Faculty Bibliography

BACKGROUND: Locking plates have become a commonly used fixation device in the operative treatment of three- and four-part proximal humerus fractures. Examining function in patients treated nonoperatively and operatively should help determine whether and when surgery is appropriate in these difficult-to-treat fractures. QUESTIONS/PURPOSES: We compared functional scores, ROM, and radiographs in patients with one-part proximal humerus fractures treated nonoperatively to those in patients with displaced three- and four-part proximal humerus fractures treated with open reduction and internal fixation using locking plates. PATIENTS AND METHODS: We retrospectively reviewed 142 patients with proximal humerus fractures treated with a standardized treatment algorithm over a 6-year period. Three- and four-part fractures were treated surgically while one-part fractures were treated nonoperatively. Functional scores, ROM, and radiographs were used to evaluate outcomes. American Shoulder and Elbow Surgeons and SF-36 scores were obtained at 12 months. Of the 142 patients, 101 (51 with three- or four-part fractures and 50 with one-part fractures) had a minimum followup of 12 months (average, 19 months; range, 12-64 months). RESULTS: The fractures united in all patients. At 1 year, the patients with one-part fractures had better SF-36 physical and mental scores and American Shoulder and Elbow Surgeons scores than the three- and four-part fractures. Both groups had similar shoulder ROM. Nine patients treated operatively had complications, four of which were related to screw penetration into the joint. CONCLUSIONS: Patients with three- and four-part fractures should be advised of the likelihood of persistent functional impairment and a relatively higher risk of complications when treated operatively with locked plates. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence

We reviewed 11 cases of luxatio erecta (inferior shoulder dislocation) managed acutely at our institutions to gain insight into the diagnostic and management principles of this condition. We then compared our findings with those in the current literature. Luxatio erecta requires careful clinical and radiographic evaluation and a high index of suspicion for associated injuries, as they occur frequently and can be significant given their tendency to be associated with higher energy trauma. Our results indicate that the majority of patients return to preinjury level of shoulder function, despite associated injuries. Closed reduction constituted definitive management in 100% of the cases in our series, and there was no recurrent instability at follow-up

OBJECTIVE: The objective of our study was to evaluate the diagnostic utility of conventional radiography for diagnosing bisphosphonate-related atypical subtrochanteric femoral fractures. MATERIALS AND METHODS: Retrospective interpretation of 38 radiographs of complete subtrochanteric and diaphyseal femoral fractures in two patient groups-one group being treated with bisphosphonates (19 fractures in 17 patients) and a second group not being treated with bisphosphonates (19 fractures in 19 patients)-was performed by three radiologists. The readers assessed four imaging criteria: focal lateral cortical thickening, transverse fracture, medial femoral spike, and fracture comminution. The odds ratios and the sensitivity, specificity, and accuracy of each imaging criterion as a predictor of bisphosphonate-related fractures were calculated. Similarly, the interobserver agreement and the sensitivity, specificity, and accuracy of diagnosing bisphosphonate-related fractures (i.e., atypical femoral fractures) were determined for the three readers. RESULTS: Among the candidate predictors of bisphosphonate-related fractures, focal lateral cortical thickening and transverse fracture had the highest odds ratios (76.4 and 10.1, respectively). Medial spike and comminution had odd ratios of 3.8 and 0.63, respectively. Focal lateral cortical thickening and transverse fracture were also the most accurate factors for detecting bisphosphonate-related fractures for all readers. The sensitivity, specificity, and overall accuracy for diagnosing bisphosphonate-related fractures were 94.7%, 100%, and 97.4% for reader 1; 94.7%, 68.4%, and 81.6% for reader 2; and 89.5%, 89.5%, and 89.5% for reader 3, respectively. The interobserver agreement was substantial (kappa > 0.61). CONCLUSION: Radiographs are reliable for distinguishing between complete femoral fractures related to bisphosphonate use and those not related to bisphosphonate use. Focal lateral cortical thickening and transverse fracture are the most dependable signs, showing high odds ratios and the highest accuracy for diagnosing these fractures

