Faculty Bibliography

The education of orthopaedic residents is an important responsibility shared by all those involved in residency training. The education of orthopaedic residents begins with the selection process, which recognizes the importance of choosing qualified individuals who can successfully complete the training program. Education during the 5 years of required training entails the acquisition of a body of knowledge, the development of surgical skills, and the exhibition of a level of professionalism consistent with being a physician and surgeon. Residency training also requires an evaluation of performance and, when necessary, measures to improve performance or correct inappropriate behaviors. The goal at the end of the 5-year training period is to have well-qualified, skilled, and knowledgeable orthopaedic surgeons who can enter practice and provide the highest level of patient care.

PURPOSE: To report radiographic, clinical, and patient-based functional outcomes following contemporary operative treatment of patients who sustained an open distal radius fracture and compare them to a similar group of patients treated operatively for closed distal radius fractures. METHODS: Over five years, 601 patients with a distal radius fracture presented to our academic medical center, including one Level 1 trauma hospital, and were prospectively enrolled in an upper extremity trauma database. Patients with open distal radius fractures underwent irrigation, debridement, and operative fixation within 24 hours of presentation. Closed distal radius fractures requiring operative fixation were treated electively. Retrospective review of the database identified eighteen open fractures of the distal radius (11 type I, 6 type II, 1 type IIIa). The open fracture patients were individually matched with eighteen closed distal radius fracture patients who underwent surgical fixation based on age, sex, injury to dominant extremity, fracture pattern, and method of fracture fixation. Clinical, radiographic, patient- based functional outcomes, and complications were recorded at routine postoperative intervals. RESULTS: Follow-up was greater than 77% in both groups at all time points. The open and closed groups were similar in regards to age, gender, BMI, race, tobacco use, income, employment status, hand dominance, injury to dominant extremity, mechanism of injury, fracture classification, method of fracture fixation, and presence of concomitant injury. Postoperative complications and reoperation rates were similar between the open and closed groups. Union rates and radiographic alignment one year postoperatively were similar between the open and closed fracture groups. At final follow-up, range of motion parameters, grip strengths, DASH indices, and subjective pain scores were similar between both groups. DISCUSSION: Open distal radius fractures treated with early debridement and fixation achieved similar outcomes to surgically treated closed fractures of the distal radius when followed for a year or more postoperatively.

BACKGROUND: One of the most catastrophic outcomes following total knee arthroplasty (TKA) is a chronic periprosthetic infection with concomitant failure of the knee extensor mechanism. This study retrospectively reviewed the clinical records of 7 patients who were treated with a 6 axis circular external fixation frame (Taylor Spatial Frame (TSF)) for this condition. Fusion was achieved in 5 of 7 patients (71%) at an average of 8.4 months after surgery. Complications occurred in the treatment of 5 of 7 patients (71%). Infection was controlled in all cases. The TSF presents another valuable tool, which the orthopaedic surgeon should consider when treating these difficult cases. PURPOSE: To evaluate the use of the Taylor Spatial Frame (TSF) to achieve knee arthrodesis in patients with chronically infected total knee arthroplasties (TKAs) with concomitant failure of the knee extensor mechanism. METHODS: We retrospectively evaluated the clinical records of 7 patients who were referred to our tertiary care orthopaedic medical center with multiple failed knee arthroplasties, chronic draining infection and complete loss of the extensor mechanism. All patients were treated with a similar protocol including, debridement and bony stabilization with an adjustable, 6 axis circular external fixation frame (TSF). Hospital charts were reviewed for sociodemographic information, surgical details, hospital course and complications. Radiographs were reviewed for healing and alignment. Follow up included clinical examination and radiographs. RESULTS: The mean age of the patients was 70.9 years (range, 59 - 83 years) at the time of application of the TSF. There were 3 men and 4 women. The average time between TKA and diagnosis of infection was 30.7 months (range, 2.6 - 67.0 months). The 7 patients had undergone an average of 3.3 prior surgical procedures (range, 2-4 procedures) on the ipsilateral extremity. Fusion was achieved in 5 of 7 patients (71%) at an average of 8.4 months after surgery (range, 6 - 10.5 months). Complications occurred in the treatment of 5 of 7 patients (71%) and included infection at the site of the pin tracks (5 patients), antibiotic- induced acute renal failure (1 patient), wound breakdown requiring flap closure (1 patient), and femur fracture secondary to a fall after placement of the antibiotic spacer but before application of the TSF (1 patient). The 2 patients in whom failure of fusion occurred returned to ambulation with an assistive device. Infection was controlled in all cases. CONCLUSION: Fusion and complication rates in this cohort are comparable to those reported in previous studies using other techniques to achieve external fixation. The TSF is a versatile external fixator that offers another tool, which the orthopaedic surgeon should consider when treating these difficult cases.

Proximal humerus fractures account for approximately 5% of all fractures. It is estimated that due to our aging population, orthopaedic surgeons will see a three-fold increase in proximal humerus fractures over the next 30 years. Internal fixation with locked plating is the current mainstay of treatment for functionally active patients who desire minimal loss of function. A thorough understanding of the indications, techniques, and drawbacks of treatment with internal fixation is essential to achieve the highest quality of patient care.

