Faculty Bibliography

PURPOSE: Rib fractures are a common chest injury that can typically be treated nonoperatively. However, a percentage of these will go on to nonunion, either because of unique characteristics of the fracture itself or because of a variety of poor healing factors of the host. If a patient has continued symptomology beyond 3 months, surgeons may consider operative management. METHODS: Although isolated resection of fibrous scar tissue from the nonunion site may be sufficient in some cases, it may also be necessary to provide additional structural integrity to the rib depending on the extent of the fracture pattern and resection. This goal can be achieved operatively with rib plating and bone grafting to promote healing. RESULTS: This video demonstrates the use of plating in the treatment of rib nonunion. It begins with relevant background information on rib fractures and nonunions, then details the approach, open reduction and internal fixation of 3 ribs using plates and bone graft aspirate. Pearls and pitfalls are included during the surgical technique aspect of the video to both help guide surgeons new to the procedure and provide potentially advantageous technical details to more experienced surgeons.

OBJECTIVES: To document the complications among obese patients who underwent surgical fixation for intertrochanteric femur (IT) fractures and to compare with nonobese patients. DESIGN: Retrospective cohort study. SETTING: Four level I trauma centers. PATIENTS: 1078 IT fracture patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Patient and fracture characteristics, surgical duration, surgical delay intraoperative and postoperative complications, inpatient mortality, and length of stay. METHOD: A retrospective review at 4 academic level I trauma centers was conducted to identify skeletally mature patients who underwent surgical fixation of intertrochanteric fractures between June 2008 and December 2014. Descriptive data, injury characteristics, OTA fracture classification, and associated medical comorbidities were documented. The outcomes measured included in-hospital complications, length of stay, rate of blood transfusion, change in hemoglobin levels, operative time, and wound infection. RESULTS: Of 1078 unique patients who were treated for an IT fracture, 257 patients had a Body mass index (BMI) of 30 or greater. Patients with a high BMI (>/=30) had a significantly lower mean age (73 vs. 77 years, P < 0.0001), higher percentage of high-energy injuries (18% vs. 9%, P = 0.0004), greater mean duration of surgery (96 vs. 86 minutes, P = 0.02), and higher mean length of stay (6.5 vs. 5.9 days, P = 0.004). The high-BMI group (n = 257) had significantly higher percentages of patients with complications overall (43% vs. 28%, P < 0.0001), respiratory complications (11% vs. 3%, P < 0.0001), electrolyte abnormalities (4% vs. 2%, P = 0.01), and sepsis (4% vs. 1%, P = 0.002). Patients with BMI >/= 40 had a much higher rate of respiratory complications (18%) and wound complications (5%) than obese (BMI: 30-39.9) and nonobese patients (BMI < 30). CONCLUSION: Intertrochanteric hip fracture patients with a BMI of >30 kg/m are much more likely to sustain systemic complications including respiratory complications, electrolyte abnormalities, and sepsis. In addition, morbidly obese patients are more likely to sustain respiratory complications and wound infections than obese (BMI: 30-39.9 kg/m) and nonobese patients (BMI: < 30 kg/m). The findings from this study can help direct surgeons in the counseling to obese patients and their family, and perhaps increase hospital reimbursement for this group of patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fracture management in pregnant patients is challenging. Anatomic and physiologic changes in pregnancy increase the complexity of treatment. Maternal trauma increases the risk of fetal loss, preterm birth, placental abruption, cesarean delivery, and maternal death. Initial resuscitation and treatment in a facility equipped to handle the orthopaedic injury and preterm births are paramount. Pelvic and acetabular injuries are potentially life threatening. The benefits and risks of surgical treatment must be carefully considered. The risks posed by anesthetic agents, antibiotic agents, anticoagulant agents, and radiation exposure must be understood. Positioning of the patient can affect the viability of the fetus. If surgery is necessary, the left lateral decubitus position decreases fetal hypotension. A specialized team including an obstetrician, perinatologist, orthopaedic surgeon, general trauma surgeon, critical care specialist, emergency medicine specialist, anesthesiologist, radiologist, and nurse must collaborate to improve maternal and fetal outcomes.

