Faculty Bibliography

BACKGROUND: Little is known about the moral reasoning utilized by orthopaedic surgery residents when resolving moral dilemmas. METHODS: Sixty-three residents in an accredited program took the Defining Issues Test-2, an online examination designed to measure and analyze moral reasoning. Scores approximate how often residents utilize three schemas in their moral reasoning: personal interest, maintaining social norms, and postconventional. Scores were analyzed for differences among years of training, previous literature, and established norms. RESULTS: Approximately 9.5% of residents utilized personal interest heavily in their moral reasoning, 27% utilized maintaining norms, and 63.5% utilized postconventional reasoning. There were no significant differences between years of training. The fourth-year (R4) class recorded the highest utilization of principled reasoning, while the fifth-year (R5) class recorded the lowest. The range of principled reasoning scores narrowed from the first year (R1) to R5. The principled reasoning scores of residents were significantly lower than previously reported scores of professional degree-holders and medical students, and empirically lower than previously reported scores of orthopaedic attendings and medical students. CONCLUSIONS: Residents utilized principled reasoning less frequently than expected for physicians. It remains unclear as to what factors contributed to high utilization of principled reasoning in the R4 class but low utilization in the R5 class. Our cross-sectional data suggest that each year of training homogenizes toward a class-specific utilization of principled reasoning. It remains unclear why residents utilized principled reasoning less than orthopaedic attendings, medical students, and other professional degree-holders.

OBJECTIVES: : The purpose of this study was to evaluate forearm rotation after volar plating of the distal radius fractures with and without pronator quadratus repair. DESIGN: : This was an institutional review board-approved retrospective review of prospectively collected data. SETTING: : The study was conducted at an Academic Medical Center. PATIENTS: : Over a 5-year period, 606 patients with distal radius fractures (OTA classifications 23-A through 23-C) were enrolled in an institutional review board-approved, prospectively collected, distal radius database. One hundred and seventy-five patients underwent open reduction and internal fixation with volar plating. Of these, 112 patients had complete 1-year follow-up (6 weeks, 3, 6, and 12 months) and were included in this study. INTERVENTION: : Volar plating of the distal radius was performed with pronator quadratus repair (group A), versus volar plating without pronator quadratus repair (group B). Surgeries in group A were performed by a fellowship trained hand surgeon utilizing volar plates from Depuy Orthopedics (Warsaw, IN), whereas the surgeries in group B were performed by a fellowship trained orthopedic trauma surgeon utilizing volar plates from Stryker (Mahwah, NJ). MAIN OUTCOME MEASUREMENTS: : Primary outcomes include forearm range of motion. Secondary outcomes include grip strength, pain levels, functional outcomes (DASH scores), radiographs, and complications. RESULTS: : Baseline and demographic characteristics of the patients were similar between the 2 groups. There was no difference in mean pronation (P = 0.08) at 1 year. Among secondary analyses, radial deviation was significantly different (P = 0.03); however, pain (P = 0.13) and DASH scores (P = 0.14) were not. The only patient that requested plate removal had the pronator repaired (group A). CONCLUSIONS: : We conclude that there is no advantage in repairing the pronator quadratus during volar plating of distal radius fractures. LEVEL OF EVIDENCE: : Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: The purpose of this study was to evaluate the outcomes following operative treatment of nonunited rotational distal fibula and medial malleolar ankle fractures. METHODS: Seventeen patients were identified as having a nonunion of a rotational ankle fracture. All patients were evaluated clinically, radiographically, and functionally with the Short Musculoskeletal Functional Assessment (SMFA) questionnaire. They were divided into lateral and medial malleolus groups and compared with 44 patients following a nonoperative (SE2/3) ankle fracture and 25 patients who underwent operative fixation of their SE4 ankle fracture for functional comparison. RESULTS: Two of the 17 patients were excluded. The patients in the medial malleolar group were notably older than those in the other groups. Nonunions included 12 distal fibulas and 3 medial malleoli. All patients were treated with open reduction with plate and screw fixation or screw fixation alone. Adjunctive grafting was performed in all but 2 cases. The average time to healing was 5.2 months post surgery. At latest follow-up, mean 33.9 months, all nonunions had resolved. Standardized SMFA scores differed notably among the groups in the Bothersome, Emotional, and Mobility categories. There was no difference between lateral malleolar nonunion patients and surgically treated SE4 patients. CONCLUSIONS: Reports of nonunions of fractures of lateral and medial malleoli have been rarely reported. Operative treatment of these nonunions in this study led to reliable bony healing. Patients who underwent surgery for these nonunions ultimately had similar outcomes and range of motion compared with patients who underwent operative treatment for acute ankle fractures. Level of Evidence: Level III, retrospective comparative series.

PURPOSE: To investigate the effects of age on the clinical, functional, and radiographic outcomes of patients with proximal humerus fractures treated operatively with locking plates. METHODS: Between February 2003 and July 2012, all patients who sustained a proximal humerus fracture who presented to our institution were enrolled into a database. Patients were followed up at 1, 6, 12, 26, and 52 weeks postoperatively with physical examination and radiographs. Validated functional outcomes scores were collected at 6 and 12 months. Complications were recorded as they occurred. Statistical analysis was conducted to assess for functional, physical, or radiographic differences between patients age younger than 65 and patients age 65 or older. RESULTS: Of the 147 consecutive patients treated operatively for a proximal humerus fracture, 115 (78%) patients with an average follow-up of 16 months met the inclusion criteria for this study. The young cohort (patients < 65) included 70 patients with an average age of 53, whereas the elderly cohort (patients >/= 65) included 45 patients with an average age of 73. The older cohort had significantly more women (P = .04), but there was no statistical difference in fracture type between the age groups. There were no differences in the radiographic measures of screw penetration, humeral head height, and neck-shaft angle between the age groups. There were no differences in physical examination scores between the age groups. There were no significant differences in functional outcomes or complication rates between the age groups. CONCLUSION: Treating proximal humerus fractures operatively with locked plates can overcome the challenges of poor bone quality that often occur with increasing age. Age should not play a significant role in the decision-making process for treating proximal humerus fractures that would otherwise be indicated for surgical fixation.

BACKGROUND: Bilateral ruptures of the extensor mechanism are rare. QUESTIONS/PURPOSE: The purpose of this study was to compare the clinical outcomes of operatively treated unilateral and bilateral knee soft tissue extensor mechanism injuries and to identify risk factors for bilateral disruption. METHODS: All patients operatively treated for a knee extensor mechanism injury were entered into a database and prospectively followed. Postoperative protocol was standardized for all patients. Demographic data, baseline characteristics, range of motion, complications, pain, and functional status were assessed. The main patient-reported outcome measures used in this study were the SF-36 Health Survey and the Lysholm Scale. RESULTS: Patients who sustained bilateral injuries were more likely to have one or more systemic medical conditions. There was no statistical difference between the groups with regard to mechanism of injury or body mass index. The average follow-up was 29 months (range 6-60 months). Patient-reported outcomes, in the form of the SF-36 Health Survey and Lysholm scores, were not significantly different between the two groups at final follow-up. Range of motion and quadriceps strength was also similar between the two cohorts. At latest follow-up, 88% of patients with unilateral injuries and 83% of patients with bilateral disruption were able to return to their pre-injury employment. CONCLUSION: Operatively treated bilateral knee extensor mechanism disruptions fare similar to unilateral injuries with regard to ultimate functional outcome. The presence of one of more preexisting medical conditions was identified as a risk factor for bilateral tendinous disruption.

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.