Faculty Bibliography

OBJECTIVES:: The aim of our study was to investigate the rate, longitudinal improvement, and risk factors of sleep disturbance following four common orthopaedic traumatic conditions. METHODS:: The functional status of 1,095 patients was prospectively assessed using validated questionnaires for patients with acute proximal humerus (n=111), distal radius (n=440), tibial plateau (n=109), and ankle fractures (n=435). Patient reported sleep difficulty was compared to the overall functional and emotional status of each patient at three, six, and twelve months post-treatment. RESULTS:: Sleep difficulty at three months follow-up was reported in 41% of proximal humerus fracture patients, 25% of distal radius fracture patients, 36% of tibial plateau patients, and 19% of ankle fracture patients. By twelve months follow-up less than 20% of patients with all fracture types reported sleep difficulty. At twelve months follow-up the SF-36 Mental Health category for patients with distal radius fractures (p=0.001) and the Short Musculoskeletal Function Assessment (SMFA) Emotional category for patients with tibial plateau fractures (p=0.024) and ankle fractures (p=<0.001) were independent predictors of poor sleep while the respective functional status categories were not. CONCLUSIONS:: At twelve months follow-up, poor sleep was independently associated with poor emotional status, but not associated with poor functional status. The mental health status of patients with sleep difficulty in the latter stages of fracture healing should be carefully assessed in order to provide the highest level of care. The results of this study should allow orthopaedic trauma surgeons to counsel patients regarding expectations of difficulty sleeping following acute fractures. LEVEL OF EVIDENCE:: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE:: The purpose of this study was to investigate the nonoperative treatment strategies for Mason-Johnson Type-I radial head fractures. DESIGN AND SETTING:: Retrospective review of every patient with a closed radial head/neck fracture who presented to our tertiary care specialty institution in the past two years.Patients/Participants: A search of ICD-9 code 813.05, closed fracture of the radial head/neck, in our electronic record system yielded 82 consecutive patients. MAIN OUTCOME MEASUREMENTS:: Complications and treatment interventions were recorded. Demographic, radiographic, and physical exam data were collected for all patients treated nonoperatively and analyzed for association with recommendation for continued follow-up and radiographic assessment. RESULTS:: 54 patients (68%) had 56 nondisplaced or minimally displaced (< 2mm) radial head or neck fractures without additional injury to the affected limb. All patients were treated nonoperatively and no patients in this cohort developed a complication or had any medical or surgical intervention other than physical therapy. No radiographic or physical exam measure was significantly associated with recommendation for a second outpatient follow-up, third outpatient follow-up, or with the number of additional radiographs ordered beyond the initial exam. An average of 4.4 (SD 3.3) additional x-rays were taken of each affected elbow after initial outpatient presentation. CONCLUSIONS:: Orthopaedic surgeons are likely over treating patients with Mason-Johnson Type-I radial head fractures by recommending frequent radiographic follow-up without modifying treatment, leading to unnecessary patient visits, radiation exposure, and increased costs. LEVEL OF EVIDENCE:: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The relationship between pharmaceutical and biomedical technology companies (industry) and medical practitioners has been a topic of discussion and concern for several de- cades. The large monetary payments and extravagant gifts to physicians from these companies have been regulated and largely stopped; however, there still exists an active rapport between physicians and industry. Little formal instruction is given to medical students and residents on what constitutes a conflict of interest when entering these business partnerships. In this study, we presented a set of scenarios depicting industry-physician interactions to medical students, orthopaedic surgery residents, and attending physicians and asked them to decide whether a conflict of interest is depicted. Our goal was to determine whether a disparity exists in the ability to identify conflicts of interest across the levels of training. Of 200 potential participants, 70 provided responses to the survey (35%). Thirty-five (50%) were attending physicians, 18 (25.7%) residents, 12 (17.1%) medical students, and 8 (11.4%) de- clined to provide level of training. There was no significant difference in the ability to identify a conflict of interest across seniority level for the 13 questions. Our results suggest that both medical students and resident physicians are able to identify which interactions with industry pose a possible conflict of interest as accurately as attending physicians can.

