Faculty Bibliography

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.

Preoperative planning is an essential prerequisite for the success of orthopaedic procedures. Traditionally, the exercise has involved the written down, step by step "blueprint" of the surgical procedure. Preoperative planning of the technical aspects of the orthopaedic procedure has been performed on hardcopy radiographs using various methods such as copying the radiographic image on tracing papers to practice the planned inter - ventions. This method has become less practical due to variability in radiographic magnification and increasing implementation of digital imaging systems. Advances in technology along with recognition of the importance of surgical safety protocols resulted in widespread changes in orthopaedic preoperative planning approaches. Nowa - days, perioperative "briefings" have gained particular importance and novel planning methods have started to integrate into orthopaedic practice. These methods include using software that enables surgeons to perform preoperative planning on digital radiographs and to construct 3D digital models or prototypes of various orthopaedic pathologies from a patient's CT scans to practice preoperatively. Evidence-to-date suggests that preoperative planning and briefings are effective means of favorably influencing the outcomes of orthopaedic procedures.

OBJECTIVE: To characterize the timing, indications, and "success rates of secondary interventions, dynamization and exchange nailing, in a large series of tibial nonunions" (dynamization and exchange nailing are types of secondary interventions). SETTING: Retrospective multicenter analysis from level 1 trauma hospitals. PATIENTS: A total of 194 tibia fractures that underwent dynamization or exchange nailing for delayed/nonunion. INTERVENTION: Records and radiographs to characterize demographic data, fracture type, and cortical contact after tibial nailing were gathered. The radiographic union score for tibias (RUST) and the timing of intervention and time to union were calculated. MAIN OUTCOME MEASURES: The primary outcome was success of either intervention, defined as achieving union, with the need for further intervention defining failure. Other outcomes included RUST scores at intervention and union, and timing to intervention and union for both techniques. Two-tailed t tests and Fisher exact with P set at <0.05 for significance were used as indicated. RESULTS: A total of 194 tibia fractures underwent dynamization (97) or exchange nailing (97). No statistical differences were found between groups with demographic characteristics. The presence of a fracture gap (P = 0.01) and comminuted fractures (P = 0.002) was more common in the exchange group. The success rates of the interventions and RUST scores were not different when performed before versus after 6 months; therefore, data were pooled. The RUST scores at the time of intervention were not different for successful or failed dynamizations (7.13 vs. 7.07, P = 0.83) or exchanges (6.8 vs. 7.3, P = 0.37). Likewise, the time to successful versus failed dynamization (165 vs. 158 days, P = 0.91) or exchange nailing (224 vs. 201 days, P = 0.48) was not different. No cortical contact or a gap was a statistically negative factor for both exchange nails (P = 0.09) and dynamizations (P = 0.06). When combined, the success in the face of a gap was 78% versus 92% when no gap was present (P = 0.02). CONCLUSIONS: Previous literature has few reports of the success rates of secondary interventions for tibial nonunions. The indications for dynamization and exchange were similar. Comminuted fractures, and fractures with no cortical contact or "gap" present after intramedullary nailing, favored having an exchange nail performed over dynamization. Fracture gap was also found to be a negative prognostic factor for both procedures. Overall, this study demonstrates high rates of union for both interventions, making them both viable options. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute fractures, nonunions, and nonunions with bone defects or osteomyelitis often need bone graft to facilitate union. There are several factors to consider when it is determined that a bone graft is needed. These factors include the source of the bone graft (autograft vs. allograft), proper timing for placement of the bone graft, strategies to avoid further complications (particularly in the setting of osteomyelitis), and with the development of a variety of bone graft substitutes, whether alternatives to autograft are available and appropriate for the task at hand. Autograft bone has commonly been referred to as the "gold standard" of bone grafts, against which the efficacy of other grafts has been measured. The best timing for when to place a bone graft or substitute is also somewhat controversial, particularly after an open fracture or a potentially contaminated bed. The treatment of infected nonunions, particularly those that require a graft to facilitate healing, can be quite challenging. Typically, the infection is completely eradicated before placement of a bone graft, but achieving a sterile bed and the timing of a bone graft require strategic thinking and planning. This review outlines the benefits of autografts, the most suitable sites for harvesting bone grafts, the timing of bone graft procedures, the potential risks and benefits of grafting in the face of infection, and the currently available bone graft extenders.

