Faculty Bibliography

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.

BACKGROUND: Many institutions perform radiographic documentation following splint application even when no manipulation had been performed. The purpose of this study was to evaluate the utility of post-splinting radiographs of acute non-displaced or minimally displaced fractures that did not undergo manipulation. Our hypothesis was that post-splinting radiographs do not demonstrate changes in fracture alignment or impact the management of the patient. METHODS: After institutional review board exemption had been granted, consultations performed by orthopaedic residents at a level-I trauma center from September 2008 to April 2010 were reviewed. Of 2862 consultations, 1321 involved acute fractures that were splinted. Radiographs revealed that 342 (25.9%) of the fractures were non-displaced or minimally displaced and angulated (defined as <5 mm and <10 degrees , respectively) and 204 of them had been assessed with radiographs after splinting. Consults were reviewed to ensure that the patients had not undergone manipulation prior to or during splinting. Consult notes and radiographs obtained in the emergency room (ER), as well as follow-up radiographs, were reviewed to assess ultimate outcome. RESULTS: None of the 204 fractures (134 non-displaced and seventy minimally displaced) changed alignment following splinting. Two splints were reapplied, and the fractures sites were reimaged for undocumented reasons. Patients were subjected to an average of ten radiographs (range, four to twenty-five radiographs) of their extremities in the acute setting. On average, three post-splinting radiographs (range, one to ten radiographs) were obtained. The mean time between the initial and post-splinting radiographs was three hours and thirty minutes (range, nine minutes to twenty-four hours). The most common injury was a fracture about the hand or wrist. The 122 patients with that type of injury waited an average of almost three hours for an average of three post-splinting radiographs, contributing to a total of nine radiographs performed acutely. ER visits tended to be longer for patients with post-splinting radiographs compared with those without them (p = 0.06). Follow-up radiographs were available for eighty-two patients. All fractures demonstrated maintained alignment. CONCLUSIONS: Post-splinting radiographs of non-displaced and minimally displaced fractures that do not undergo manipulation before or during immobilization are associated with longer ER waits, additional radiation exposure, and increased health-care costs without providing helpful information. While certain circumstances call for additional imaging, routine performance of post-splinting radiography of non-displaced or minimally displaced fractures should be discouraged. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

We compared standard and specialized plain radiographs with computed tomography (CT) for their ability to detect screw penetration of the articular surface of the distal radius in volar plating. Eight human cadaveric specimens were implanted with a fixed angle volar plate and 5 screws. Two groups were evaluated: (1) no articular screw penetration or (2) intra-articular screw penetration. Radiographs were obtained of each specimen. CT using 0.4 mm thickness slices were obtained and images were reconstructed in the sagittal and coronal planes. The radiographs and CTs were evaluated based on whether or not articular penetration occurred. The sensitivity, specificity, and accuracy of each radiographic modality were evaluated. CT was found to be much more sensitive and specific in detecting screw penetration than plain radiographs. The kappa (kappa) statistic demonstrated "almost perfect interobserver agreement" based on CT readings, but only "substantial interobserver agreement based on plain radiographs." CT is more sensitive and specific and achieves a higher kappa statistic than plain radiographs in detecting radiocarpal screw penetration after volar plating. CT should be used in detecting screw penetration when there is suspicion for radiocarpal joint penetration.

Mastering rapidly evolving orthopaedic surgical techniques requires a lengthy period of training. Current work-hour restrictions and cost pressures force trainees to face the challenge of acquiring more complex surgical skills in a shorter amount of time. As a result, alternative methods to improve the surgical skills of orthopaedic trainees outside the operating room have been developed. These methods include hands-on training in a laboratory setting using synthetic bones or cadaver models as well as software tools and computerized simulators that enable trainees to plan and simulate orthopaedic operations in a three-dimensional virtual environment. Laboratory-based training offers potential benefits in the development of basic surgical skills, such as using surgical tools and implants appropriately, achieving competency in procedures that have a steep learning curve, and assessing already acquired skills while minimizing concerns for patient safety, operating room time, and financial constraints. Current evidence supporting the educational advantages of surgical simulation in orthopaedic skills training is limited. Despite this, positive effects on the overall education of orthopaedic residents, and on maintaining the proficiency of practicing orthopaedic surgeons, are anticipated.

