCLUSIONS: The results of this study highlighted significant shortcomings in the completeness of the interns' spine history and physical exam, and the accuracy and completeness of their EMR note. The study provides a valuable exercise for evaluating residents in a multifaceted, multi-milestone manner that more accurately documents residents' clinical strengths and weaknesses. The study demonstrates that orthopaedic residents require further instruction on the complexities of the spinal exam. It validates a need for increased systemic support for improving resident documentation through comprehensive education and evaluation modules.

OBJECTIVES: To identify the association between social and moderate alcohol consumption and functional outcomes after surgical management of orthopaedic fractures. DESIGN: Prospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seven hundred eighty-four patients who were operatively treated for an isolated orthopaedic fracture were prospectively followed. Patients were categorized into groups according to self-reported drinking frequencies based on NIAAA guidelines. MAIN OUTCOME MEASUREMENTS: SMFA scores at baseline, 3, 6, and 12 months postoperatively; postoperative complications; and subsequent operations. RESULTS: There were 367 (46.8%) abstinent, 327 (41.7%) social, 52 (6.6%) moderate, and 38 (4.8%) heavy drinkers. Mean SMFA scores of social and moderate drinkers were significantly lower than those of abstinent patients at 3-, 6-, and 12-month follow-ups, denoting better functional outcomes (social: 24.3 vs. 30.5, P = 0.001; 14.8 vs. 21.5, P < 0.005; and 10.1 vs. 18.8, P < 0.005); (moderate: 18.3 vs. 30.5, P = 0.001; 9.7 vs. 21.5, P = 0.001; and 5.4 vs. 18.8, P < 0.005). Multiple linear regression revealed that social drinking and baseline SMFA scores were the only statistically significant independent predictors of lower SMFA scores at 12 months after surgery. CONCLUSIONS: Social to moderate drinking may have a protective effect on functional outcomes at 3, 6, and 12 months after surgery. Social drinking may also have a protective effect on postoperative complications and reoperation rates. Further studies should be performed to fully appreciate the clinical effect of social and moderate drinking after operative treatment of orthopaedic fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION: This study sought to assess and compare long-term functional and clinical outcomes in patients with tibial plateau fractures that are treated nonsurgically. METHODS: Over a period of 8 years, 305 consecutive tibial plateau fractures were treated by three surgeons at a single institution and followed prospectively in an Institutional Review Board-approved study. Overall, 41 patients (13%) were treated nonsurgically and 37 were available for follow-up. Indications for nonsurgical management were minimal fracture displacement or preclusion of surgery because of comorbidities. A series of univariate retrospective analyses were used to identify individual risk factors potentially predictive of Short Musculoskeletal Functional Assessment scores. RESULTS: Thirty-seven patients were included with a mean follow-up of 21 +/- 14.9 months. Overall, 59% of patients (n = 22) attained good to excellent functional outcomes. In patients for whom surgery was precluded because of comorbidities, outcome scores were significantly poorer (38.8 +/- 23.0 versus 12.7 +/- 14.2; P = 0.001). Surgery precluded by a factor other than minimal fracture displacement predicted poor outcome (P = 0.002). DISCUSSION: Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

BACKGROUND: With an expected doubling of the geriatric population within the next thirty years it is becoming increasingly important to determine who among the elderly population benefit from orthopaedic interventions. This study assesses post-operative outcomes in patients aged seventy or greater who sustained a proximal humerus fracture and were treated surgically as compared to a younger geriatric cohort to determine if there is a chronologic age after which post-operative outcomes significantly decline. METHODS: A retrospective chart review was conducted for 201 patients who sustained fractures of the proximal humerus (OTA 11A-C) and were treated operatively by open reduction and internal fixation. Data from 132 independent, active patients aged fifty-five or older was identified and analyzed. Forty-seven patients age 70 or older were compared to 78 patients aged 55-69. Average length of follow-up was 19.5 months. All complications were recorded. Univariate and multivariate analysis was conducted to assess for differences between groups. RESULTS: 95% of patients achieved fracture union within 6 months. No significant differences were found between cohorts with regard to gender, fracture severity, or CCI (p = 0.197, p = 0.276, p = 0.084, respectively). Functional outcome scores, shoulder range of motion, and complications rates for patients aged 70 and older were not significantly different from patients aged 55-69. There were 10 complications in the older elderly cohort (21%), 6 of which required re-operation and 13 complications in the young elderly cohort (17%), 8 of which required re-operation. CONCLUSIONS: Operative fracture repair using locked plating of the proximal humerus in septuagenarians and octogenarians can provide for excellent long-term outcomes in appropriately selected patients. These patients tend to have long term functional outcome scores, post-operative range of motion, and complication rates that are comparable to younger geriatric patients. Physicians should not exclude patients for repair of proximal humerus fractures based on chronological age cutoffs.