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.

INTRODUCTION: Participants who sustain a fragility fracture are at increased risk for subsequent fractures. Despite the consequences of recurrent fractures, bone mineral density (BMD) testing and treatment rates for osteoporosis after a fracture remain low. The New York University (NYU) Langone Osteoporosis Model of Care was developed to identify women at increased risk for recurrent fractures and to reduce the rates of subsequent fracture through patient and physician education. METHODS: Women aged 50 years and older who had a fracture and received their care at NYU affiliated hospitals were contacted via mail after discharge. Participants were provided educational materials explaining decreased bone strength and its possible relationship to their fracture and were asked to complete a questionnaire. One year postfracture, participants were sent follow-up questionnaires requesting their most recent fracture treatment and BMD information. Educational material was also provided to the treating orthopedic surgeons. RESULTS: Overall, 524 patients were contacted and 210 (40%) enrolled. By the end of 24 months, 92 participants completed their 1-year questionnaire (44% of the enrollees). Forty-two (46%) participants had undergone new BMD testing and 37 (40%) were receiving antiresorptive medications, including 6 (6%) who had not been prescribed these medications before enrolling in the program. CONCLUSIONS: The Osteoporosis Model of Care is a simple and cost-effective educational program, which improved comprehensive fracture care in an actual clinical setting. Patient enrollment remains a challenge in implementing the program. Our program highlights difficulties in providing community-dwelling participants with appropriate postfracture care. With increasing concern among the public regarding the use of bone strengthening medications and continued low postfracture treatment rates, educating patients with high fracture risk is critical to reducing the rate of subsequent fracture. Our Model of Care Program demonstrates both the success and limitations of a postfracture educational approach using discharge diagnosis data to identify patients with fracture.

OBJECTIVES: To evaluate the impact of diabetes mellitus (DM) and associated complications on cost, length of stay, and inpatient mortality after open reduction internal fixation (ORIF) of an ankle fracture, and the implications of these variables during a time of health care payment reform. DESIGN: Retrospective study. SETTING: The Statewide Planning and Research Cooperative System database, which includes all admissions to New York State hospitals from 2000 to 2011. PATIENTS/PARTICIPANTS: A total of 58,748 patients were identified as having undergone the primary procedure of ORIF of the ankle (ICD-9-CM procedure code 79.36). INTERVENTION: ORIF of the ankle. MAIN OUTCOME MEASURE: Cost, length of stay, and inpatient mortality. RESULTS: Of the 58,748 patients evaluated, 7501 (12.8%) had DM. Mean length of stay and total hospital charges were significantly greater for the DM cohort compared to the without DM cohort (P < 0.01). Patients with DM had greater Charlson Comorbidity Index scores and greater in-hospital mortality than patients without DM (both P < 0.01). Of the patients with diabetes, 1098/7501 had complicated diabetes mellitus (C-DM). Patients with C-DM stayed 2.4 days longer and were $6895 more costly than those with diabetes alone (both P < 0.01). Patients with C-DM also had a significantly higher in-hospital mortality rate than those with diabetes alone. CONCLUSIONS: Patients with diabetes admitted to the hospital for ankle ORIF have more expensive hospital stays and higher in-hospital mortality rates than patients without diabetes. The presence of diabetic complications further increases these risks. These data will help provide risk-adjustment for future health care payment reform initiatives. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