Hip fracture is a potentially devastating condition for older adults. Hip fracture leads to pain and immobilization with complications ranging from delirium to functional loss and death. Although a mainstay of treatment is orthopedic repair, a multidisciplinary comanagement approach, including medical specialists and rehabilitation, may maximize patient recovery. Using the case of Mr W, an older man who sustained a fall and hip fracture, we present evidence-based components of care both in the hospital and outpatient settings. Preoperatively, clinicians should correct medical abnormalities and consider the appropriateness, timing, and type of surgical repair in the context of the patient's life expectancy and goals of care. Perioperative care should include prophylaxis with antibiotics, chemoprophylaxis for venous thromboembolism, and correction of major clinical abnormalities prior to surgery. Pain control, delirium, and pressure ulcer prevention are important inpatient care elements. Multidisciplinary models incorporating these care elements can decrease complications during inpatient stay. Rehabilitation strategies should be tailored to patient needs; early mobilization followed by rehabilitation exercises in institutional, home, and group settings should be considered to maximize restoration of locomotive abilities. Attention to care transitions is necessary and treatment for osteoporosis should be considered. The road to recovery for hip fracture patients is long and most patients may not regain their prefracture functional status. Understanding and anticipating issues that may arise in the older patient with hip fracture, while delivering evidence-based care components, is necessary to maximize patient recovery.

OBJECTIVES: Because locked plates as a neutralization device for lag screw fracture fixation have different biomechanics than that of unlocked plates, we investigated how this would affect lag screw load at the fracture site. The purpose of this study was to assess the load at a fracture site compressed with a lag screw when both locked and unlocked plates are used as neutralization devices. MATERIALS AND METHODS: Nine cadaver femurs had a mid-shaft oblique fracture created and were fixed with a lag screw, incorporating load transducers at the fracture site and lag screw. Three neutralization plate constructs (a standard plate, a locked plate, and an offset locked plate) were sequentially applied and loaded. Loads at the fracture site and the lag screw were measured after sequential application of axial loads. RESULTS: Plate application to the lag screw fixations did not significantly change (P > 0.26) the load at the fracture site or on the lag screw that were approximately 200 N. The unlocked, locked, and offset locked plates behaved similarly. The addition of a load to the specimens did not change the lag screw loads but increased the average fracture loads by approximately 20% of the applied load. CONCLUSIONS: Unlocked and locked neutralization plates do not affect the initial compressive load across a fracture fixed by a lag screw, and both behave similarly in transferring the load when the fracture was loaded. For a well-fixed stable fracture fixed with a lag screw, there is no advantage in using a more expensive locked plate over a standard plate for neutralization purposes if adequate screw purchase can be achieved.

OBJECTIVE:: To compare the efficacy of anesthetic type on clinical outcomes after operative treatment of distal radius fractures. DESIGN:: Retrospective review of prospectively collected data. SETTING:: Academic medical center. PATIENTS:: One hundred eighty-seven patients with a distal radius fracture (OTA type 23) were identified within a registry of 600 patients. INTERVENTION:: Patients with operative distal radius fractures underwent open reduction and internal fixation with a volarly applied plate and screws under regional or general anesthesia. MAIN OUTCOME MEASUREMENTS:: Clinical, radiographic, and patient-based functional outcomes were recorded at routine postoperative intervals. Complications were recorded. RESULTS:: One hundred eighty-seven patients met inclusion criteria and had a minimum of 1-year follow-up. There were no differences between the groups with regard to patient demographics or fracture types treated. At both 3 and 6 months post surgery, pain was diminished among those patients who received a regional block. Wrist and finger range of motion for patients who received regional versus general anesthesia was improved at all follow-up points. Patients who received regional anesthesia also had higher functional scores as measured by the Disabilities of the Arm, Shoulder and Hand at 3 months (P = 0.04) and 6 months (P = 0.02). CONCLUSION:: Patients who are candidates should be offered regional anesthesia when undergoing repair of a displaced distal radius fracture.

BACKGROUND: We sought to examine fracture settling and screw penetration after open reduction-internal fixation of 2-, 3-, and 4-part proximal humeral fractures and determine whether the use of calcium phosphate cement reduced these unwanted complications. METHODS: We performed a retrospective study of prospective data. Inclusion criteria included patient age of 18 years or older and an acute traumatic fracture of the proximal humerus that was treated with open reduction-internal fixation with a locked plate. Metaphyseal defects were treated with 1 of 3 strategies: no augmentation, augmentation with cancellous chips, or augmentation with calcium phosphate cement. Various radiographic measurements were made at each follow-up visit to assess for humeral head settling or collapse. Overall, 92 patients (81%) met the inclusion criteria and form the basis of this study. Augmentation type included 29 patients (32%) with cancellous chips, 27 (29%) with calcium phosphate cement, and 36 (39%) with no augmentation. RESULTS: There were no statistical differences among the groups with respect to patient age, sex, and fracture type. At the 3, 6, and 12-month follow-up visits, there was less humeral head settling with calcium phosphate cement compared with repair with no augmentation or with cancellous chips. Findings of joint penetration were significant among patients treated with plates and screws alone versus those augmented with calcium phosphate (P = .02) and for those augmented with cancellous chips versus those augmented with calcium phosphate (P = .009). CONCLUSION: Augmentation with calcium phosphate cement in the treatment of proximal humeral fractures with locked plates decreased fracture settling and significantly decreased intra-articular screw penetration.