BACKGROUND: The optimal treatment for high energy pilon fractures is controversial. Good clinical and functional results have been reported with traditional open reduction techniques and minimally invasive techniques utilizing external fixation (EF). The purpose of this study was to critically evaluate clinical, radiographic and functional outcomes following high-energy fractures of the tibial plafond. METHODS: Between 2000 and 2006, 62 patients who were diagnosed with 63 Type 43C pilon fractures were treated surgically by a single surgeon and retrospectively reviewed. Twenty-seven patients were treated with a hinged bridging external fixator (EF) with supplemental limited internal fixation and 35 were treated with open reduction and internal fixation (ORIF) utilizing traditional small fragment plates and screws. Out of the 62 patients, a total of 46 patients were available for review. Charts and radiographs were reviewed and a Short Musculoskeletal Function Assessment (SMFA) questionnaire was administered by a trained interviewer. Seventy-four percent of both the ex-fix patients and ORIF patients were available for followup with a mean of 18 and 22 months, respectively. Results were compared using student's T-tests. RESULTS: There were no differences between the cohorts with respect to mechanism of injury, presence of an open wound and age. Functional outcomes were similar between the two groups based on the American Orthopaedic Foot and Ankle Society (AOFAS) score and the 'function' index of the SMFA. The overall complication and union rates were similar between the two groups. CONCLUSION: Both ORIF and EF appear to be comparable for treatment of OTA type 43C (pilon) fractures with regard to final range of ankle motion, development of arthritis and hindfoot scores

The purpose of this study was to compare fixation stability and lag screw sliding characteristics between 2 different hip-nail lag screw designs, a telescoping screwbarrel and a solid helical blade. Simulated, unstable, 4-part intertrochanteric hip fractures were created in 6 pairs of cadaveric femurs. Each nail type was randomly assigned within each femur pair. Lag screw sliding and inferior and lateral head displacements were measured following an applied static load of 750 N. Measurements were obtained before, during, and after cyclical loading with 750 N for 105 cycles. Ultimate failure strength was determined. After considering inferior head displacements, no significant differences between the 2 screw designs were found. Mean head displacement for the helical screw was 2.18 mm, compared with 1.87 mm for the telescoping screw (P = .731). A significant difference in the amount of lateral movement of the lag screws was found, however. The helical lag screws had mean lateral sliding of 2.68 mm, compared with 0.25 mm for the telescoping screws (P = .007). Neither of the lag screw constructs failed by screw cutout from the head. Both screw designs provide similar fixation strength for stabilization of 4-part intertrochanteric fractures. Both the telescoping lag screw and the helical blade facilitate fracture collapse, but the telescoping lag screw also minimizes lateral projection of the screw from the nail. This advantage may help minimize postoperative lateral soft-tissue impingement

'Skiving' is commonly used to refer to the condition when the subchondral plate is disrupted and the overlying cartilage physically displaced without the screw tip entering the joint. In this study we sought to define radiographic parameters of skiving and compare radiographs with computed tomography (CT) for accuracy in determining joint skiving. Cadaveric specimens of the distal radius were implanted with a volar plate and screws. Arthrotomies were performed to definitively assess the positions of the screws. Standard and anatomic tilt radiographs as well as CT were performed. Orthopaedic surgeons and radiologists evaluated the images and reported whether screw penetration or skiving had occurred. For screws which penetrated or skived, measurements were made to record the distances from the screw tips to the subchondral plate. Sensitivity, specificity and percent correct interpretations were 53%, 83%, 60% respectively for radiographs; and 100%, 72%, 69% for CT. Screws penetrating the articular surface protruded an average 2.3 mm (range 2-2.6 mm) from the subchondral plate and those skiving protruded 1.4 mm (range 1-1.8 mm). This study shows that articular skiving can occur with penetration of the subchondral plate of up to 1.8 mm. CT has a greater sensitivity and lower specificity in determining skiving compared to radiographs