OBJECTIVES: To determine the effect of spinal anesthesia (SA) on short-term outcomes when compared with general anesthesia in operatively managed tibial plateau fractures. DESIGN: This is an institutional review board-approved retrospective review of prospectively collected data. SETTING: Two level-1 trauma centers. PARTICIPANTS: One hundred twelve patients with a surgically managed tibial plateau fracture were identified within a registry of patients. INTERVENTION: Of these, 29 (25.9%) received SA and 83 (74.1%) received general anesthesia in a nonrandomized fashion. MAIN OUTCOME MEASURES: Short Musculoskeletal Functional Assessment scores, pain levels, knee range of motion, complications, and reoperations. RESULTS: SA was found to be a predictor of lower pain scores at 3 months (odds ratio, 0.32; 95% confidence interval, 0.12-0.95; P = 0.039) but not at 6 months (P = 0.266) or the latest follow-up (P = 0.056). In the multivariate Short Musculoskeletal Functional Assessment model, although anesthesia type was not found to be a statistically significant predictor, other predictors were identified. Anesthesia type was not a predictor of complications or reoperations. In the univariate analysis, SA was associated with an increased knee range of motion at 3 months (121 vs. 111 degrees; P = 0.048) but not at 6 months (P = 0.31) or the latest follow-up (P = 0.053). CONCLUSION: In patients who undergo surgical management of a tibial plateau fracture, the use of SA is associated with decreased pain levels in the early postoperative period; however, there was no effect on functional assessment scores. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE: The purpose of this study was to determine whether the finding of failed fracture implants in association with lower extremity long bone fracture nonunion portends worse clinical or functional outcome following surgical nonunion repair. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Academic Medical Center. PATIENTS: One hundred eighty-one patients who presented to our institution over a 10-year period and underwent surgical repair of a lower extremity fracture nonunion. INTERVENTION: Surgical repair of lower extremity fracture nonunion. MAIN OUTCOME MEASUREMENTS: Time to union, postoperative complications, VAS pain scores, and Short Musculoskeletal Function Assessment (SMFA) scores following lower extremity nonunion repair. Data was analyzed to assess for differences in postoperative outcomes based on the integrity of fracture implants at the time of nonunion diagnosis. Implant integrity was defined using 3 groups: broken implants (BI), implants intact (II), and no implants (NI). RESULTS: There was no significant difference in time to union following surgery between the BI, II, or NI groups (mean 8.1 months vs 7.6 months vs 6.2 months, respectively). Fourteen patients (7.7%) failed to heal, including 5 BI patients, 7 II patients, and 2 NI patients. One tibial nonunion patient in each of the 3 groups underwent amputation for persistent nonunion following multiple failed revision attempts at a mean of 4.8 years after initial injury. There was no difference in postoperative pain scores, the rate of postoperative complications, or functional outcome scores identified between the 3 groups. CONCLUSION: The finding of failed fracture implants at the time of lower extremity long bone nonunion diagnosis does not portend worse clinical or functional outcome following surgical nonunion repair. Patients who present with failed fracture implants at the time of nonunion diagnosis can anticipate similar time to union, complication rates, and functional outcomes when compared to patients who present with intact implants or those with history of nonoperative management. LEVEL OF EVIDENCE: Prognostic Level IV.

Patient care is 1 of the 6 core competencies defined by the Accreditation Council for Graduate Medical Education (ACGME). The physical examination (PE) is a fundamental skill to evaluate patients and make an accurate diagnosis. The purpose of this study was to investigate 3 different methods to teach PE skills and to assess the ability to do a complete PE in a simulated patient encounter. DESIGN: Prospective, uncontrolled, observational. SETTING: Northeastern academic medical center. PARTICIPANTS: A total of 32 orthopedic surgery residents participated and were divided into 3 didactic groups: Group 1 (n = 12) live interactive lectures, demonstration on standardized patients, and textbook reading; Group 2 (n = 11) video recordings of the lectures given to Group 1 and textbook reading alone; Group 3 (n = 9): 90-minute modules taught by residents to interns in near-peer format and textbook reading. RESULTS: The overall score for objective structured clinical examinations from the combined groups was 66%. There was a trend toward more complete PEs in Group 1 taught via live lectures and demonstrations compared to Group 2 that relied on video recording. Near-peer taught residents from Group 3 significantly outperformed Group 2 residents overall (p = 0.02), and trended toward significantly outperforming Group 1 residents as well, with significantly higher scores in the ankle (p = 0.02) and shoulder (p = 0.02) PE cases. CONCLUSIONS: This study found that orthopedic interns taught musculoskeletal PE skills by near-peers outperformed other groups overall. An overall score of 66% for the combined didactic groups suggests a baseline deficit in first-year resident musculoskeletal PE skills. The PE should continue to be taught and objectively assessed throughout residency to confirm that budding surgeons have mastered these fundamental skills before going into practice.

Chronic use of selective serotonin re-uptake inhibitors (SSRI) for the treatment of depression has been linked to osteoporosis. In this study, we investigated the effect of chronic SSRI use on fracture healing in two murine models of bone regeneration. First, we performed a comprehensive analysis of endochondral bone healing in a femur fracture model. C57/BL6 mice treated with fluoxetine, the most commonly prescribed SSRI, developed a normal cartilaginous soft-callus at 14 days after fracture and demonstrated a significantly smaller and biomechanically weaker bony hard-callus at 28 days. In order to further dissect the mechanism that resulted in a smaller bony regenerate, we used an intramembranous model of bone healing and revealed that fluoxetine treatment resulted in a significantly smaller bony callus at 7 and 14 days post-injury. In order to test whether the smaller bony regenerate following fluoxetine treatment was caused by an inhibition of osteogenic differentiation and/or mineralization, we employed in vitro experiments, which established that fluoxetine treatment decreases osteogenic differentiation and mineralization and that this effect is serotonin-independent. Finally, in a translational approach, we tested whether cessation of the medication would result in restoration of the regenerative potential. However, histologic and microCT analysis revealed non-union formation in these animals with fibrous tissue interposition within the callus. In conclusion, fluoxetine exerts a direct, inhibitory effect on osteoblast differentiation and mineralization, shown in two disparate murine models of bone repair. Discontinuation of the drug did not result in restoration of the healing potential, but rather led to complete arrest of the repair process. Besides the well-established effect of SSRIs on bone homeostasis, our study provides strong evidence that fluoxetine use negatively impacts fracture healing