This review summarizes symposium presentations from the OTA's Basic Science Focus Forum on care for osteoporotic fractures. The limitations of diaphyseal osteoporotic animal bone models are discussed, together with the potential benefits of using metaphyseal models to study osteoporotic fracture fixation constructs. Metaphyseal bone repair models provide better simulation of the most common osteoporotic fractures. Selection of an osteoporotic model for mechanical testing is also challenging. One should always thoroughly define the clinical problem to be addressed. The selected model should then be validated for behavior matched to known clinical behavior with known fixation configurations. The medical management of osteoporosis is directed at enhancing bone mass, improving bone quality, and lowering fracture risk. Medical strategies to achieve these goals are discussed. The medical strategy should include provision of an adequate calcium and vitamin D environment to facilitate well-mineralized bone and improve bone quality, prevent excessive bone resorption, and provide an anabolic stimulus to enhance bone formation. Atypical femur fractures continue to be a serious issue for the orthopaedic community. Risk factors, treatment modalities, and prevention strategies are discussed. A comprehensive strategy for the improved treatment of osteoporotic fractures must address both biological and mechanical issues and includes 4 specific approaches: (1) removal of inhibitors to bone healing; (2) introduction of bone healing stimulants; (3) modification of fracture fixation constructs; and (4) application of bone augmentation or substitutes. There is currently no optimal bone substitute. Substitutes should be chosen based on the most critical need when treating a particular fracture.

OBJECTIVE: To determine the reliability of the Radiographic Union Scale for Tibia (RUST) score and a new modified RUST score in quantifying healing and to define a value for radiographic union in a large series of metadiaphyseal fractures treated with plates or intramedullary nails. DESIGN: Healing was evaluated using 2 methods: (1) evaluation of interrater agreement in a series of radiographs and (2) analysis of prospectively gathered data from 2 previous large multicenter trials to define thresholds for radiographic union. INTERVENTION: Part 1: 12 orthopedic trauma surgeons evaluated a series of radiographs of 27 distal femur fractures treated with either plate or retrograde nail fixation at various stages of healing in random order using a modified RUST score. For each radiographic set, the reviewer indicated if the fracture was radiographically healed. Part 2: The radiographic results of 2 multicenter randomized trials comparing plate versus nail fixation of 81 distal femur and 46 proximal tibia fractures were reviewed. Orthopaedic surgeons at 24 trauma centers scored radiographs at 3, 6, and 12 months postoperatively using the modified RUST score above. Additionally, investigators indicated if the fracture was healed or not healed. MAIN OUTCOME MEASURES: The intraclass correlation coefficient (ICC) with 95% confidence intervals was determined for each cortex, the standard and modified RUST score, and the assignment of union for part 1 data. The RUST and modified RUST that defined "union" were determined for both parts of the study. RESULTS: ICC: The modified RUST score demonstrated slightly higher ICCs than the standard RUST (0.68 vs. 0.63). Nails had substantial agreement, whereas plates had moderate agreement using both modified and standard RUST (0.74 and 0.67 vs. 0.59 and 0.53). UNION: The average standard and modified RUST at union among all fractures was 8.5 and 11.4. Nails had higher standard and modified RUST scores than plates at union. The ICC for union was 0.53 (nails: 0.58; plates: 0.51), which indicates moderate agreement. However, the majority of reviewers assigned union for a standard RUST of 9 and a modified RUST of 11, and >90% considered a score of 10 on the RUST and 13 on the modified RUST united. CONCLUSIONS: The ICC for the modified RUST is slightly higher than the standard RUST in metadiaphyseal fractures and had substantial agreement. The ICC for the assessment of union was moderate agreement; however, definite union would be 10 and 13 with over 90% of reviewers assigning union. These are the first data-driven estimates of radiographic union for these scores.

Increasing attention has been placed on providing higher quality and safer patient care. This requires the development of a new set of competencies to better understand and navigate the system and lead the orthopaedic team. While still trying to learn and develop these competencies, the academic orthopaedist is also expected to model and teach them.The orthopaedic surgeon must understand what is being measured and why, both for purposes of providing better care and to eliminate unnecessary expense in the system. Metrics currently include hospital-acquired conditions, "never events," and thirty-day readmission rates. More will undoubtedly follow.Although commitment and excellence at the individual level are essential, the orthopaedist must think at the systems level to provide the highest value of care. A work culture characterized by respect and trust is essential to improved communication, teamwork, and confidential peer review. An increasing number of resources, both in print and electronic format, are available for us to understand what we can do now to improve quality and safety.Resident education in quality and safety is a fundamental component of the systems-based practice competency, the Next Accreditation System, and the Clinical Learning Environment Review. This needs to be longitudinally integrated into the curriculum and applied parallel to the development of resident knowledge and skill, and will be best learned if resident learning is experiential and taught within a genuine culture of quality and safety.