Faculty Bibliography

BACKGROUND: Two-part proximal humerus fractures are common orthopedic injuries for which surgical intervention is often indicated. Choosing a fixation device remains a topic of debate. PURPOSE: The purpose of this study is to compare two methods of fixation for two-part proximal humerus fractures, locking plate (LP) with screws versus intramedullary nailing (IMN), with respect to alignment, healing, patient outcomes, and complications. To our knowledge, a direct comparison of these two devices in treating two-part proximal humerus fractures has never before been studied. We hope that our results will help surgeons assess the utility of LP versus IMN. METHODS: A retrospective chart review was performed on 24 cases of displaced two-part surgical neck fractures of the humerus. Twelve shoulders were treated using IMN fixation and 12 others were fixated with LP. Data collected included sociodemographic, operative details, and postoperative care and function. RESULTS: Radiographic comparison of fixation demonstrated an average neck-shaft angle of 124 degrees and 120 degrees in the IMN group and LP group, respectively. Adjusted postoperative 6-month follow-up range of motion was 134 degrees of forward elevation in the IMN group and 141 in the LP group. The differences in range of motion and in complication rates were not found to be significant. CONCLUSIONS: Our results suggest that either LP fixation or IMN fixation for a two-part proximal humerus fracture provides acceptable fixation and results in a similar range of shoulder motion. Although complication rates were low and insignificant between the two groups, a trend toward increased complications in the IMN group is noted.

Wire breakage and migration is a known complication of using a wire tension band construct to treat displaced patella fractures. We report a case of a broken K-wire that migrated from the patella completely into the proximal tibia without complication 9 years after the index surgery. This report highlights the fact that wire migration can occur long after fracture healing and be relatively asymptomatic. But because the complications of wire migration can be deadly, it requires diligence on the part of the physician to educate the patient that new knee pain after operative fixation requires formal evaluation by the treating surgeon.

PURPOSE: Nonunions of the upper and lower extremity have been associated with pain and functional deficits. Recent studies have demonstrated that healing of these nonunions is associated with pain relief and both subjective and objective functional improvement. The purpose of this study was to determine which patient and surgical factors correlated with successful healing of a nonunion following surgical intervention. METHODS: Between September 2004 and February 2008, all patients with a "long bone nonunion" presenting to our academic trauma service were enrolled in a prospective data base. Baseline functional, demographic and pain status was obtained. Follow-up was obtained at 3, 6, and 12 months following surgical intervention, with longer follow-up as possible. One hundred and thirty-four patients with a variety of fracture nonunions were operated on by four different fellowship trained trauma surgeons with experience ranging from 2 to 15 years and variable nonunion surgery loads. Patients were stratified into one of three groups: 1. Patients who healed following one surgical intervention, 2. those who healed following multiple surgical intervention, and 3. those who failed to heal (remain ununited or underwent amputation). Healing was determined radiographically and clinically. Complications were recorded. Logistic regression analysis was performed to assess the cor-relation between specific baseline and surgical characteristics and healing. RESULTS: A minimum of 1 year follow-up was available for all 134 patients. One hundred and one patients (76%) with a mean age of 50 years healed at a mean of 6 months (range, 3 to 16) after one surgery. Twenty-two patients (16%) with a mean age of 47 years, who required more than one intervention, healed their nonunions at a mean of 11 months (range, 4 to 23). Eleven patients (8%) with a mean age of 50 years failed to heal at an average of 12 months follow-up. Complication rates were 11%, 68%, and 100% respectively for those who healed following one procedure, multiple procedures, and those who never healed. Higher surgeon volume (greater than 10 cases per year) was associated with 85% increased healing rates (OR = 0.15, 0.05-0.47 CI). The presence of a postoperative complication was associated with a 9 times lower likelihood of successful union as well (OR = 9.0, 2.6-31.7 CI). Patient age, sex, BMI, initial injury mechanism, tobacco use, and initial injury characteristics did not correlate with failure to heal. CONCLUSION: Our data is similar to other studies assessing outcomes following other complex reconstructive procedures. It appears that more experienced (higher volume) reconstructive surgeons and the development of fewer postoperative complications is associated with greater success following repair of a long bone nonunion. Infection at any point during treatment is associated with failure to achieve successful union.