Standard techniques for immobilization of a tibia shaft fracture in the emergency department in a long-leg splint can be cumbersome, technically difficult, and often requires the use of an assistant. We have developed a novel technique for the reduction and splinting of tibial shaft fractures, which uses a 'hammock' constructed of stockinette, which allows a single consulting orthopaedic physician to rapidly reduce and place a long-leg plaster splint or cast on a patient. This technique was performed on 12 consecutive patients with a total of 12 tibial shaft fractures. Translation, angulation, and shortening of the fracture were documented in anteroposterior and lateral views of the injured tibia and these parameters were compared against values measured after the hammock technique was used to reduce and splint the fracture. Pre-'hammock' average values for fracture displacement in the anteroposterior plane for translation, angulation, and shortening were 10.5 mm (53.1%), 12.0 degrees , and 9.4 mm, respectively. Post-'hammock' average values for fracture displacement in the anteroposterior plane for the same parameters were 8.7 mm (44.4%), 4.2 degrees , and 7.9 mm, respectively. Pre-'hammock' average values for fracture displacement in the lateral plane for translation and angulation were 4.9 mm and 8.7 degrees . Post-'hammock' average values for fracture displacement in the lateral plane for the same parameters were 4.9 mm and 2.0 degrees , respectively. These results show that this technique is able to achieve the goals of fracture reduction and immobilization in a rapid fashion when help is not available

BACKGROUND: Although most medical centers are equipped for 24-h care, some 'middle of the night' services may not be as robust as they are during daylight hours. This would have potential impact upon certain outcome measurements in trauma patients. The purpose of this paper was to assess the effect of patient arrival time at hospital emergency departments on in-hospital survival following trauma. MATERIALS AND METHODS: Data of patients, 18 years of age or older, with no evidence that they were transferred to or from that center were obtained from the National Trauma Data Bank Version 7.0. Patients meeting the above criteria were excluded if there was no valid mortality status, arrival time information, injury severity score, or trauma center designation. The primary analyses investigated the association of arrival time and trauma center level on mortality. Relative risks of mortality versus patient arrival time and trauma level were determined after controlling for age, gender, race, comorbidities, injury, region of the country, and year of admission. RESULTS: In total, 601,388 or 71.7% of the 838,284 eligible patients were retained. The overall in-hospital mortality rate was 4.7%. The 6 p.m. to 6 a.m. time period had a significantly higher adjusted relative risk for in-hospital mortality than the 6 a.m. to 6 p.m. time frame (ARR=1.18, P<;0.0001). This pattern held across trauma center levels, but was the weakest at Level I and the strongest at Level III/IV centers (Level I: ARR=1.10, Level II: ARR=1.14, and combined Level III/IV: ARR=1.32, all P<0.0001). CONCLUSION: Hospital arrival between midnight and 6 a.m. was associated with a higher mortality rate than other times of the day. This relationship held true across all trauma center levels. This information may warrant a redistribution of hospital resources across all time periods of the day

This article describes a case of a 21-year old man who presented with symptomatic heterotopic ossification of the patellar tendon 3.5 years postinjury. The patient sustained an open tibia fracture during a fall and was treated by reamed intramedullary nailing through a medial paratendinous approach. Radiographic evidence of heterotopic ossification in the patellar tendon was first noted at the 4-week follow-up. He presented at 3.5 years postinjury with new-onset anterior knee pain and reported no interval trauma to the knee. Radiographs revealed a well-circumscribed area of calcification within the patellar tendon, which was excised within 2 weeks. On excision, the patient's symptoms had resolved. This case is unique because the patellar tendon was not violated at initial or subsequent surgeries, and because of the delayed presentation of heterotopic bone within the patellar tendon. To date, there have been only 3 reported cases of heterotopic ossification of the patellar tendon after intramedullary nailing of the tibia. We present a case of late symptomatic heterotopic ossification of the patellar tendon after medial paratendinous intramedullary nailing of an open tibia shaft fracture

Multiple studies have attempted to determine which attributes are predictive of success during residency as well as the optimal method of selecting residents who possess these attributes. Factors that are consistently ranked as being important in the selection of candidates into orthopaedic residency programs include performance during orthopaedic rotation, United States Medical Licensing Examination (USMLE) Step 1 score, Alpha Omega Alpha Honor Medical Society membership, medical school class rank, interview performance, and letters of recommendation. No consensus exists regarding the best predictors of resident success, but trends do exist. High USMLE Step 1 scores have been shown to correlate with high Orthopaedic In-Training Examination scores and improved surgical skill ratings during residency, whereas higher numbers of medical school clinical honors grades have been correlated to higher overall resident performance, higher residency interpersonal skills grading, higher resident knowledge grading, and higher surgical skills evaluations. Successful resident performance can be measured by evaluating psychomotor abilities, cognitive skills, and affective domain