AIMS: The purpose of this study was to determine if there was an association between iatrogenic fractures and closed reduction of shoulder dislocations. PATIENTS AND METHODS: In a retrospective case series, 150 consecutive patients with acute first time shoulder dislocations were evaluated. Patient demographics, direction of dislocation, associated injuries, reduction methods, number of attempts, and type of anesthesia/analgesia were determined. Pre- and post-reduction radiographs and medical record were reviewed to identify the presence of proximal humerus fractures. RESULTS: There were thirty nine fracture-dislocations (26%) of the proximal humerus. Eight patients (5%) failed reduction on initial attempt. Four of these (3%) were unable to be reduced in the emergency room and were taken to OR for reduction. There was no statistically significant difference in reduction maneuver or type of anesthesia/analgesia used when comparing fracture-dislocations to dislocations only (p<0.05). No new fractures after reduction were identified. CONCLUSION: Iatrogenic fractures of the proximal humerus due to reduction of a shoulder dislocation are extremely rare. None were identified in this review of 150 patients. We believe that closed reduction is safe even in the setting of fracture dislocations.

PURPOSE: The purpose of this study was to investigate the early complications associated with the dorsal approach to the proximal radius. This approach, also called the Thompson approach, is used relatively infrequently for the treatment of forearm fractures. It is primarily reserved for proximal one-third radius fractures where a volar plate may not be placed sufficiently proximal for adequate fixation. METHODS: A retrospective chart review was performed on forearm fractures performed at our institution. Over a period from January 2008 to May 2014 a total of 120 patients underwent fixation for radius shaft fractures either isolated or associated with ulna fractures; of these 120 patients, 11 were found to have utilized the Thompson approach to the proximal radius. Demographic data was collected, along with fracture pattern, and associated complications in the first 2 weeks after surgery. RESULTS: The average age of the patients was 31 years (range: 20 to 46 years). Ten patients were male and one was female. The mean follow-up time was 15 weeks (range: 1 to 52 weeks). The stated indication for the dorsal approach was a proximal location of the radius fracture in 10 cases and presence of dorsal open wounds in one patient. In all cases, the posterior interosseous nerve was identified and protected. The average distance from the fracture to the radial head articular surface was 72 mm (range: 34 mm to 132 mm). Four fractures were open, and seven were closed injuries. There were two postoperative posterior interosseous nerve palsies, along with one compartment syndrome requiring fasciotomy. There were no wound complications. There was an overall complication rate of 27%. CONCLUSION: Postoperative posterior interosseous nerve palsy was the most common complication in this series, occurring in 18% of the patients in spite of identification and protection of the nerve throughout the procedure. High vigilance for compartment syndrome must also be maintained after fixation of any forearm fracture, as it occurred in 1 of 11 patients in this study.

The fibula microvascular free flap is widely used for mandible reconstruction including patients with medication- related osteonecrosis of the jaw(MRONJ) who are refractory to conservative management.1 In comparison with other free flaps used in mandible reconstruction, the fibula provides the greatest bone length and provides soft tissue replacement. While the fibula has little effect on bearing weight, it is an essential insertion for the biceps femoris muscle, one of the hamstrings, which assists in flexion of the knee as well as rotation of the leg. In addition, it is an attachment of the fibular collateral ligament, a structural component of the knee joint.2 There is a paucity of literature related to the feasibility of mandible reconstruction utilizing a microvascular free fibula flap in a patient with previous knee replacement surgery. Our patient is a 60-year-old female diagnosed with medication-related osteonecrosis of the jaw (MRONJ). She was refractory to multiple courses of antibiotic therapy and oral rinses. Upon physical examination, intraorally she has draining fistula at the right body of the mandible. Computed tomography of the mandible was significant for osteolytic bone destruction from at the body of the right mandible and nearing the inferior border. Her concerning surgical history included bilateral knee replacements which was taken into consideration during surgical planning. Due to the size of the planned defect, reconstruction with a fibula microvascular free flap was planned using virtual surgical planning (Medical Modeling Inc., Golden CO) and a prefabricated reconstruction plate (Stryker, Kalamazoo, MI). The surgical procedure included a tracheostomy, segmental resection of the right body of the mandible, rigid fixation, extraction of all teeth and microvascular fibular free flap reconstruction. The patient continued physical therapy and occupational therapy and became full weight bearing 12-days postoperatively. The patient was back to her preoperative ambulatory status one month after surgery. An English language search of three databases (PubMed, Science Direct, OvidMD) was performed to determine if a microvascular free fibula flap had been attempted in a patient with a history of knee replacement. The dearth of literature related to this concern lead to an interdisciplinary meeting between the Oral and Maxillofacial Surgery, Plastic Surgery, and Orthopaedic Surgery services to review the feasibility and risks for the proposed reconstruction in our patient. It was determined that as long as 10 cm of superior bone was to remain in place, the stability of the patient's knee should not be compromised. We conclude that microvascular fibular graft reconstruction of the mandible remains an option for patients with bilateral knee replacement

