Faculty Bibliography

BACKGROUND: Rotational injuries are the most common and usually classified as per the Lauge Hansen classification; with the most common subgroup being the supination external rotation (SER) mechanism. Isolated fractures of the distal fibula (SE2) without associated ligamentous injury are usually treated with a splint or brace and the patient may be allowed to weight bear as tolerated. This study reports the functional outcomes following a stable, low energy, rotational ankle fracture supination external rotation (SER2) when compared to unstable SER4 fractures treated operatively. MATERIALS AND METHODS: 64 patients who were diagnosed and treated nonoperatively for a stable SER2 ankle fracture were followed prospectively. In the comparison group, 93 operatively treated fibular fractures were extracted from a prospectively collected database and evaluated comparison. Baseline characteristics obtained by trained interviewers at the time of injury included: Patient demographics, short form-36, short musculoskeletal functional assessment (SMFA) and American Orthopedic Foot and Ankle Society (AOFAS) questionnaires. Patients were followed at 3, 6 and 12 months postsurgery. Additional information obtained at each followup point included any complications or evidence on fracture healing. Data were analyzed by the Student's t-test and theFisher's Exact Test to compare demographic and functional outcomes between the two cohorts. P < 0.05 was considered to be significant. RESULTS: The average of patients' age in the stable fracture cohort was 43 versus 45 in the SER4 group. Nearly 64% of the patient population was female when compared with 37% in the operative group. In the SER2 by 6 months all patients had returned to baseline functional status. There were 18 delayed unions (all healed by 6 months). Based on the functional outcome scores all patients had returned to preoperative level. In comparison, SE4 patients had less functional recovery at 3 and 6 months (P < 0.05) based on the SMFA scores and at 3, 6 and 12 months based on the AOFAS (P < 0.001) scores. There was no difference in pain levels between the two groups at all time points. There were three nonunions in the SE4 group and six delayed unions. CONCLUSIONS: An SER2 ankle fracture is a relatively benign injury with functional limitations resolving by 3 months while the need for surgical fixation in SER ankle fractures appears to affect lower extremity function to a greater degree for a longer time period. Patients should be counseled as to these expected outcomes.

Negative pressure wound therapy (NPWT) is a useful management tool in the treatment of traumatic wounds and high-risk incisions after surgery. Since its development nearly 2 decades ago, uses and indications of NPWT have expanded, allowing its use in a variety of clinical scenarios. In addition to providing a brief summary on its mechanism of action, this article provides a focused, algorithmic approach on the use of NPWT by reviewing the available data, the appropriate clinical scenarios and indications, and the specific strategies that can be used to maximize outcomes.

