Faculty Bibliography

OBJECTIVES:: The purpose of this study is to characterize the presentation, size, treatment, and complications of pulmonary embolism (PE) in a large series of orthopaedic trauma patients who developed PE after injury. METHODS:: We reviewed the records of orthopaedic trauma patients who developed a PE within 6 months of injury at 9 trauma centers and 2 tertiary care facilities. RESULTS:: There were 312 patients, 186 men and 126 women, avg age 58. Average BMI was 29.6, avg ISS was 18. 17% received anticoagulation prior to injury, and 5% had a prior history of PE. After injury, 87% were placed on prophylactic anticoagulation; 68% with low molecular weight heparin. 53% of patients exhibited shortness of breath or chest pain. Average heart rate and O2 saturation prior to PE diagnosis were 110 and 94, respectively. 39% had abnormal ABG and 30% had abnormal EKG findings. 89% had CTPA for diagnosis. Most clots were segmental (63%), followed by subsegmental (21%), lobar (9%), and central (7%). The most common treatment was unfractionated heparin and Coumadin (25%). Complications of anticoagulation were common: 10% had bleeding at the surgical site. Other complications of anticoagulation included GI bleed, anemia, wound complications, death, and compartment syndrome. PE recurred in 1%. 4% died of PE within 6 months. CONCLUSIONS:: This is the first large data set to evaluate the course of PE in an orthopaedic trauma population. The complications of anticoagulation are significant and were as common in the patients with lower risk clots as those with higher risk clots. LEVEL OF EVIDENCE:: III (retrospective).

BACKGROUND: Prior studies have suggested that Asian patients and women may be more likely to sustain atypical femoral fractures in association with bisphosphonate use. However, they do not account for confounders such as asymptomatic patients who are long-term bisphosphonate users or patients sustaining osteoporotic fractures. QUESTIONS/PURPOSES: The purpose of this study was to determine the differences in sex and racial association with atypical femoral fractures by comparing demographic characteristics of patients who sustained an atypical bisphosphonate-associated fracture with patients on long-term bisphosphonates without fractures and with patients who sustained osteoporotic fractures. METHODS: Three groups from prospective registries were identified: (1) patients with atypical femur fractures associated with long-term bisphosphonate use (BFF) (n = 54); (2) patients on long-term bisphosphonates but with no associated fractures (BNF) (n = 119); and (3) patients with osteoporotic proximal femur fractures not associated with bisphosphonates (PFF) (n = 216). Age, sex, and self-reported race/ethnicity were documented and compared. Multivariate and univariate analyses were done as well as age- and sex-stratified analyses. RESULTS: Age and sex distributions of the BFF and BNF patients were similar. There was a higher percentage of Asian patients in the BFF group (17%) than in the BNF group (3%; p = 0.004) as well as Hispanics (13% versus 3% in BNF; p = 0.011). Patients in the BFF group were younger than those in the PFF group (67.5 versus 78.4 years; p < 0.001) and had fewer males (7% versus 14%; p < 0.001). CONCLUSIONS: These data suggest that Asians are at higher risk for atypical bisphosphonate-associated fractures. We recommend closer followup in Asian patients who are taking bisphosphonates. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

BACKGROUND: We investigated the radiographic parameters that may predict distal radial ulnar joint (DRUJ) instability in surgically treated radial shaft fractures. In our clinical experience, there are no previously reported radiographic parameters that are universally predictive of DRUJ instability following radial shaft fracture. MATERIALS AND METHODS: Fifty consecutive patients, ages 20-79 years, with unilateral radial shaft fractures and possible associated DRUJ injury were retrospectively identified over a 5-year period. Distance from radial carpal joint (RCJ) to fracture proportional to radial shaft length, ulnar variance, and ulnar styloid fractures were correlated with DRUJ instability after surgical treatment. RESULTS: Twenty patients had persistent DRUJ incongruence/instability following fracture fixation. As a proportion of radial length, the distance from the RCJ to the fracture line did not significantly differ between those with persistent DRUJ instability and those without (p = 0.34). The average initial ulnar variance was 5.5 mm (range 2-12 mm, SD = 3.2) in patients with DRUJ instability and 3.8 mm (range 0-11 mm, SD = 3.5) in patients without. Only 4/20 patients (20 %) with DRUJ instability had normal ulnar variance (-2 to +2 mm) versus 15/30 (50 %) patients without (p = 0.041). CONCLUSION: In the setting of a radial shaft fracture, ulnar variance greater or less than 2 mm was associated with a greater likelihood of DRUJ incongruence/instability following fracture fixation.

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.