We conducted a study to evaluate the outcomes and complications of open reduction and internal fixation (ORIF) of 2-, 3-, and 4-part proximal humerus fractures using a standard management protocol with locking plates. Of 72 patients with acute proximal humerus fractures managed with ORIF and locking plates, 63 were available at the minimum follow-up of 1 year and met the inclusion criteria. At each follow-up, radiographs were reviewed for healing, hardware failure, osteonecrosis, shoulder range of motion, and DASH (Disabilities of the Arm, Shoulder, and Hand) scores; any complications were recorded. Mean age was 62 years and mean follow-up was 19 months. There were 12 two-part fractures, 42 three-part fractures, and 9 four-part fractures. Thirteen patients had complications. Mean shoulder forward elevation was 135; patients with complications had a significantly lower mean forward elevation (P=.002). DASH scores were significantly lower in patients without complications than in those with complications (P=.01). Although excellent outcomes can be achieved when locking plates are used to manage proximal humerus fractures, complications are possible. Physicians must weigh the functional outcome data when considering management options for these types of injuries.

Both early and late complications following open reduction and internal fixation of proximal humerus fractures have been reported extensively in the literature. Although orthopedic implants are known to cause irritation and inflammation, to our knowledge, this is the first case report to describe a patient with rice bodies secondary to an orthopedic implant. Although the etiology of rice bodies is unclear, histological studies reveal that they are composed of an inner amorphous core surrounded by collagen and fibrin. The differential diagnosis in this case included synovial chondromatosis, infection, and the formation of a malignant tumor. Additional imaging studies, such as magnetic resonance imaging, and more specific tests were necessary to differentiate the rice bodies due to bursitis versus neoplasm, prior to excision. The patient presented 5 years following open reduction and internal fixation of a displaced proximal humerus frature, with swelling in the area of the previous surgical site. Examination revealed a large, painless tumor-like mass on the anterior aspect of the shoulder. The patient's chief concern was the unpleasant aesthetic of the mass; no pain was reported. Upon excision of the mass, the patient's full, painless range of motion returned.

OBJECTIVES: : Recombinant human parathyroid hormone (PTH 1-34) has been previously shown to enhance fracture healing in animal models. Here, we sought to determine whether the systemic administration of PTH 1-34 is effective in preventing atrophic fracture nonunion in a murine, surgical nonunion model. METHODS: : We used an established reproducible long-bone murine fracture nonunion model by generating a midshaft femur fracture, followed by fracture distraction using an intramedullary pin and custom metallic clip to maintain a fracture gap of 1.7 mm. Mice were randomized to receive either daily intraperitoneal injections of 30 mug/kg PTH 1-34 for 14 days or saline injections. At 6 weeks after the procedure, radiographic and histologic assessment of fracture healing was performed. RESULTS: : At 6 weeks after surgery, the group treated with PTH showed higher rates of bony union (50% vs 8%; P < 0.05) as assessed by radiographic analysis. Mean gap size was also significantly lower in the PTH group (1.42 vs 0.36 mm in the control group; P < 0.05). Histologic analysis of atrophic nonunions in the control group revealed a persistent fracture gap with intervening fibrous tissue. In contrast, healed subjects in the PTH-treated group had cortical bridging with mature bone and relatively little callus, which is consistent with primary intramembranous ossification. CONCLUSIONS: : Daily systemic administration of recombinant PTH 1-34 increased the rate of union in a mouse atrophic nonunion model. This may have important implications for the potential clinical role of PTH 1-34 in the treatment of atrophic fracture nonunions.

