Faculty Bibliography

Delays in bone healing or even the development of a nonunion could be related to the concentrations and/or functions of the bone morphogenetic proteins (BMPs). The RNA expression profile of the BMPs within fracture nonunion tissue is unknown. This preliminary descriptive study was performed to define the RNA profiles of the BMPs, their receptors, and their inhibitors within human fracture nonunion tissue and correlate them to matched healing bone. All patients had hypertrophic nonunions. Tissue samples taken from the nonunion site of 15 patients undergoing surgical treatment for an established nonunion were analyzed. The RNA expression patterns of BMP-2, BMP-4, BMP-5, BMP-6, BMP-7, BMP-8; BMP receptor Types IA, IB, and II; and the BMP inhibitors chordin, Noggin, Drm (Gremlin), and follistatin were determined in the nonunion (fibrous tissue) and healing bone (callus tissue) using quantitative real-time PCR. Comparison between the nonunion and healing bone samples revealed substantially elevated concentrations of BMP-4, Drm/Gremlin, follistatin, and Noggin in nonunion tissue when compared to healing bone. In contrast, BMP-7 concentration was higher in the healing bone. Our data suggest inhibition of BMP-7, by Drm (Gremlin), follistatin, and Noggin and upregulation of BMP-4 may play an integral role in the development of nonunions

There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12-36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence

BACKGROUND: The goal of this review was to compare the functional outcomes of patients less than 60 and greater than or equal to 60 years old following operative stabilization of unstable ankle fractures. The review was conducted as a retrospective analysis of prospectively collected data at two level one trauma centers and a tertiary referral academic center. MATERIALS AND METHODS: All patients operatively treated for an unstable ankle fracture were entered into a database and prospectively followed. The postoperative protocol was standardized for all patients. Baseline characteristics, complications, additional surgery, functional status and the American Orthopaedic Foot and Ankle Society score (AOFAS) were assessed. The intervention chosen was open reduction and internal fixation of unstable ankle fractures. AOFAS hindfoot score and Short Musculoskeletal Functional Assessment (SMFA) questionnaire were used as the main outcome measures in the study. A p < 0.05 was considered significant. RESULTS: Three hundred sixty-nine (369) patients were entered into the database, 313 (84.8%) were less than 60 years old. At 3 months, 57% (32/56) of patients greater than or equal to 60 years old reported limitation of activities versus 33% (103/313) of patients less than 60 years old (p = 0.005). At 6 and 12 months, these percentages improved to 41% versus 10% (p = 0.001), and 29% versus 7.4% (p = 0.001) for older and younger individuals respectively. However, when compared to their baseline scores, both groups achieved a return to pre-injury status. Total AOFAS scores were not significantly different at 3, 6, or 12 months (p = 0.431). CONCLUSION: Operative fixation of unstable ankle fractures in patients greater than or equal to 60 years old can provide a reasonable functional result at the 1-year followup with a return to preoperative baseline even though they report more limitation of activities than younger patients

Geriatric hip fracture management requires a specialized treatment algorithm secondary to the complex medical and social needs of this patient demographic. The overall goal of the treatment is early mobilization, in an effort to prevent the complications associated with prolonged recumbency and to return the patient to functional activity. There is near-universal agreement among orthopedic surgeons that fractures about the hip require operative fixation, but surgical management in this patient population brings with it a set of issues that require important consideration. The current article reviews the perioperative considerations associated with geriatric hip fractures and takes an evidence-based look at the complex issues involved in managing these patients

BACKGROUND: Treatment of tibial stress fractures in elite dancers is centered on rest and activity modification. Surgical intervention in refractory cases has important implications affecting the dancers' careers. HYPOTHESIS: Refractory tibial stress fractures in dancers can be treated successfully with drilling and bone grafting or intramedullary nailing. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 1992 and 2006, 1757 dancers were evaluated at a dance medicine clinic; 24 dancers (1.4%) had 31 tibial stress fractures. Of that subset, 7 (29.2%) elite dancers with 8 tibial stress fractures were treated operatively with either intramedullary nailing or drilling and bone grafting. Six of the patients were followed up closely until they were able to return to dance. One patient was available only for follow-up phone interview. Data concerning their preoperative treatment regimens, operative procedures, clinical union, radiographic union, and time until return to dance were recorded and analyzed. RESULTS: The mean age of the surgical patients at the time of stress fracture was 22.6 years. The mean duration of preoperative symptoms before surgical intervention was 25.8 months. Four of the dancers were male and 3 were female. All had failed nonoperative treatment regimens. Five patients (5 tibias) underwent drilling and bone grafting of the lesion, and 2 patients (3 tibias) with completed fractures or multiple refractory stress fractures underwent intramedullary nailing. Clinical union was achieved at a mean of 6 weeks and radiographic union at 5.1 months. Return to full dance activity was at an average of 6.5 months postoperatively. CONCLUSION: Surgical intervention for tibial stress fractures in dancers who have not responded to nonoperative management allowed for resolution of symptoms and return to dancing with minimal morbidity