Faculty Bibliography

The Accreditation Council of Graduate Medical Education requires that residency programs teach and assess trainees in six core competencies. Assessments are imperative to determine trainee competence and to ensure that excellent care is provided to all patients. A structured, direct observation program is feasible for assessing nontechnical core competencies and providing trainees with immediate constructive feedback. Direct observation of residents in the outpatient setting by trained faculty allows assessment of each core competency. Checklists are used to document residents' basic communication skills, clinical reasoning, physical examination methods, and medical record keeping. Faculty concerns regarding residents' professionalism, medical knowledge, fatigue, or ability to self-assess are tracked. Serial observations allow for the reinforcement and/or monitoring of skills and attitudes identified as needing improvement. Residents who require additional coaching are identified early in training. Progress in educational milestones is recorded, allowing an individualized educational program that ensures that future orthopaedic surgeons excel across all domains of medical and surgical competence.

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: 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: This video presents the digitized, original, reel-to-reel footage of Victor Frankel's groundbreaking 1960s experiments demonstrating the viscoelastic properties and fracture mechanics of loaded bone. As can be seen, novel instrumentation was used that resulted in an easily reproducible method of controlling bone loading rates. The innovation, and associated experiments, radically advanced our understanding of the mechanisms of acute fractures and bone's response to energy. METHODS: Using the "Standard Torsion Testing Machine" that he helped design, the author explains how the mechanical and functional properties of bone are affected by various defects. Examples used include an intact dog femur, a femur with a hole in the cortex, and a femur with an open section defect. Slow motion depiction allows the viewer to appreciate the potential soft tissue damage associated with bone fragmentation and how this varies with energy input. The video concludes with a demonstration of the effect of torsional motion on the vasculature. RESULTS: Graphs produced by the torsion tester display torque versus angular deformation plots for each experiment. These illustrate the relationship between bone structure, fracture, and energy. The x-ray contrast segment provides an example of associated arterial damage secondary to a fracture. CONCLUSION: This previously unreleased piece of orthopaedic history provides viewers with perspective on the early days of biomechanical study and an easy-to-understand tutorial on acute fracture mechanics and the role of energy in injury.

In end stage renal disease (ESRD) patients on hemodialysis (HD), it is known that renal bone disease has a negative impact on postoperative complication rate of fracture repair compared to non-ESRD patients. Previous studies have examined complications following surgical hip fracture repair in ESRD patients on HD. However, there is paucity of information outside of hip fracture repair. This study was undertaken to investigate complications associated with surgical fracture repair in ESRD patients on hemodialysis and to compare quality measures with a control group for various fracture types. Data of all consecutive ESRD patients on HD was collected prospectively starting in 2013. Charts of 2,558 ESRD patients on HD from 2010 to 2013 were also reviewed. Thirty-four patients who underwent surgical fracture repair were included in the study. Additionally, 1,000 patients without ESRD who underwent fracture repair were also identified, and a random sample of 267 patients was selected for inclusion as a control group. Primary outcomes were major complications as defined by the Clavien-Dindo complication rating system for orthopaedic surgery. Secondary outcomes were minor complications, defined by the same method. Demographic information and hospital quality measures, such as hospital length of stay (LOS) and discharge disposition, were also collected. There were no differences between the two groups in terms of BMI, ethnicity, or gender distribution. The ESRD patients were older than control patients (62.6 versus 46.8 years; p > 0.01). Overall, the complication rate in the ESRD group was 14.7% compared to 3% in the control group (p < 0.05) while the rate of major complications was similar (5.8% versus 2.2%, p = 0.2). The rate of minor complications was higher in the ESRD group though this did not reach statistical significance (8.8% versus 1%, p = 0.07). Median LOS was significantly higher in the ESRD group (15.9 versus 6.4 days; p < 0.01), and patients in the ESRD group were less likely to be discharged to home (29.4% versus 78%; p < 0.01). Surgical fracture repair in ESRD patients can be performed with similar major complication rate as a control group. However, the higher rate of minor complications and poorer hospital quality measures in the ESRD group must be taken into account as we move toward "pay for performance" and bundled payment initiatives for orthopaedic trauma patients.