OBJECTIVES: : The purpose of this study was to compare the outcome after the operative treatment of patella fractures (PFs) as compared with those of quadriceps tendon and patella tendon (PT) ruptures. DESIGN: : This pertains to a retrospective case control. SETTING: : The setting was in academic teaching hospitals. PATIENTS: : Ninety-four patients with 99 extensor mechanism disruptions were treated operatively. Of these, 50 (50%) were PFs; 36 (37%) were quadriceps ruptures; and 13 (13%) were PT ruptures. MAIN OUTCOME MEASURES: : The patients were evaluated at 6 and 12 months and were tested for range of motion, quadriceps circumference and strength, SF36, Lysholm, and Tegner outcome scores by independent observers. Radiographs of the knee were obtained to assess bony healing, posttraumatic arthritis, and heterotopic ossification RESULTS: : A minimum of 12-month follow-up (range 12-81 months) was available for 76 patients (77%). PFs were seen more commonly in women (P < 0.001) and PT ruptures tended to occur in younger males (P < 0.001), with no difference in the body mass index. Thigh circumference was significantly smaller than normal in PFs at 1 year as compared with tendon injuries. At latest follow-up, there were no significant differences noted with respect to knee range of motion, radiographic arthritis, Tegner, Lysholm, or SF36 scores. CONCLUSIONS: : There were no significant differences with regard to outcome in patients sustaining these injuries. LEVEL OF EVIDENCE: : Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A retrospective review of surgically treated lower-extremity long-bone fractures in wheelchair-bound patients was conducted. Between October 2000 and July 2009, eleven lower-extremity fractures in 9 wheelchair-bound patients underwent surgical fixation. The Short Musculoskeletal Function Assessment, Short Form, and Spinal Cord Injury Quality of Life questionnaires were used to assess functional outcome.Mechanism of injury for all patients was a low-energy fall that occurred while transferring. Four patients who sustained a distal femur fracture, 1 patient who sustained a distal femur fracture and a subsequent proximal tibia fracture, and 1 patient who sustained a proximal third tibia shaft fracture underwent open reduction and internal fixation with plates and screws. Three patients with 4 midshaft tibia fractures underwent intramedullary nailing.At last follow-up, all 9 patients had returned to their baseline preoperative function. Quality of life was significantly higher (P<.01) than the Spinal Cord Injury Quality of Life questionnaire's reference score. Self-reported visual analog scale pain scores improved significantly from time of fracture to last follow-up (P=.02). All fractures achieved complete union, and no complications were reported. This study's findings demonstrate that operative treatment in active, wheelchair-bound patients can provide an improved quality of life postinjury and a rapid return to activities.

OBJECTIVES: : To compare postoperative pain control in patients treated surgically for ankle fractures who receive popliteal blocks with those who received general anesthesia alone. DESIGN: : Institutional Review Board approved prospective randomized study. SETTING: : Metropolitan tertiary-care referral center. PATIENTS: : All patients being treated with open reduction internal fixation for ankle fractures who met inclusion criteria and consented to participate were enrolled. INTERVENTIONS: : Patients were randomized to receive either general anesthesia (GETA) or intravenous sedation and popliteal block. MAIN OUTCOME MEASURES: : Patients were assessed for duration of procedure, total time in the operating room, and postoperative pain at 2, 4, 8, 12, 24, and 48 hours after surgery using a visual analog scale. RESULTS: : Fifty-one patients agreed to participate in the study. Twenty-five patients received popliteal block, while 26 patients received GETA. There were no anesthesia-related complications. At 2, 4, and 8 hours postoperatively, patients who underwent GETA demonstrated significantly higher pain. At 12 hours, there was no significant difference between the 2 groups with regard to pain control. However, by 24 hours, those who had received popliteal blocks had significantly higher pain with no difference by 48 hours. CONCLUSIONS: : Popliteal block provides equivalent postoperative pain control to general anesthesia alone in patients undergoing operative fixation of ankle fractures. However, patients who receive popliteal blocks do experience a significant increase in pain between 12 and 24 hours. Recognition of this "rebound pain" with early narcotic administration may allow patients to have more effective postoperative pain control. LEVEL OF EVIDENCE: : Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.