OBJECTIVES:: To empirically define a "delay" for hip fracture surgery based on clinical outcomes, and to identify patient demographics and hospital factors contributing to surgical delay. DESIGN:: Retrospective database analysis. SETTING:: Hospital discharge data. PATIENTS/PARTICIPANTS:: A total of 2,121,215 patients undergoing surgical repair of hip fracture in the National Inpatient Sample (NIS) between 2000 and 2009. INTERVENTION:: Internal fixation or partial/total hip replacement. MAIN OUTCOME MEASUREMENTS:: Logistic regressions were performed to assess the effect of surgical timing on in-hospital complication and mortality rates, controlling for patient characteristics and hospital attributes. Subsequent regressions were performed to analyze which patient characteristics (age, gender, race, comorbidity burden, insurance status, and day of admission) and hospital factors (size, teaching status, and region) independently contributed to the likelihood of surgical delay. RESULTS:: Compared to same-day surgery, each additional day of delay was associated with a significantly higher overall complication rate. However, next-day surgery was not associated with an increased risk of in-hospital mortality. Surgery 2 calendar days (OR: 1.13) and 3+ days (OR: 1.33) following admission was associated with higher mortality rates. Based on these findings, "delay" was defined as surgery performed two or more days after admission. Significant factors related to surgical delay included comorbidity score, race, insurance status, hospital region, and day of admission. CONCLUSIONS:: Surgical delay in hip fracture care contributes to patient morbidity and mortality. A variety of patient and hospital characteristics seem to contribute to surgical delay, and point to important health care disparities. LEVEL OF EVIDENCE:: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE:: To evaluate the ability of surgeons to determine if the fibula is reduced in the sagittal plane in relation to the tibia based upon fluoroscopic images by comparison with the known normal for both the ipsilateral and contralateral ankles. METHODS:: Perfect lateral radiographs of both ankles were obtained in seven cadaveric specimens. The fibula was translated 2.5mm and 5mm in the anterior and posterior directions. Four orthopedic trauma-trained surgeons were presented with a fictitious case consisting of a "normal" image, followed by 10 randomly selected images from both ankles, and were asked to determine if the fibula was reduced, or displaced anteriorly or posteriorly. The ability of the surgeons to identify displacement and inter-observer reliability were assessed. RESULTS:: The surgeons were better able to identify malreduction than reduction (NPV 95% ipsilateral, 85% contralateral). The overall sensitivity for reduction was 94% for the ipsilateral ankle, but only 68% for the contralateral ankle. Anterior displacement and greater magnitudes of displacement were most easily diagnosed. All reviewers had the most difficulty with 2.5mm of posterior displacement. The intraobserver agreement was excellent for anterior displacement and 5mm of displacement in either direction (kappa .71/.75). Surgeons who routinely used the contralateral lateral radiograph were more accurate. CONCLUSIONS:: While it is unknown how much translational displacement of the syndesmosis is acceptable, it seems that the experienced surgeon will be able to reduce the joint within 2.5mm and that fluoroscopic comparisons to the normal ankle are helpful in determining malreduction.

OBJECTIVES: While the posteromedial fragment in tibial plateau fractures is often considered unstable, biomechanical evidence supporting this view is lacking. We aimed to evaluate the stability of the fragment in a cadaver model. Our hypothesis was that under the expected small axial force during rehabilitation and the combined effects of this force with shear force, internal rotation torque and varus moment, the most common posteromedial tibia fragment morphology could maintain stability in early flexion. METHODS: Axial compression force alone or combined with either posterior shear, internal rotation torque, or varus moment was applied to the femurs of five fresh cadaveric knees. A Tekscan pressure mapping system was used to measure pressure and contact area between the femoral condyles, meniscus, and tibial plateau. A Microscribe 3D digitizer was used to define the three-dimensional positions of the femur and tibia. A 10 mm and then a 20 mm osteotomy was created with a saw at an angle of 30 degrees in the axial plane with respect to the tangent of the posterior tibial plateau and 75 degrees in the sagittal plane, representing a typical posteromedial fracture fragment. At each flexion angle (15 degrees , 30 degrees , 60 degrees , 90 degrees , 120 degrees ) and loading condition (axial compression only, compression with shear force, torque, and varus moment), distal displacement of the medial femoral condyle as well as the tibial fracture fragments, were determined. RESULTS: For the 10 mm fragment, medial femoral condyle displacement was little affected up to approximately 30 degrees flexion, after which it increased. For the 20 mm fragment, there was progressive medial femoral condyle displacement with increasing flexion from baseline. However, for the 10mm and 20mm fragments themselves, displacements were noted at every flexion angle, starting at 1.7mm inferior displacement with 15 degrees of flexion and internal rotation torque and up to 10.2mm displacement with 90 degrees flexion and varus bending moment. CONCLUSIONS: In this cadaveric model of a posteromedial tibial plateau fracture, both fracture fragments studied displaced with knee flexion, even at low flexion angles. While such fragments may initially appear non-displaced after injury, posteromedial fragments similar to these tested are likely to displace during knee range of motion exercises in non-weight bearing conditions.