BACKGROUND: Despite frequent complaints by orthopaedic trauma patients, to our knowledge there is no data regarding weather's effect on pain and function following acute and chronic fracture. The aim of our study was to investigate the influence of daily weather conditions on patient reported pain and functional status. METHODS: We retrospectively examined prospectively collected data from 2369 separate outpatient visits of patients recovering from operative management of acute tibial plateau fractures, acute distal radius fractures, and chronic fracture nonunions. Pain and functional status were assessed using a visual analogue scale (VAS) and the DASH and SMFA functional indexes. For each visit date, the mean temperature, difference between mean temperature and expected temperature, dew point, mean humidity, amount of rain, amount of snow, and barometric pressure were recorded. Statistical analysis was run to search for associations between weather data and patient reported pain and function. RESULTS: Low barometric pressure was associated with increased pain across all patient visits (p=0.007) and for patients at 1-year follow-up only (p=0.005). At 1-year follow-up, high temperature (p=0.021) and high humidity (p=0.030) were also associated with increased pain. No significant association was noted between weather data and patient reported functional status at any follow-up interval. CONCLUSIONS: Patient complaints of weather influencing pain after orthopaedic trauma are valid. While pain in the immediate postoperative period is most likely dominated by incisional and soft tissue injuries, as time progresses barometric pressure, temperature, and humidity impact patient pain levels. Affirming and counseling that pain may vary based on changing weather conditions can help manage patient expectations and improve satisfaction.

OBJECTIVE: To examine the potential benefits and risks associated with weight-bearing after intramedullary (IM) nailing of unstable tibial shaft fractures. DESIGN: Randomized controlled trial. SETTING: Two New York State level 1 trauma centers, one level 2 trauma center, and 1 tertiary care orthopaedic hospital in a large urban center in New York City. PATIENTS/PARTICIPANTS: Eighty-eight patients with 90 tibial shaft fractures were enrolled. The following were used as inclusion criteria: (1) skeletally mature adult patients 18 years of age or older, (2) displaced fractures of tibial diaphysis (OTA type 42) treated with operative intervention, and (3) radiographs, including injury, operative, and completion of follow-up. Sixty-eight patients with 70 tibial shaft fractures completed follow-up. INTERVENTION: All patients were treated with locked IM nailing. Patients were randomized to 1 of 2 groups: immediate weight-bearing-as-tolerated (WBAT) or non-weight-bearing for the first 6 postoperative weeks (NWB). MAIN OUTCOME MEASURES: Fracture union or treatment failure/revision surgery. RESULTS: There was no statistical difference in the observed time to union between groups (WBAT = 22.1 +/- 11.7 weeks vs. NWB = 21.3 +/- 9.9 weeks; P = 0.76). Rates of complications did not statistically differ between groups. No fracture loss of reduction leading to malunion was encountered. Short Musculoskeletal Function Assessment scores for all domains did not statistically differ between groups. CONCLUSIONS: Immediate weight-bearing after IM nailing of tibial shaft fractures is safe and is not associated with an increase in adverse events or complications. Patients should be allowed to bear weight as tolerated after IM nailing of OTA subtype 42-A and 42-B tibial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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

Rumpel-Leede phenomenon is a rare clinical sign involving the appearance of purpura after application of a tourniquet or in noninvasive arterial blood pressure monitoring. This sign has been most commonly associated with hypertensive and diabetic microvascular fragility and thrombocytopenia. We describe a case of Rumpel-Leede phenomenon in an otherwise healthy patient with positive laboratory markers for Sjogren disease, a previously undescribed relationship. We aim to inform physicians of this potential complication in patients with Sjogren disease and suggest special consideration be given to patients with autoimmune diseases with secondary vascular or dermal manifestations.

OBJECTIVES: To evaluate long-term clinical and radiographic outcomes following surgical fixation of unstable ankle fractures. DESIGN: Prospective follow-up study. SETTING: Academic medical center with two Level-I trauma centers and a tertiary care center. PATIENTS: One hundred forty-one patients who underwent surgical repair of an unstable ankle fracture. INTERVENTION: Open reduction internal fixation of an unstable ankle fracture. MAIN OUTCOME MEASUREMENTS: Short Musculoskeletal Function Assessment (SMFA) scores and radiographic outcomes based on the van Dijk criteria at a mean of 11.6 years follow-up. RESULTS: Of the 281 patients meeting the inclusion criteria for this study, follow-up data was obtained from 141 patients (50%), at a mean of 11.6 years following surgery. Overall, mean long-term SMFA scores were improved when compared to scores at 1-year. ASA Class 1 or 2 was found to be a significant predictor of recovery based on SMFA scores. Sixty-three percent of follow-up radiographs demonstrated evidence of radiographic arthritis, including 31% with mild osteoarthritis, 22% with moderate osteoarthritis, and 10% with severe osteoarthritis. Fracture-dislocation at injury was found to be a significant predictor of radiographic posttraumatic osteoarthritis at latest follow-up. One patient (0.7%) underwent a tibiotalar fusion secondary to symptomatic posttraumatic arthrosis. One patient (0.7%) underwent total ankle replacement due to severe osteoarthritis. CONCLUSIONS: Our data indicate that over a decade after ankle fracture fixation, the majority of patients are doing well. Despite the presence of radiographic arthritis in 63% of patients, few experience pain or have restrictions in function, and mean long-term functional outcome scores are improved when compared to scores at 1-year. Patients undergoing operative fixation of unstable ankle fractures can anticipate functional outcomes that are maintained over time. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.