Faculty Bibliography

Orthopaedic research has advanced tremendously in parallel with accelerated progress in medical science. Possession of a fundamental understanding of basic and clinical science has become more essential than previously for orthopaedic surgeons to be able to translate advances in research into clinical practice. The number of medical graduates with prior education in scientific research who choose to pursue careers in orthopaedic surgery is small. Therefore, it is important that a core of research education be included during residency training to ensure the continued advancement of the clinical practice of orthopaedics. The authors examine some of the challenges to a comprehensive research experience during residency, including deficient priority, inadequate institutional infrastructure, financial strain on residency budgets, restricted time, and an insufficient number of mentors to encourage and guide residents to become clinician-scientists. They also present some strategies to overcome these challenges, including development and expansion of residency programs with clinician-scientist pathways, promotion of financial sources, and enhancement of opportunities for residents to interact with mentors who can serve as role models. Successful integration of research education into residency programs will stimulate future orthopaedic surgeons to develop the critical skills to lead musculoskeletal research, comprehend related discoveries, and translate them into patient care. Lessons learned from incorporating research training within orthopaedic residency programs will have broad application across medical specialties-in both primary and subspecialty patient care.

Computed tomography (CT) has been deemed a necessary part of management for Tillaux and triplane pediatric ankle fractures. However, no previously published study has attempted to quantify its usefulness in changing management. Six third-party, blinded orthopedic surgeons (F.A.L., E.N.K., D.M.P., K.J.K., D.S.F., K.A.E.) were randomly assigned to evaluate 24 pediatric Tillaux or triplane fractures with plain radiographs; after 6 months, they were again randomly assigned to evaluate the 24 radiographs plus CT scans, totaling 144 third-party, blinded evaluations. Intra- and interobserver agreements were assessed via correlation coefficient analysis. Evaluation of CT scans changed the original diagnosis of fracture type from Tillaux to triplane fracture in 7 (4.9%) of 144 evaluations. Inter- and intraobserver agreements regarding primary treatment plans did not significantly differ between radiographs and radiographs plus CT scans (0.5 vs 0.4, respectively; P>.05). The addition of CT did not significantly change the impression of the amount of displacement per case. By adding CT, more patients who were assigned nonoperative management were reassigned to operative treatment (P=.033). Adding CT, although it may influence the decision to operate on Tillaux and triplane fractures, may not be as useful as previously thought.

OBJECTIVES: : The purpose of this study was to determine whether overlap between temporary external fixator pins and definitive plate fixation correlates with infection in high-energy tibial plateau fractures. DESIGN: : Retrospective chart and radiographic review. SETTING: : Academic medical center. PATIENTS: : Seventy-nine patients with unilateral high-energy tibial plateau fractures formed the basis of this report. INTERVENTION: : Placement of knee-spanning external fixation followed by delayed internal fixation for high-energy tibial plateau fractures treated at our institution between 2000 and 2008. METHODS: : Demographic patient information was reviewed. Radiographs were reviewed to assess for the presence of overlap between the temporary external fixator pins and the definitive plate fixation. Fisher exact and t test analyses were performed to compare those patients who had overlap and those who did not and were used to determine whether this was a factor in the development of a postoperative infection. MAIN OUTCOME MEASUREMENTS: : Development of infection in those whose external fixation pin sites overlapped with the definitive internal fixation device compared with those whose pin sites did not overlap with definitive plate and screws. RESULTS: : Six knees in six patients developed deep infections requiring serial irrigation and debridement and intravenous antibiotics. Of these six infections, three were in patients with closed fractures and three in patients with open fractures. Two of these six infections followed definitive plate fixation that overlapped the external fixator pin sites with an average of 4.2 cm of overlap. In the four patients who developed an infection and had no overlap, the average distance between the tip of the plate to the first external fixator pin was 6.3 cm. There was no correlation seen between infection and distance from pin to plate, pin-plate overlap distance, time in the external fixator, open fracture, classification of fracture, sex of the patient, age of the patient, or healing status of the fracture. CONCLUSION: : Fears of definitive fracture fixation site contamination from external fixator pins do not appear to be clinically grounded. When needed, we recommend the use of a temporary external fixation construct with pin placement that provides for the best reduction and stability of the fracture, regardless of plans for future surgery