INTRODUCTION: Osteoporosis is a disease of weak bone. Our goal was to determine the measurement reproducibility of magnetic resonance assessment of proximal femur strength. METHODS: This study had institutional review board approval, and written informed consent was obtained from all subjects. We obtained images of proximal femur microarchitecture by scanning 12 subjects three times within 1 week at 3T using a high-resolution 3-D FLASH sequence. We applied finite element analysis to compute proximal femur stiffness and femoral neck elastic modulus. RESULTS: Within-day and between-day root-mean-square coefficients of variation and intraclass correlation coefficients ranged from 3.5 to 6.6 % and 0.96 to 0.98, respectively. CONCLUSION: The measurement reproducibility of magnetic resonance assessment of proximal femur strength is suitable for clinical studies of disease progression or treatment response related to osteoporosis bone-strengthening interventions.

PURPOSE: To describe the features of displaced intra-articular fractures confined to the volar rim of the distal radius and compare outcomes after their operative fixation to complete intra-articular and extra-articular fractures treated with operative fixation. METHODS: A total of 627 distal radius fractures were treated over a 6-year period. Twenty-eight patients had volar rim fractures (type 23-B3, as classified by the Orthopaedic Trauma Association [OTA]), all treated with operative reduction and fixation using a volar buttress plate. Clinical outcome information including radiographs, Short Form-36 health survey, and Disabilities of the Arm, Shoulder, and Hand questionnaire were collected at regular postoperative intervals. Patients with volar rim fractures were compared with patients who sustained other types of operatively managed distal radius fractures (OTA types 23-A, 23-B1/B2, and 23-C). RESULTS: The most common type of volar rim fracture consisted of a single large fragment (OTA 23-B3.2; 46%), followed by comminuted fractures (OTA 23-B3.3; 36%). Restoration of radiographic parameters was similar between groups except for an increased volar tilt in volar rim fractures compared with group 23-B1/B2. Active wrist and finger motion improved in all groups except for wrist extension, which was less in the 23-B1/B2 groups. The 23-B1/B2 group had the greatest pain and worst Short Form-36 scores. Disabilities of the Arm, Shoulder, and Hand questionnaire scores were similar and without differences between groups. CONCLUSIONS: Our data suggest that patients with volar rim distal radius fractures can expect a rapid return to function with minimal risk for complications and have outcomes similar to other types of operatively treated distal radius fractures. Further investigation of type 23-B fractures (23-B1/B2) is warranted owing to evidence of diminished outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

