Faculty Bibliography

PURPOSE: To demonstrate the feasibility of performing bone microarchitecture, high-resolution cartilage, and clinical imaging of the hip at 7T. MATERIALS AND METHODS: This study had Institutional Review Board approval. Using an 8-channel coil constructed in-house, we imaged the hips of 15 subjects on a 7T magnetic resonance imaging (MRI) scanner. We applied: 1) a T1-weighted 3D fast low angle shot (3D FLASH) sequence (0.23 x 0.23 x 1-1.5 mm3 ) for bone microarchitecture imaging; 2) T1-weighted 3D FLASH (water excitation) and volumetric interpolated breath-hold examination (VIBE) sequences (0.23 x 0.23 x 1.5 mm3 ) with saturation or inversion recovery-based fat suppression for cartilage imaging; 3) 2D intermediate-weighted fast spin-echo (FSE) sequences without and with fat saturation (0.27 x 0.27 x 2 mm) for clinical imaging. RESULTS: Bone microarchitecture images allowed visualization of individual trabeculae within the proximal femur. Cartilage was well visualized and fat was well suppressed on FLASH and VIBE sequences. FSE sequences allowed visualization of cartilage, the labrum (including cartilage and labral pathology), joint capsule, and tendons. CONCLUSION: This is the first study to demonstrate the feasibility of performing a clinically comprehensive hip MRI protocol at 7T, including high-resolution imaging of bone microarchitecture and cartilage, as well as clinical imaging. J. Magn. Reson. Imaging 2013;. (c) 2013 Wiley Periodicals, Inc.

The purpose of this study is to describe our experience with distal femur nonunions and to report on the functional recovery of patients treated for these injuries. Twenty-two patients with an established distal femur nonunion were identified and followed prospectively. Results were compared with a control group consisting of 18 similar patients who had sustained an acute distal femur fracture. Compared with acute fracture patients, patients with a nonunion were more likely to have had an open fracture at initial injury (p = 0.02) and required a longer time to heal after final surgery (p = 0.054). No demographic variables were found to be predictive of complications, Short Musculoskeletal Functional Assessment scores, or time to union. These results show that patients with a distal femoral nonunion can expect to attain similar ultimate outcomes to patients receiving treatment for an acute distal femur fracture. Unlike the development of nonunions following other types of fracture, such as the hip, distal femur nonunions do not portend poor functional outcomes as long as bone union is achieved.

BACKGROUND: Bisphosphonate therapy for osteoporosis has been associated with atypical femoral fractures. To date, there have been few reports in the literature regarding the preoperative and postoperative courses of patients who have sustained bisphosphonate-associated complete atypical femur fractures. OBJECTIVES/PURPOSES: The purposes of this study were to (1) characterize the preoperative course of patients who eventually presented with bisphosphonate-associated complete atypical femur fractures (duration of bisphosphonate treatment, pain history, risk of converting a nondisplaced fracture to a complete fracture); (2) evaluate the percentage of patients who achieved radiographic union of those fractures after treatment; and (3) determine the patients' recovery of function using the Short Musculoskeletal Functional Assessment. METHODS: Thirty-three patients with 41 atypical, low-energy femur fractures associated with >/= 5 years of bisphosphonate use were treated with intramedullary nailing between 2004 and 2011 at one center. The main outcome measurements were Short Musculoskeletal Functional Assessment for function and radiographic evaluation for fracture healing. Patients had been treated with bisphosphonates for an average of 8.8 years (range, 5-20 years) before presentation. RESULTS: Patients reported a mean of 6 months of pain before presentation (range, 1-8 months). Sixty-six percent of patients with surgically treated complete fractures became pain-free and 98% were radiographically healed by 12 months. Sixty-four percent of patients who underwent intramedullary nailing reported a functional return to baseline within 1 year. Patients who reported major functional limitations at latest followup listed pain and apprehension as the major causes of their limitation. CONCLUSIONS: Patients with surgically treated bisphosphonate-associated complete femur fractures achieved generally reliable although delayed fracture healing if malaligned, and nearly two-thirds of patients returned to self-reported baseline function within 1 year. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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.

OBJECTIVES: The purpose of this study was to determine what patient and injury factors are associated with the presence of a meniscus tear in tibial plateau fractures. We also sought to compare functional outcome, pain scores, and range of motion between patient groups with and without meniscal injury. MATERIALS AND METHODS: A total of 99 patients with 101 acute tibial plateau fractures were included in the study cohort. Patients were divided into two groups: those with and without meniscus tears at the time of initial injury. Statistical analysis with Student's t-test for continuous variables and chi square test for categorical variables was performed to compare those with and without a meniscal tear. Logistic regression was performed to identify the variables that predicted the presence of a meniscus tear and repeated ANOVA measures were used to assess functional outcome scores. RESULTS: Fifty-four patients with 56 tibial plateau fractures (55%) were found to have an associated meniscal tear. The average amount of joint depression in this group was 12.3 mm (range: 2.0 to 29.5 mm). The remaining 45 patients with 45 fractures (45%) had an average depression of 5.4 mm (range: 0.0 to 12.8 mm). Degree of tibial plateau depression was the only significant predictor of meniscal injury. CONCLUSIONS: Our findings suggest that amount of depression in tibial plateau fractures is a significant predictor of the occurrence of a meniscus tear with an odds ratio of 1.36. We also found no significant difference in the functional outcome, pain scores, and knee range of motion between the group with and without meniscus tears at the longest follow-up interval. These findings suggest that acute repair of meniscal injury following traumatic fracture of the tibial plateau could produce functional results similar to those patients that did not sustain a meniscus tear.

PURPOSE: The purpose of this study was to evaluate the efficacy of sugar tongs splints to maintain reduction of pediatric distal radius and distal both bones forearm fractures compared to acute casting. MATERIALS AND METHODS: The trauma database of an urban level-one trauma center was queried for skeletally immature patients who had sustained a displaced extraphyseal distal radius fracture. Inclusion criteria included: complete radiographs, skeletal immaturity, and presence of a displaced fracture of the radius within the metaphyseal segment, proximal to the distal radial physis, with or without an associated ulna fracture. All patients were seen in the emergency department and treated with a standardized protocol of closed reduction and immobilization. All radiographs were reviewed for initial and residual displacement. Baseline demographic data was also collected, including age at time of injury, handedness, and mechanism of injury. Need for operative intervention and associated complications were noted. All fractures were followed until union. RESULTS: Thirty-three patients were treated with closed reduction and immobilization in a sugar tongs splint, 10 patients were acutely casted, and 2 patients were placed into a short arm volar splint. Twenty-five patients who were initially splinted were treated to completion without the need for operative intervention. Eight of the patients treated with sugar tongs splints (24%) required surgery. Eight patients who were initially casted were treated to completion closed. Two of the patients who were initially casted (22%) required operative intervention for loss of reduction. Both of the patients who were initially immobilized using a volar splint were treated to completion without operative intervention. There was no statistically significant difference in the need for operative intervention amongst these groups. CONCLUSIONS: This study demonstrates that use of closed reduction and placement of a sugar tongs splint can effectively maintain reduction of extraphyseal distal radius fractures with rates of displacement similar to that seen with acute casting.

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.