A fracture construct, representing a worst-case model of a comminuted intertrochanteric fracture, was created in order to compare the fixation stability of two different cephalomedullary nails: one where the lag screw can telescope within itself to achieve displacement of the head-neck fragment, and the other where the solid lag screw slides only. After nail fixation, the models were loaded and then cycled, and positions of the head-neck fragment and lag screw were determined. Both nails similarly acted to limit motion of the head-neck fragment by the sliding of their lag screws, causing impingement of the fragment against the nail. Fragment movement was achieved with significantly less force with the telescoping lag screws, which also showed no final lateral projection from the nail. This was in contrast to the solid lag screws that demonstrated lateral projection in all cases.

The purpose of this retrospective chart and radiographic review is to describe an effective reduction technique during intramedullary nailing of distal metaphyseal tibia fractures with the use of a pointed percutaneous clamp. Between 2007 and 2010, 100 patients who sustained 102 tibia fractures were definitively treated with an intramedullary nail at one of two medical centers. Diaphyseal fractures and injuries with an associated disruption of the distal tibiofibular joint were excluded from our study. A total of 27 patients with 27 distal metaphyseal tibia fractures (OTA types 42-A, 43-A, and 43-B) were included. All 27 patients underwent IM nailing of their fractures with anatomic reduction achieved using a percutaneously placed pointed reduction clamp prior to insertion of the IM implant. Fracture alignment and angular deformity was assessed using goniometric measurement functions on the PACS system (GE, Waukeshau, WI) obtained from preoperative and postoperative anteroposterior and lateral images for all subjects. Malalignment was defined as more than 5 degrees of angulation in any plane. Fourteen of the fractures were classified as OTA 42-A, 9 were OTA 43-A, and 4 were OTA 43-B. Analysis of post-closed reduction, preoperative anteroposterior radiographs revealed a mean of 7.9 degrees of coronal plane (range: 0.9 degrees-26 degrees) angulation. Post closed reduction preoperative lateral radiographs revealed a mean of 6.8 degrees sagittal plane (range: 0 degrees-24.6 degrees) angulation. Postoperative anteroposterior and lateral radiographs showed the distal segment returned to its anatomical alignment with a mean angulation of 0.5 degrees (range, 0 degrees-3.5 degrees) and 0.7 degrees (range, 0 degrees-4.2 degrees) of varus/ valgus and apex anterior/posterior angulation, respectively. These results showed an acceptable postopertative alignment in all 27 distal third fractures. No intra-operative or postoperative complications were noted in the study group. This study suggests that the use of percutaneous clamps during intramedullary nailing of distal metaphyseal tibia fractures is an easily-reproducible and effective method of reduction with no associated intraoperative complications.

BACKGROUND: Although most medical centers are equipped for 24-h care, some 'middle of the night' services may not be as robust as they are during daylight hours. This would have potential impact upon certain outcome measurements in trauma patients. The purpose of this paper was to assess the effect of patient arrival time at hospital emergency departments on in-hospital survival following trauma. MATERIALS AND METHODS: Data of patients, 18 years of age or older, with no evidence that they were transferred to or from that center were obtained from the National Trauma Data Bank Version 7.0. Patients meeting the above criteria were excluded if there was no valid mortality status, arrival time information, injury severity score, or trauma center designation. The primary analyses investigated the association of arrival time and trauma center level on mortality. Relative risks of mortality versus patient arrival time and trauma level were determined after controlling for age, gender, race, comorbidities, injury, region of the country, and year of admission. RESULTS: In total, 601,388 or 71.7% of the 838,284 eligible patients were retained. The overall in-hospital mortality rate was 4.7%. The 6 p.m. to 6 a.m. time period had a significantly higher adjusted relative risk for in-hospital mortality than the 6 a.m. to 6 p.m. time frame (ARR=1.18, P<;0.0001). This pattern held across trauma center levels, but was the weakest at Level I and the strongest at Level III/IV centers (Level I: ARR=1.10, Level II: ARR=1.14, and combined Level III/IV: ARR=1.32, all P<0.0001). CONCLUSION: Hospital arrival between midnight and 6 a.m. was associated with a higher mortality rate than other times of the day. This relationship held true across all trauma center levels. This information may warrant a redistribution of hospital resources across all time periods of the day