OBJECTIVES: The purpose of this study was to determine what patient and injury factors are associated with the presence of a meniscus tear in tibial plateau fractures. We also sought to compare functional outcome, pain scores, and range of motion between patient groups with and without meniscal injury. MATERIALS AND METHODS: A total of 99 patients with 101 acute tibial plateau fractures were included in the study cohort. Patients were divided into two groups: those with and without meniscus tears at the time of initial injury. Statistical analysis with Student's t-test for continuous variables and chi square test for categorical variables was performed to compare those with and without a meniscal tear. Logistic regression was performed to identify the variables that predicted the presence of a meniscus tear and repeated ANOVA measures were used to assess functional outcome scores. RESULTS: Fifty-four patients with 56 tibial plateau fractures (55%) were found to have an associated meniscal tear. The average amount of joint depression in this group was 12.3 mm (range: 2.0 to 29.5 mm). The remaining 45 patients with 45 fractures (45%) had an average depression of 5.4 mm (range: 0.0 to 12.8 mm). Degree of tibial plateau depression was the only significant predictor of meniscal injury. CONCLUSIONS: Our findings suggest that amount of depression in tibial plateau fractures is a significant predictor of the occurrence of a meniscus tear with an odds ratio of 1.36. We also found no significant difference in the functional outcome, pain scores, and knee range of motion between the group with and without meniscus tears at the longest follow-up interval. These findings suggest that acute repair of meniscal injury following traumatic fracture of the tibial plateau could produce functional results similar to those patients that did not sustain a meniscus tear.

PURPOSE: The purpose of this study was to evaluate the efficacy of sugar tongs splints to maintain reduction of pediatric distal radius and distal both bones forearm fractures compared to acute casting. MATERIALS AND METHODS: The trauma database of an urban level-one trauma center was queried for skeletally immature patients who had sustained a displaced extraphyseal distal radius fracture. Inclusion criteria included: complete radiographs, skeletal immaturity, and presence of a displaced fracture of the radius within the metaphyseal segment, proximal to the distal radial physis, with or without an associated ulna fracture. All patients were seen in the emergency department and treated with a standardized protocol of closed reduction and immobilization. All radiographs were reviewed for initial and residual displacement. Baseline demographic data was also collected, including age at time of injury, handedness, and mechanism of injury. Need for operative intervention and associated complications were noted. All fractures were followed until union. RESULTS: Thirty-three patients were treated with closed reduction and immobilization in a sugar tongs splint, 10 patients were acutely casted, and 2 patients were placed into a short arm volar splint. Twenty-five patients who were initially splinted were treated to completion without the need for operative intervention. Eight of the patients treated with sugar tongs splints (24%) required surgery. Eight patients who were initially casted were treated to completion closed. Two of the patients who were initially casted (22%) required operative intervention for loss of reduction. Both of the patients who were initially immobilized using a volar splint were treated to completion without operative intervention. There was no statistically significant difference in the need for operative intervention amongst these groups. CONCLUSIONS: This study demonstrates that use of closed reduction and placement of a sugar tongs splint can effectively maintain reduction of extraphyseal distal radius fractures with rates of displacement similar to that seen with acute casting.

OBJECTIVES: : Recombinant human parathyroid hormone (PTH 1-34) has been previously shown to enhance fracture healing in animal models. Here, we sought to determine whether the systemic administration of PTH 1-34 is effective in preventing atrophic fracture nonunion in a murine, surgical nonunion model. METHODS: : We used an established reproducible long-bone murine fracture nonunion model by generating a midshaft femur fracture, followed by fracture distraction using an intramedullary pin and custom metallic clip to maintain a fracture gap of 1.7 mm. Mice were randomized to receive either daily intraperitoneal injections of 30 mug/kg PTH 1-34 for 14 days or saline injections. At 6 weeks after the procedure, radiographic and histologic assessment of fracture healing was performed. RESULTS: : At 6 weeks after surgery, the group treated with PTH showed higher rates of bony union (50% vs 8%; P < 0.05) as assessed by radiographic analysis. Mean gap size was also significantly lower in the PTH group (1.42 vs 0.36 mm in the control group; P < 0.05). Histologic analysis of atrophic nonunions in the control group revealed a persistent fracture gap with intervening fibrous tissue. In contrast, healed subjects in the PTH-treated group had cortical bridging with mature bone and relatively little callus, which is consistent with primary intramembranous ossification. CONCLUSIONS: : Daily systemic administration of recombinant PTH 1-34 increased the rate of union in a mouse atrophic nonunion model. This may have important implications for the potential clinical role of PTH 1-34 in the treatment of atrophic fracture nonunions.

OBJECTIVES: : The purpose of this study was to compare the outcome after the operative treatment of patella fractures (PFs) as compared with those of quadriceps tendon and patella tendon (PT) ruptures. DESIGN: : This pertains to a retrospective case control. SETTING: : The setting was in academic teaching hospitals. PATIENTS: : Ninety-four patients with 99 extensor mechanism disruptions were treated operatively. Of these, 50 (50%) were PFs; 36 (37%) were quadriceps ruptures; and 13 (13%) were PT ruptures. MAIN OUTCOME MEASURES: : The patients were evaluated at 6 and 12 months and were tested for range of motion, quadriceps circumference and strength, SF36, Lysholm, and Tegner outcome scores by independent observers. Radiographs of the knee were obtained to assess bony healing, posttraumatic arthritis, and heterotopic ossification RESULTS: : A minimum of 12-month follow-up (range 12-81 months) was available for 76 patients (77%). PFs were seen more commonly in women (P < 0.001) and PT ruptures tended to occur in younger males (P < 0.001), with no difference in the body mass index. Thigh circumference was significantly smaller than normal in PFs at 1 year as compared with tendon injuries. At latest follow-up, there were no significant differences noted with respect to knee range of motion, radiographic arthritis, Tegner, Lysholm, or SF36 scores. CONCLUSIONS: : There were no significant differences with regard to outcome in patients sustaining these injuries. LEVEL OF EVIDENCE: : Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.