PURPOSE: In order to identify predictors for hand stiff- ness following distal radius fractures and understand the consequences of this common clinical finding, we studied 260 patients. Our null hypothesis was that we would find no predictors of post injury hand stiffness. METHODS: Baseline demographics and injury character- istics were obtained at distal radius fracture presentation. Treatment and healing was documented. Stiffness was de- fined as tip to palm distance greater than 1 cm for any one finger. Outcome parameters obtained at regular intervals included wrist and hand range of motion, radiographs, vi- sual analog pain scales, and Disability of the Arm Shoulder and Hand (DASH) questionnaires. RESULTS: Forty-nine of 260 patients (19%) patients were considered to be "stiff" by our criteria. Grip strength was weaker for stiff patients as well. Patient demographics were similar in both groups with the "stiff" cohort having a greater mean age, p = 0.05. There was no significant differ- ence in stiffness seen in operative cases versus nonoperative cases. Injury ulnar variance was 3.1mm (SD = 3.5) in the "stiff" cohort and 1.8 (SD = 2.9) in the "non-stiff" cohort (p= 0.02). Functional disability as measured by the DASH differed (p = 0.001) between stiff and non-stiff patients for both 6 month and 1 year follow-up time points. Stiff patients were more likely than non-stiff patients to have lower grip strength at 12-month post fracture (p = 0.001). CONCLUSION: Older patients who present with significant ulnar variance at injury are more likely to experience hand stiffness at some time during their recovery. The develop- ment of hand stiffness is associated with poorer functional outcome than those who do not develop stiffness.

Background and aims: This study seeks to determine the effect of spinal anesthesia (SA) on clinical outcomes when compared to general anesthesia (GA) in operatively managed tibial plateau fractures. Methods: Over 8 years, all operative tibial plateau fractures treated by two surgeons were prospectively followed. 113 patients were identified for this study. 30 received SA and 83 received GA. All patients were treated using a similar operative protocol and physiotherapy regimen. Clinical outcomes were compared at 3 months, 6 months and the latest follow-up. These outcomes include Short Musculoskeletal Functional Assessment (SMFA) scores, pain levels, complications and reoperations. Analysis was done using student's t-tests, Chi-squared tests and multivariate linear regression. Results: Using univariate analysis, SMFA scores were improved at 6 months in SA vs. GA patients (beta = -1.14, 95% confidence interval [CI] = -2.06 to -.23, p=0.015), and pain scores were lower in SA vs. GA at 6 months (p =0.004) and at the latest followup (p=0.012). After controlling for group differences, pain scores were found to be lower in SA vs. GA at 3 months (beta = -0.16, 95% CI = -0.24 to 2.02, p=0.048), but not at 6 months or the latest followup. The odds ratio of higher pain scores of a patient who received GAvs SA at 3 months was 3.1 (95% CI, 1.06 to 9.26, p=0.039). Conclusions: In patients who undergo surgical management of a tibial plateau fracture, the use of spinal anesthesia is associated with improved functional scores and decreased pain levels up to 6 months postoperatively

BACKGROUND: The purpose of this study was to examine functional outcomes following ORIF of displaced proxi- mal humerus fractures in patients who received brachial plexus blocks compared to those who underwent general anesthesia. METHODS: We retrospectively reviewed prospectively col- lected data on 92 patients. Patients were grouped according to anesthesia type: regional interscalene brachial plexus block, with or without general anesthesia, or general anes- thesia alone. Patients were asked to complete the Disabili- ties of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion assessments at a minimum of 6-month follow-up. Plain radiographic films were obtained to assess fracture healing. RESULTS: Forty-five (48.9%) patients with 45 proximal humerus fractures received a regional anesthetic, while 47 (51.1%) patients with 48 proximal humerus fractures had general anesthesia. No significant differences existed in demographic information or fracture type. DASH scores at the most recent follow-up were significantly better in the regional block group (38.6) compared to the general anes- thesia group (53.1) (p = 0.003). The regional block group had significantly better passive and active forward elevation and external rotation range and equivalent internal rotation (p = 0.002, 0.005, 0.002, and 0.507, respectively). CONCLUSION: Patients who received regional anesthetic via a brachial plexus interscalene blocks had better functional outcomes and range of motion at the most recent clinical follow-up. Regional anesthesia provides patients with pro- longed postoperative pain relief, which may allow for early mobilization, increasing the likelihood that the patient's function and range of motion will return to baseline.

Today's increasingly complex health-care landscape requires that physicians take an active role in minimizing health-care costs and expenditures. Judicious choice of implants, a fracture-driven treatment algorithm, capitation models, use of generic fracture implants, and reuse of external fixation constructs all represent mechanisms that can result in substantial savings. In some health-care environments, these cost savings programs may be directly linked to physician reimbursement in the form of gainsharing plans. Evidence-based critical evaluations of implant usage patterns are necessary to help control implant-related health-care spending but are lacking in the current literature. Physicians need to acknowledge their influence and responsibility in this realm and assume an active role to help reduce costs.