In 2009, 36.9 million people living in the USA were over the age of 65 years. It is speculated that by the year 2030, that number will jump to 72.1 million. The increased physical demand of the aging American population has been accompanied by an amplification in the number and severity of ankle and foot fractures in the elderly. This article reviews the various issues associated with ankle and foot fractures in this potentially complex patient population, focusing on risk factors for fracture and the continued debate over surgical versus nonsurgical management. The higher level of activity of the aging American population has significantly increased the incidence of ankle and foot fractures in the elderly. Although certain authors have suggested that osteoporosis is the single strongest risk factor for both foot and ankle fractures, it appears that lifestyle factors such as an increased BMI and a propensity for falling play a larger role in ankle fractures, while foot fractures are more typical fragility fractures. Caused by the prevalence of medical comorbidities in older patients, controversy exists over the optimal management of these fractures. While early investigators cited unacceptable postoperative complication rates and poor outcome following surgical management, more recent studies have demonstrated superior outcome following operative treatment. These authors agree that chronological age should not dictate the management of foot and ankle fractures, but rather level of functional activity and the presence of co-morbid medical conditions. Based on current evidence, the literature supports the surgical treatment of displaced ankle, calcaneus, metatarsal, talus and Lisfranc fractures in geriatric patients who are surgical candidates. 2011 Future Medicine Ltd

Ankle fractures are among the most common injuries managed by orthopaedic surgeons. Many ankle fractures are simple, with straightforward management leading to successful outcomes. Some fractures, however, are challenging, and debate arises regarding the best treatment to achieve an optimal outcome. Some patients have medical comorbidities that increase the risk for complications or may require modifications to standard surgical techniques and fixation methods. Several recent investigations have highlighted the pitfalls in accurately reducing syndesmotic injuries. Controversy remains regarding the number and diameter of screws, the duration of weight-bearing limitations, and the need or timing of screw removal. Open reduction may allow more accurate reduction than standard closed methods. Direct fixation of associated posterior malleolus fractures may provide improved syndesmotic stability. Posterior malleolus fractures vary in size and can be classified based on the orientation of the fracture line. As the size of the posterior malleolus fracture fragment increases, the load pattern in the ankle is altered. Direct or indirect reduction and surgical fixation may be required to prevent posterior talar subluxation and restore articular congruency. The supination-adduction fracture pattern is also important to recognize. Articular depression of the medial tibial plafond may require reduction and bone grafting. Optimal fixation requires directing screws parallel to the ankle joint or using a buttress plate. Identifying ankle fractures that may present additional treatment challenges is essential to achieving a successful outcome. A careful review of radiographs and CT scans, a thorough patient assessment, and detailed preoperative planning are needed to improve patient outcomes

BACKGROUND: Locking plates have become a commonly used fixation device in the operative treatment of three- and four-part proximal humerus fractures. Examining function in patients treated nonoperatively and operatively should help determine whether and when surgery is appropriate in these difficult-to-treat fractures. QUESTIONS/PURPOSES: We compared functional scores, ROM, and radiographs in patients with one-part proximal humerus fractures treated nonoperatively to those in patients with displaced three- and four-part proximal humerus fractures treated with open reduction and internal fixation using locking plates. PATIENTS AND METHODS: We retrospectively reviewed 142 patients with proximal humerus fractures treated with a standardized treatment algorithm over a 6-year period. Three- and four-part fractures were treated surgically while one-part fractures were treated nonoperatively. Functional scores, ROM, and radiographs were used to evaluate outcomes. American Shoulder and Elbow Surgeons and SF-36 scores were obtained at 12 months. Of the 142 patients, 101 (51 with three- or four-part fractures and 50 with one-part fractures) had a minimum followup of 12 months (average, 19 months; range, 12-64 months). RESULTS: The fractures united in all patients. At 1 year, the patients with one-part fractures had better SF-36 physical and mental scores and American Shoulder and Elbow Surgeons scores than the three- and four-part fractures. Both groups had similar shoulder ROM. Nine patients treated operatively had complications, four of which were related to screw penetration into the joint. CONCLUSIONS: Patients with three- and four-part fractures should be advised of the likelihood of persistent functional impairment and a relatively higher risk of complications when treated operatively with locked plates. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence