Faculty Bibliography

Synovial Chondromatosis (SC) is a rare, benign synovial growth most frequently involving the knee or hip joint. Common presenting symptoms include pain throughout the affected joint, reduced range of motion and a palpable mass. We present an unusual case of SC presenting with symptoms of chronic venous stasis ulcer. A 49-year-old patient presented with swelling, hyperpigmentation and ulcerations of his right lower extremity. Work-up including duplex and CT scan revealed a calcified mass in the hip joint, highly suspicious for Synovial Chondromatosis. A joint surgical approach from a Vascular and Orthopaedic surgeon successfully removed the growths and decompressed the surrounding vessels. The mass effect of the SC on overlying veins resulted in obstruction of venous return due and subsequent venous stasis ulcerations and symptoms of venous hypertension. We present this case due to the unique vascular sequelae related to the Synovial Chondromatosis in order to explore this as a new diagnosis to consider in patients who present with venous stasis ulceration and radiographic findings consistent with SC.

This article aims to provide a systematic review of the limited literature and clinical knowledgebase available on the Hoffa fractures. It is inclusive of the normal anatomy, pathology, diagnosis, treatment options comprising of non-operative and operative protocols, and postoperative findings.

OBJECTIVES/OBJECTIVE:To compare the efficacy of an infraclavicular single-shot nerve block to a continuous infusion through an OnQ infusion pump for rebound pain (between 12 and 24 hours postoperatively) and postoperative narcotic analgesia requirements in distal radius fractures. DESIGN/METHODS:Prospective randomized control trial. SETTINGS/METHODS:Performed at 2 hospitals affiliated with a large urban academic medical center. PATIENTS/METHODS:Fifty patients undergoing operative fixation of distal radius fractures (OTA/AO type 23B/C). INTERVENTION/METHODS:Patients were randomized to receive either an infraclavicular block as a single shot (SSB group) or a continuous infusion through an OnQ pump (OnQ group). MAIN OUTCOME MEASURES/METHODS:Visual analog scale (0-10) pain levels and amount of pain medication taken. RESULTS:At all time points after discharge, mean postoperative pain scores were lower in the OnQ group versus the SSB group but did not reach statistical significance. At 12 hours postoperatively, the SSB group and OnQ group pain scores, respectively, were 5.2 and 4.1 (P = 0.1615). At 24 hours, the pain scores for the SSB and OnQ group, respectively, were 5.4 and 4.8 (P = 0.1918). At these same time points, the Percocet taken were the same at 1.3 and 2.3 (P = 0.8328 and 0.8617). Overall 5 of 24 patients in the OnQ group had pump malfunctions with 4 being removed before 48 hours. CONCLUSION/CONCLUSIONS:OnQ pump is not associated with statistically improved postoperative pain control compared with a single nerve block for distal radius fractures and did not address rebound pain. LEVEL OF EVIDENCE/METHODS:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION/BACKGROUND:The population of patients in the USA over the age of 65 is expected to significantly increase over the next 40 years. These patients are at increased risk for hip fractures and will pose a burden to providers in the near future. In order to provide high value care, providers will need to maintain positive outcomes, mitigate complications, and reduce overall cost burdens. This study was designed to investigate the safety and efficacy of a patient transfer protocol between a large academic medical center and a single specialty orthopaedic institution. The protocol was, in turn, designed to provide high value care to the patients by safely redirecting a large volume of patients to the single specialty institution. MATERIALS AND METHODS/METHODS:Over one calendar year, data was prospectively gathered on all patients admitted to our academic center's ER with hip fractures. Patients were then triaged to high or low risk for transfer according to an established set of medical criteria. Patients deemed low risk for transfer were sent to our single specialty orthopaedic institution for management. Data capture and analysis were completed using MS Excel and SPSS, respectively. RESULTS:Patients treated at the single specialty orthopaedic institution experienced shorter overall hospital stays and were more likely to be discharged to home than a rehabilitation facility (6.35 versus 8.79 days, p < 0.0001; 22% versus 4%, p = 0.49). There was no significant delay in time to surgery for patients that were transferred (65 versus 79 hours, p = 0.18). CONCLUSION/CONCLUSIONS:The transfer protocol was both safe and effective for patients with hip fractures. Transferring patients for treatment at single specialty institutions has the potential to significantly reduce hospital stays and is more likely to result in discharge to home than a rehabilitation facility, thus successfully providing high value care to patients.