OBJECTIVES:: To quantify the impact of compartment syndrome in the setting of tibial shaft fracture on hospital length of stay and total hospital charges. DESIGN:: Retrospective case-control study. SETTING:: All New York State hospital admissions from 2001-2011, as recorded by the New York Statewide Planning and Research Cooperative System (SPARCS) database. PATIENTS:: 33,629 inpatients with isolated open or closed fractures of the tibia and/or fibula (AO/OTA 41-43). 692 patients developed a compartment syndrome in the setting of tibia fracture. All patients were filtered to ensure none had other complications or medical comorbidities that would increase length of stay or total hospital charges. INTERVENTION:: Fasciotomy and delayed closure in patients who developed a compartment syndrome. MAIN OUTCOME MEASURE:: Hospital length of stay (days) and total inflation-adjusted hospital charges RESULTS:: A total of 33,629 patients with tibial shaft fracture were included in the study. There were 32,937 patients who did not develop a compartment syndrome. For this group, the mean length of stay was 6 days and the mean inflation-adjusted hospital charges were $34,000. Patients who developed compartment syndrome remained in-house for an average of 14 days with average charges totaling $79,000. These differences were highly significant for both lengths of stay and hospital charges (p < 0.001). CONCLUSION:: Besides the obvious physical detriment experienced by patients with compartment syndrome, there is also a significant economic impact to the healthcare system. Compartment syndrome following a tibial fracture more than doubles length of stay and total hospital charges. These findings highlight the need for a standardized care algorithm aimed towards efficiently and adequately treating acute compartment syndrome. Such an algorithm would optimize cost of care and presumably decrease length of stay. LEVEL OF EVIDENCE:: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION: We hypothesized that resident participation in a hands-on fracture fixation course leads to significant improvement in their performance as assessed in a simulated fracture fixation model. METHODS: Twenty-three junior orthopaedic surgery residents were tasked to treat radial shaft fractures with standard fixation techniques in a sawbones fracture fixation simulation twice during the year. Before the first simulation, 6 of the residents participated in a fraction fixation skills course. The simulation repeated 6 months later after all residents attended the course. Residents also completed a 15-question written examination. Assessment included evaluation of each step of the procedure, a score based on the objective structured assessment of technical skill (OSATS) system, and grade on the examination. Comparisons were made between the two cohorts and the two testing time points. RESULTS: Significant improvements were present in the percentage of tasks completed correctly (64.1% vs 84.3%) the overall OSATS score (13.8 vs 17.1) and examination correct answers (8.6 vs 12.5) for the overall cohort between the two testing time points (p<0.001, p<0.03, p<0.04 respectively). Residents who had not participated in the surgical skills course at the time of their initial simulation demonstrated significant improvements in percentage of tasks completed correctly (61.3% vs 81.2%) and OSATS score (12.4 vs 17.0) (p<0.002, p<0.01 respectively). No significant difference was noted in performance for the cohort who had already participated in the course (p=0.87 and p=0.68). The cohort that had taken the course prior to the initial simulation showed significantly higher scores at initial evaluation (88.5% vs 58.5% percentage of tasks completed correctly, 17.3 vs 12.0 OSATS score, 12.5 vs 8.6 correct answers on the examination). At the second simulation, no significant difference was seen with task completion or examination grade, but a significant difference still existed with respect to the OSATS score (20.0 vs 17.0; p<0.03). CONCLUSION: Participation in a formal surgical skills course significantly improved practical operative skills as assessed by the simulation. The benefits of the course were maintained to 6 months with residents who completed the training earlier continuing to demonstrate an advantage in skills. Such courses are a valuable training resource which directly impact resident performance.

Osteoporosis is a disease of poor bone quality. Bone mineral density (BMD) has limited ability to discriminate between subjects without and with poor bone quality, and assessment of bone microarchitecture may have added value in this regard. Our goals were to use 7 T MRI to: (1) quantify and compare distal femur bone microarchitecture in women without and with poor bone quality (defined clinically by presence of fragility fractures); and (2) determine whether microarchitectural parameters could be used to discriminate between these two groups. This study had institutional review board approval, and we obtained written informed consent from all subjects. We used a 28-channel knee coil to image the distal femur of 31 subjects with fragility fractures and 25 controls without fracture on a 7 T MRI scanner using a 3-D fast low angle shot sequence (0.234 mm x 0.234 mm x 1 mm, parallel imaging factor = 2, acquisition time = 7 min 9 s). We applied digital topological analysis to quantify parameters of bone microarchitecture. All subjects also underwent standard clinical BMD assessment in the hip and spine. Compared to controls, fracture cases demonstrated lower bone volume fraction and markers of trabecular number, plate-like structure, and plate-to-rod ratio, and higher markers of trabecular isolation, rod disruption, and network resorption (p < 0.05 for all). There were no differences in hip or spine BMD T-scores between groups (p > 0.05). In receiver-operating-characteristics analyses, microarchitectural parameters could discriminate cases and controls (AUC = 0.66-0.73, p < 0.05). Hip and spine BMD T-scores could not discriminate cases and controls (AUC = 0.58-0.64, p >/= 0.08). We conclude that 7 T MRI can detect bone microarchitectural deterioration in women with fragility fractures who do not differ by BMD. Microarchitectural parameters might some day be used as an additional tool to detect patients with poor bone quality who cannot be detected by dual-energy X-ray absorptiometry (DXA).