OBJECTIVE: To examine the potential benefits and risks associated with weight-bearing after intramedullary (IM) nailing of unstable tibial shaft fractures. DESIGN: Randomized controlled trial. SETTING: Two New York State level 1 trauma centers, one level 2 trauma center, and 1 tertiary care orthopaedic hospital in a large urban center in New York City. PATIENTS/PARTICIPANTS: Eighty-eight patients with 90 tibial shaft fractures were enrolled. The following were used as inclusion criteria: (1) skeletally mature adult patients 18 years of age or older, (2) displaced fractures of tibial diaphysis (OTA type 42) treated with operative intervention, and (3) radiographs, including injury, operative, and completion of follow-up. Sixty-eight patients with 70 tibial shaft fractures completed follow-up. INTERVENTION: All patients were treated with locked IM nailing. Patients were randomized to 1 of 2 groups: immediate weight-bearing-as-tolerated (WBAT) or non-weight-bearing for the first 6 postoperative weeks (NWB). MAIN OUTCOME MEASURES: Fracture union or treatment failure/revision surgery. RESULTS: There was no statistical difference in the observed time to union between groups (WBAT = 22.1 +/- 11.7 weeks vs. NWB = 21.3 +/- 9.9 weeks; P = 0.76). Rates of complications did not statistically differ between groups. No fracture loss of reduction leading to malunion was encountered. Short Musculoskeletal Function Assessment scores for all domains did not statistically differ between groups. CONCLUSIONS: Immediate weight-bearing after IM nailing of tibial shaft fractures is safe and is not associated with an increase in adverse events or complications. Patients should be allowed to bear weight as tolerated after IM nailing of OTA subtype 42-A and 42-B tibial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Distal radius fractures are very common injuries and surgical treatment for them can be painful. Achieving early pain control may help improve patient satisfaction and improve functional outcomes. Little is known about which anesthesia technique (general anesthesia versus brachial plexus blockade) is most beneficial for pain control after distal radius fixation which could significantly affect patients' postoperative course and experience. QUESTIONS/PURPOSES: We asked: (1) Did patients receiving general anesthesia or brachial plexus blockade have worse pain scores at 2, 12, and 24 hours after surgery? (2) Was there a difference in operative suite time between patients who had general anesthesia or brachial plexus blockade, and was there a difference in recovery room time? (3) Did patients receiving general anesthesia or brachial plexus blockade have higher narcotic use after surgery? (4) Do patients receiving general anesthesia or brachial plexus blockade have higher functional assessment scores after distal radius fracture repair at 6 weeks and 12 weeks after surgery? METHODS: A randomized controlled study was performed between February, 2013 and April, 2014 at a multicenter metropolitan tertiary-care referral center. Patients who presented with acute closed distal radius fractures (Orthopaedic Trauma Association 23A-C) were potentially eligible for inclusion. During the study period, 40 patients with closed, displaced, and unstable distal radius fractures were identified as meeting inclusion criteria and offered enrollment and randomization. Three patients (7.5%), all with concomitant injuries, declined to participate at the time of randomization as did one additional patient (2.5%) who chose not to participate, leaving a final sample of 36 participants. There were no dropouts after randomization, and analyses were performed according to an intention-to-treat model. Patients were randomly assigned to one of two groups, general anesthesia or brachial plexus blockade, and among the 36 patients included, 18 were randomized to each group. Medications administered in the postanesthesia care unit were recorded. Patients were discharged receiving oxycodone and acetaminophen 5/325 mg for pain control, and VAS forms were provided. Patients were called at predetermined intervals postoperatively (2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours) to gather pain scores, using the VAS, and to document the doses of analgesics consumed. In addition, patients had regular followups at 2 weeks, 6 weeks, and 12 weeks. Pain scores were again recorded using the VAS at these visits. RESULTS: Patients who received general anesthesia had worse pain scores at 2 hours postoperatively (general anesthesia 6.7 +/- 2.3 vs brachial plexus blockade 1.4 +/- 2.3; mean difference, 5.381; 95% CI, 3.850-6.913; p < 0.001); whereas reported pain was worse for patients who received a brachial plexus blockade at 12 hours (general anesthesia 3.8 +/- 1.9 vs brachial plexus blockade 6.3 +/- 2.4; mean difference, -2.535; 95% CI, -4.028 to -1.040; p = 0.002) and 24 hours (general anesthesia 3.8 +/- 2.2 vs brachial plexus blockade 5.3 +/- 2.5; mean difference, -1.492; 95% CI, -3.105 to 0.120; p = 0.031).There was no difference in operative suite time (general anesthesia 119 +/- 16 minutes vs brachial plexus blockade 125 +/- 23 minutes; p = 0.432), but time in the recovery room was greater for patients who received general anesthesia (284 +/- 137 minutes vs 197 +/- 90; p = 0.0398). Patients who received general anesthesia consumed more fentanyl (64 mug +/- 93 mug vs 6.9 mug +/- 14 mug; p < 0.001) and morphine (2.9 mug +/- 3.6 mug vs 0.0 mug; p < 0.001) than patients who received brachial plexus blockade. Functional outcome scores did not differ at 6 weeks (data, with mean and SD for both groups, and p value) or 12 weeks postoperatively (data, with mean and SD for both groups, and p value). CONCLUSIONS: Brachial plexus blockade pain control during the immediate perioperative period was not significantly different from that of general anesthesia in patients undergoing operative fixation of distal radius fractures. However, patients who received a brachial plexus blockade experienced an increase in pain between 12 to 24 hours after surgery. Acknowledging "rebound pain" after the use of regional anesthesia coupled with patient counseling regarding early narcotic administration may allow patients to have more effective postoperative pain control. It is important to have a conversation with patients preoperatively about what to expect regarding rebound pain, postoperative pain control, and to advise them about being aggressive with taking pain medication before the waning of regional anesthesia to keep one step ahead in their pain control management. LEVEL OF EVIDENCE: Level 1, therapeutic study.