PURPOSE: Rib fractures are a common chest injury that can typically be treated nonoperatively. However, a percentage of these will go on to nonunion, either because of unique characteristics of the fracture itself or because of a variety of poor healing factors of the host. If a patient has continued symptomology beyond 3 months, surgeons may consider operative management. METHODS: Although isolated resection of fibrous scar tissue from the nonunion site may be sufficient in some cases, it may also be necessary to provide additional structural integrity to the rib depending on the extent of the fracture pattern and resection. This goal can be achieved operatively with rib plating and bone grafting to promote healing. RESULTS: This video demonstrates the use of plating in the treatment of rib nonunion. It begins with relevant background information on rib fractures and nonunions, then details the approach, open reduction and internal fixation of 3 ribs using plates and bone graft aspirate. Pearls and pitfalls are included during the surgical technique aspect of the video to both help guide surgeons new to the procedure and provide potentially advantageous technical details to more experienced surgeons.

OBJECTIVES: To document the complications among obese patients who underwent surgical fixation for intertrochanteric femur (IT) fractures and to compare with nonobese patients. DESIGN: Retrospective cohort study. SETTING: Four level I trauma centers. PATIENTS: 1078 IT fracture patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Patient and fracture characteristics, surgical duration, surgical delay intraoperative and postoperative complications, inpatient mortality, and length of stay. METHOD: A retrospective review at 4 academic level I trauma centers was conducted to identify skeletally mature patients who underwent surgical fixation of intertrochanteric fractures between June 2008 and December 2014. Descriptive data, injury characteristics, OTA fracture classification, and associated medical comorbidities were documented. The outcomes measured included in-hospital complications, length of stay, rate of blood transfusion, change in hemoglobin levels, operative time, and wound infection. RESULTS: Of 1078 unique patients who were treated for an IT fracture, 257 patients had a Body mass index (BMI) of 30 or greater. Patients with a high BMI (>/=30) had a significantly lower mean age (73 vs. 77 years, P < 0.0001), higher percentage of high-energy injuries (18% vs. 9%, P = 0.0004), greater mean duration of surgery (96 vs. 86 minutes, P = 0.02), and higher mean length of stay (6.5 vs. 5.9 days, P = 0.004). The high-BMI group (n = 257) had significantly higher percentages of patients with complications overall (43% vs. 28%, P < 0.0001), respiratory complications (11% vs. 3%, P < 0.0001), electrolyte abnormalities (4% vs. 2%, P = 0.01), and sepsis (4% vs. 1%, P = 0.002). Patients with BMI >/= 40 had a much higher rate of respiratory complications (18%) and wound complications (5%) than obese (BMI: 30-39.9) and nonobese patients (BMI < 30). CONCLUSION: Intertrochanteric hip fracture patients with a BMI of >30 kg/m are much more likely to sustain systemic complications including respiratory complications, electrolyte abnormalities, and sepsis. In addition, morbidly obese patients are more likely to sustain respiratory complications and wound infections than obese (BMI: 30-39.9 kg/m) and nonobese patients (BMI: < 30 kg/m). The findings from this study can help direct surgeons in the counseling to obese patients and their family, and perhaps increase hospital reimbursement for this group of patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fracture management in pregnant patients is challenging. Anatomic and physiologic changes in pregnancy increase the complexity of treatment. Maternal trauma increases the risk of fetal loss, preterm birth, placental abruption, cesarean delivery, and maternal death. Initial resuscitation and treatment in a facility equipped to handle the orthopaedic injury and preterm births are paramount. Pelvic and acetabular injuries are potentially life threatening. The benefits and risks of surgical treatment must be carefully considered. The risks posed by anesthetic agents, antibiotic agents, anticoagulant agents, and radiation exposure must be understood. Positioning of the patient can affect the viability of the fetus. If surgery is necessary, the left lateral decubitus position decreases fetal hypotension. A specialized team including an obstetrician, perinatologist, orthopaedic surgeon, general trauma surgeon, critical care specialist, emergency medicine specialist, anesthesiologist, radiologist, and nurse must collaborate to improve maternal and fetal outcomes.