Faculty Bibliography

Atypical femoral fractures, deformities of the subtrochanteric region of the femur identified with plain anteroposterior or lateral lower extremity radiographs and characterized by a specific fracture pattern, are uncommon manifestations in osteoporotic patients. However, the high prevalence of these fractures in patients receiving long-term bisphosphonate therapy led to the many investigations of this association. The purpose of this article is to evaluate and address the link between this fracture type with long-term bisphosphonate therapy, outline the clinical scenario and better define treatment options for optimal care and recovery. In order to do this, a PubMed search was carried out for significant articles using the following keywords: 'alendronate', 'fracture', 'atypical' and 'femur'. 2013 Future Medicine Ltd

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.

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.

OBJECTIVE:: To 1) determine the incidence and injury profile of open periarticular fractures about the knee joint in a cohort of patients presenting to the emergency department with a deep periarticular knee wound and to 2) determine the effectiveness of CT scan to detect and guide management of these open fractures compared to plain radiographs. DESIGN:: Retrospective Review SETTING:: Level I trauma center PATIENTS/PARTICIPANTS:: 78 patients (79 knees) with deep periarticular knee wounds of which 62 patients (63 knees) received both a plain radiograph and a CT scan of the knee. INTERVENTION:: Plain radiograph and CT scan of the injured knee. MAIN OUTCOME MEASUREMENTS:: Comparison of OTA fracture classification and surgeon produced management plan as determined by plain radiographs versus CT scans. CT scan was considered the gold-standard test to detect a fracture. RESULTS:: Twenty-one (27%, 21/79) knees had an open periarticular fracture of the knee and 95% (20/21) of these knees had intra-articular air indicative of an associated traumatic arthrotomy. Of 41 (52%, 41/79) knees with a traumatic arthrotomy, 51% (21/41) had an associated open periarticular fracture of the knee. Plain radiographs detected 18 fractures in 17 knees (of which 1 fracture was later determined to not be a true fracture) whereas CT scan detected 26 fractures in 21 knees. Overall, CT scan detected 9 additional fractures in 6 knees. The specificity and sensitivity and positive predictive and negative predictive values of plain radiographs to detect and rule-out a fracture was 98%/65% and 94%/82%, respectively. Compared to plain radiographs, CT scan altered the fracture classification in 48% of patients and altered the management plan in 43% of patients, respectively. Gunshot wounds to the knee had a 48% (12/25) incidence of an associated open periarticular fracture compared to an 17% (9/54) incidence for all other injury mechanisms combined (p<.01). CONCLUSION:: Patients with a periarticular knee wound have a high incidence of open periarticular fractures, and the incidence is even higher if the mechanism of injury is a GSW or there is associated traumatic arthrotomy. CT scan improves detection and management of open fractures of the knee compared to plain radiographs. Consideration should be given to routinely using CT scan to evaluate knees with deep periarticular wounds that present to the ED, especially if secondary to gunshot injuries, given the high incidence open periarticular fractures of the knee. LEVEL OF EVIDENCE:: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE:: To report our experience with computed tomography (CT) scans to detect traumatic arthrotomies of the knee joint (TAK) based upon the presence of intra-articular air. DESIGN:: Retrospective review SETTING:: Level I trauma center PATIENTS/PARTICIPANTS:: Sixty-two consecutive patients (63 knees) underwent a CT scan of the knee in the emergency department and had a minimum of 14 days follow-up. Cohort of 37 patients (37 knees) from the original 62 patients who underwent a Saline Load Test (SLT) INTERVENTION:: CT scan and SLT MAIN OUTCOME MEASUREMENTS:: Positive traumatic arthrotomy of the knee (+TAK) was defined as operating room (OR) confirmation of an arthrotomy or no intra-articular air on CT scan (-iaCT) (and -SLT if performed) with follow-up revealing a septic knee. Periarticular wound equivalent to no traumatic arthrotomy (pw=(-TAK)) was defined as OR evaluation revealing no arthrotomy or -iaCT (and -SLT if performed) with follow-up revealing no septic knee. RESULTS:: All 32 knees with intra-articular air on CT scan (+iaCT) had OR confirmation of a TAK and none of these patients had a knee infection at a mean follow-up of 140.0+/-279.6 days. None of the 31 patients with -iaCT had a knee infection at a mean follow-up of 291.0+/-548.1 days. Based on these results, the sensitivity and specificity of the CT scan to detect +TAK and pw=(-TAK) was 100%. In a subgroup of 37 patients that received both a CT scan and the conventional SLT, the sensitivity and specificity of the CT scan was 100% compared to 92% for the SLT (p<0.001). CONCLUSION:: CT scan performs better than the conventional SLT to detect traumatic knee arthrotomies and identify periarticular knee wounds that do not require surgical intervention and should be considered a valid diagnostic test in the appropriate clinical setting. LEVEL OF EVIDENCE:: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES:: To determine the lowest estimated radiation dose necessary to reproducibly detect intra-articular air in the knee joint of a cadaver model. METHODS:: 10 adult fresh-frozen cadaver knees with intact joint capsules provided by Science Care(R), Phoenix, AZ. were thawed and scanned at 5 decreasing radiation doses (decreasing by approximately half from 8.42 mGy to 0.74 mGy) after introducing increasing volumes (0 cc, 0.1 cc, 0.3 cc, 0.5 cc, 0.7 cc, 0.9cc) of intra-articular air. Scans were performed using 2.0 mm slice-thickness from the distal 1/3 of the femur to the proximal 1/3 of the tibia. Sagittal and coronal reconstructions of each scan using 1.0 mm slice-thickness were rendered. All scans were reviewed by 1) a single attending radiologist, 2) a single attending orthopedic surgeon, and 3) a single chief resident, for the presence of intra-articular air. RESULTS:: The sensitivity and specificity of CT scan to detect intra-articular air at each volume of intra-articular air (0.1 cc, 0.3 cc, 0.5 cc, 0.7 cc, 0.9cc) was 100% at 0.74 mGy - the radiation threshold dose (RadTH) (scan parameters: voltage 80kV, current: 33mA, and scan time: 12.17 sec). The effective radiation dose at 0.74 mGy for a CT scan of the knee is approximately 0.10 mSV CONCLUSIONS:: CT scan to detect traumatic knee arthrotomies can be successfully accomplished at a threshold radiation dose of 0.74 mGy and for an intra-articular volume of 0.1cc of air. This low radiation dose protocol and volume of intra-articular air should be taken into consideration with future studies evaluating the use of CT scan to detect traumatic arthrotomies.