Faculty Bibliography

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.

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.

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.

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.

OBJECTIVES:: The purpose of this study is to characterize the presentation, size, treatment, and complications of pulmonary embolism (PE) in a large series of orthopaedic trauma patients who developed PE after injury. METHODS:: We reviewed the records of orthopaedic trauma patients who developed a PE within 6 months of injury at 9 trauma centers and 2 tertiary care facilities. RESULTS:: There were 312 patients, 186 men and 126 women, avg age 58. Average BMI was 29.6, avg ISS was 18. 17% received anticoagulation prior to injury, and 5% had a prior history of PE. After injury, 87% were placed on prophylactic anticoagulation; 68% with low molecular weight heparin. 53% of patients exhibited shortness of breath or chest pain. Average heart rate and O2 saturation prior to PE diagnosis were 110 and 94, respectively. 39% had abnormal ABG and 30% had abnormal EKG findings. 89% had CTPA for diagnosis. Most clots were segmental (63%), followed by subsegmental (21%), lobar (9%), and central (7%). The most common treatment was unfractionated heparin and Coumadin (25%). Complications of anticoagulation were common: 10% had bleeding at the surgical site. Other complications of anticoagulation included GI bleed, anemia, wound complications, death, and compartment syndrome. PE recurred in 1%. 4% died of PE within 6 months. CONCLUSIONS:: This is the first large data set to evaluate the course of PE in an orthopaedic trauma population. The complications of anticoagulation are significant and were as common in the patients with lower risk clots as those with higher risk clots. LEVEL OF EVIDENCE:: III (retrospective).

The evolution of locking plates and modern nail constructs provides the orthopaedic trauma surgeon with a myriad of options with regard to implant selection for common fractures. There is a significant amount of biomechanical literature comparing modern constructs with those conventionally used. A basic understanding of this literature is required to make informed decisions with regard to implant selection in the management of these injuries. This article reviews the most recent biomechanical literature regarding implant selection and application for a variety of commonly treated injuries, including fractures of the clavicle, proximal humerus, distal humerus, intertrochanteric hip region, distal femur, and bicondylar tibial plateau.

Distal radius fractures are the most common fracture involving the upper extremity. Despite their frequency, there is a lack of consensus within the orthopedic community regarding indications for operative management of these injuries in the elderly population. An increase in the rate of operative fixation has been cited in the past decade, however, there is no definitive evidence in the literature to support such a trend. Although studies have reported successful functional outcomes with both operative and nonoperative management, the current evidence regarding indications for operative management remains inconclusive due to a lack of large-scale, prospective, randomized trials in the elderly population. Until evidence-based algorithms can be established, treatment decisions must be made based on clinical judgment and risk assessment, while taking into account the functional demands of each patient. 2014 Springer Science+Business Media New York

Pain emanating from an orthopaedic implant can be a difficult problem to identify. Hardware removal frequently is performed with successful results but may not always lead to resolution of all symptoms. A combination of patient history, physical examination, and diagnostic testing should guide management. Proper patient counseling on treatment options and outcomes is equally important to give patients reasonable expectations. The purpose of this review is to summarize the current literature and advise on the most appropriate means to evaluate and treat these patients.