Faculty Bibliography
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691
Ulnar variance as a predictor of persistent instability following Galeazzi fracture-dislocations
BACKGROUND: We investigated the radiographic parameters that may predict distal radial ulnar joint (DRUJ) instability in surgically treated radial shaft fractures. In our clinical experience, there are no previously reported radiographic parameters that are universally predictive of DRUJ instability following radial shaft fracture. MATERIALS AND METHODS: Fifty consecutive patients, ages 20-79 years, with unilateral radial shaft fractures and possible associated DRUJ injury were retrospectively identified over a 5-year period. Distance from radial carpal joint (RCJ) to fracture proportional to radial shaft length, ulnar variance, and ulnar styloid fractures were correlated with DRUJ instability after surgical treatment. RESULTS: Twenty patients had persistent DRUJ incongruence/instability following fracture fixation. As a proportion of radial length, the distance from the RCJ to the fracture line did not significantly differ between those with persistent DRUJ instability and those without (p = 0.34). The average initial ulnar variance was 5.5 mm (range 2-12 mm, SD = 3.2) in patients with DRUJ instability and 3.8 mm (range 0-11 mm, SD = 3.5) in patients without. Only 4/20 patients (20 %) with DRUJ instability had normal ulnar variance (-2 to +2 mm) versus 15/30 (50 %) patients without (p = 0.041). CONCLUSION: In the setting of a radial shaft fracture, ulnar variance greater or less than 2 mm was associated with a greater likelihood of DRUJ incongruence/instability following fracture fixation.
PMCID:3948522
PMID: 23989858
ISSN: 1590-9921
CID: 779622
The association of education level on outcome after distal radius fracture
BACKGROUND: Socioeconomic factors have been found to be predictors of outcome for other ailments. The purpose of this study was to evaluate the association of patient education level on pain and disability after distal radius fracture. METHODS: A series of patients with distal radius fractures (n = 335) were enrolled into a prospective research registry. Standard demographic information was obtained from patients, including a five-value categorical education variable. After treatment with closed reduction, external fixation, or internal fixation patients were evaluated for pain, function (Disability of the Arm, Shoulder, and Hand score [DASH]), range of motion (ROM), and grip strength at standard intervals until 12 months post-injury. A series of linear mixed effects models were developed to evaluate the relationship between time from injury and education level with each of the outcomes measured. RESULTS: Complete demographic and 12-month follow-up data were available on 227 patients (75 %). There were neither group differences in mode of injury, severity, nor treatment modality after stratification by education level. Mixed effects model analyses revealed a significant linear association between level of education and measured outcomes at each follow-up point. Overall, each increase in education level demonstrated a doubling of improvement in pain, ROM, grip strength, and DASH score. CONCLUSIONS: Outcome of distal radius fracture depends on acute care and follow-up rehabilitation; however, patient-related factors indicative of socioeconomic status are becoming increasingly relevant as predictors of outcome and should be considered by the orthopaedist.
PMCID:3928390
PMID: 24570641
ISSN: 1558-9447
CID: 820742
Do elderly patients fare worse following operative treatment of distal femur fractures using modern techniques?
BACKGROUND: The purpose of this study was to compare the functional outcomes and quality of life of older and younger patients with similarly treated distal femur fractures. METHODS: We conducted an assessment of 57 patients who sustained distal femur fractures (Orthopaedic Trauma Association Type 33B, C) and underwent surgical treatment at our academic medical center. Patients were divided into 2 groups for analysis: an elderly cohort of patients aged 65 or older and a comparison cohort of patients younger than age of 65. A retrospective review of demographics, preoperative ambulatory status, radiographic data, and physical examination data was collected from the medical records. Follow-up functional data were collected via telephone at a mean of 2.5 years (range 6 months-8 years) using a Short Musculoskeletal Functional Assessment (SMFA). All patients underwent standard operative treatment of either nail or plate fixation. RESULTS: There was no statistical difference in gender, fracture type, surgical technique, surgeon, or institution where the surgery was performed. The percentage of patients with healed fractures at 6-months follow-up was not significantly different between the cohorts. The elderly cohort had slightly worse knee range of motion at 3, 6, and 12 months postoperatively but there was not a statistically significant difference between the groups. The SMFA Daily Activity, Functional, and Bother indices were significantly worse in the older cohort (P < .01, P = .01, P = .02, respectively). However, there was no significant difference in the SMFA Emotional or Mobility indices. CONCLUSION: Despite lower quality of life and functional scores, this study suggests that relatively good clinical outcomes can be achieved with surgical fixation of distal femoral fractures in the elderly patients. Age should not be used as a determinate in deciding against operative treatment of distal femur fractures in the elderly patients.
PMCID:3962055
PMID: 24660097
ISSN: 2151-4585
CID: 897232
Scapula fractures: interobserver reliability of classification and treatment
OBJECTIVES: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN: Web-based reliability study. SETTING: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS: Fleiss kappa (kappa) was used to assess the reliability of agreement between the surgeons. RESULTS: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, kappa = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, kappa = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), kappa = 0.79) was substantial and the agreement about a fractured body (Body (B), kappa = 0.57) or process was moderate (Process (P), kappa = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (kappa = 0.57) with a 73% PA. CONCLUSIONS: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.