PURPOSE: This study compares clinical and functional outcomes of patients with displaced olecranon fractures treated with either tension band wiring (TBW) or a hook plate construct. METHODS: We performed a retrospective review of olecranon fractures operatively treated with either TBW or plate fixation (PF) using a hook plate over a 7-year period. Patient demographics, injury information, and surgical management were recorded. Fractures were classified according to the Mayo system. Measured outcomes included range of elbow motion, time to union, and development of postoperative complications. Mayo Elbow Performance Index (MEPI) scores were obtained for all patients. All patients were followed for a minimum of 6 months. RESULTS: A total of 48 patients were included in this study, 23 treated with TBW and 25 treated with hook PF. Groups did not differ with respect to patient demographics, Mayo fracture type, or duration of follow-up. Patients undergoing PF had less terminal extension than TBW patients (-8.6 degrees +/- 7 degrees vs. -3.5 degrees +/- 9.3 degrees , p = 0.036) and a longer time to radiographic union (19 +/- 8 vs. 12 +/- 6 weeks, p = 0.001). There were no differences in rates of symptomatic hardware, MEPI scores, or other clinical outcomes. Two patients in each group required a second surgery. CONCLUSIONS: TBW and PF of olecranon fractures had similarly excellent functional outcomes in this study. Patients undergoing PF had a longer time to union and slightly worse extension at final follow-up. TBW remains an effective treatment for appropriately selected olecranon fractures and in this cohort outperformed plate osteosynthesis.