PMID: 23629469
ISSN: 1531-2291
CID: 991952
Displaced Insufficiency Femoral Neck Stress Fracture in the Setting of Ochronosis: A Case Report
PMID: 29252580
ISSN: 2160-3251
CID: 2892612
Distal Femur Nonunion Patients Can Expect Good Outcomes
The purpose of this study is to describe our experience with distal femur nonunions and to report on the functional recovery of patients treated for these injuries. Twenty-two patients with an established distal femur nonunion were identified and followed prospectively. Results were compared with a control group consisting of 18 similar patients who had sustained an acute distal femur fracture. Compared with acute fracture patients, patients with a nonunion were more likely to have had an open fracture at initial injury (p = 0.02) and required a longer time to heal after final surgery (p = 0.054). No demographic variables were found to be predictive of complications, Short Musculoskeletal Functional Assessment scores, or time to union. These results show that patients with a distal femoral nonunion can expect to attain similar ultimate outcomes to patients receiving treatment for an acute distal femur fracture. Unlike the development of nonunions following other types of fracture, such as the hip, distal femur nonunions do not portend poor functional outcomes as long as bone union is achieved.
PMID: 23881530
ISSN: 1538-8506
CID: 495182
Multidisciplinary Reconstructive Approach to Traumatic Extensor Mechanism Disruption: A Case Report
PMID: 29252381
ISSN: 2160-3251
CID: 2892632
The effect of two different trochanteric nail lag-screw designs on fixation stability of four-part intertrochanteric fractures: a clinical and biomechanical study
OBJECTIVES: To compare lag-screw sliding characteristics and fixation stability of two cephalomedullary nails (CMN) with different lag-screw designs (solid and telescopic), we conducted a biomechanical study and an analysis of clinical results. METHODS: Six pairs of cadaver femurs with simulated intertrochanteric fractures were randomly assigned to one of two CMN fixations. Femur constructs were statically then cyclically loaded on an MTS machine. Lag-screw sliding and inferior and lateral femoral head displacements were measured, following which failure strength of the construct was determined. Forty-five patients with intertrochanteric fractures treated with these CMN were identified. Medical records and radiographs were reviewed and analyzed using Fisher's exact test and Student's t test to determine lag-screw sliding. RESULTS: No difference was seen with cycling in inferior femoral head displacement between the two screw designs. The solid screw had an average inferior head displacement of 1.75 mm compared with 1.59 mm for the telescoping screw (p = 0.772). The solid lag screws slid an average of 2.79 mm lateral from the nail, whereas the telescoping screws slid an average of 0.27 mm (p = 0.003). In our clinical review, the average lateral sliding of the telescoping screw was 0.5 mm and of the solid screw was 3.7 mm (p < 0.001). Despite differences in lateral sliding, there were no reoperations for prominent or painful hardware in either group. CONCLUSIONS: Both designs are acceptable devices for stabilization of intertrochanteric fractures. Clinical and biomechanical data demonstrate greater lateral sliding in the solid lag-screw group, making for greater potential for lateral-sided hip pain in CMNs with solid lag screws as opposed to telescoping lag screws.
PMID: 24248549
ISSN: 0949-2658
CID: 777992
Low velocity gunshot wounds result in significant contamination regardless of ballistic characteristics
Controversy exists among the orthopedic community regarding the treatment of gunshot injuries. No consistent treatment algorithm exists for treatment of low energy gunshot wound (GSW) trauma. The purpose of this study was to critically examine the wound contamination following low velocity GSW based upon bullet caliber and clothing fiber type found within the injury track. Four types of handguns were fired at ballistic gel from a 10-foot distance. Various clothing materials were applied (denim, cotton, polyester, and wool) circumferentially around the tissue agar in a loose manor. A total of 32 specimens were examined. Each caliber handgun was fired a minimum of 5 times into a gel. Regardless of bullet caliber there was gross contamination of the entire bullet track in 100% of specimens in all scenarios and for all fiber types. Furthermore, as would be expected, the degree of contamination appeared to increase as the size of the bullet increased. Low velocity GSWs result in significant contamination regardless of bullet caliber and jacket type. Based upon our results further investigation of low velocity GSW tracks is warranted. Further clinical investigation should focus on the degree to which debridement should be undertaken.
PMID: 24490188
ISSN: 1078-4519
CID: 800122
Atypical Femur Fractures
Osteoporosis (OP) results from an imbalance between bone production and absorption that results in decreased bone mass as well as microstructural deterioration of the bone trabeculae, leading to diminished bone quality and fragility fractures. It is synonymous with decreased bone strength and affects millions of people worldwide.The most commonly prescribed drugs for the treatment of OP are the bisphosphonates (BPs). Long-term BP use may be associated with stress fractures of the subtrochanteric and shaft regions of the femur known as atypical femur fractures (AFFs). Although AFFs can be devastating, BPs have decreased the number of low-energy hip fractures as well as the number of vertebral and non-vertebral fractures that occur each year.Many trials and population-based studies have assessed the association between AFF and BP, and several studies have attempted to establish AFF's true incidence. We will summarize a few of the major studies and discuss their strengths and limitations. The findings of an association between BPs and AFFs have been variable and may reflect sample selection and measurement bias.AFFs are uncommon; the increase in risk associated with BP use is very small and does not outweigh the benefit of fracture prevention in patients with OP. Evidence for the efficacy of BPs for the prevention of fractures in postmenopausal women with OP is very strong, and the current clinical practice of using BPs as first-line therapy for these patients should be continued. Further information is required to determine the appropriate duration and time of discontinuation of BP therapy.
PMID: 24476604
ISSN: 0890-5339
CID: 779582
