Faculty Bibliography

BACKGROUND: To our knowledge, no study to date has compared the use of spinal and general anesthesia in patients undergoing operative fixation of an unstable ankle fracture. The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients. METHODS: Between October 2000 and November 2006, 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively. Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia. All patients were evaluated at three, six, and twelve months postoperatively with use of standardized, validated general and limb-specific outcome instruments. Standard and multivariable analyses comparing outcomes at these intervals were performed. RESULTS: Four hundred and sixty-six patients (93%) who had been followed for a minimum of one year met the inclusion criteria. Compared with the general anesthesia group, the spinal anesthesia group had a greater mean age (p = 0.005), higher classification on the American Society of Anesthesiologists system (p = 0.03), and a greater number of patients with diabetes (p = 0.02). There was no difference in sex distribution between the groups. At three months, patients who received spinal anesthesia had significantly better pain scores (p = 0.03) and total scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 0.02). At six months, patients in the spinal anesthesia group continued to have better pain scores (p = 0.04), but there was no longer a difference in total scores (p = 0.06). At twelve months, no difference was detected between the groups in terms of functional or pain scores. There was no difference in complication rates between the groups. CONCLUSIONS: Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period. We recommend that, unless there is a specific contraindication, patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence

Background: When challenged with extremity wounds that require further debridement, edema reduction and decreased bacterial content, temporarily implanting vacuum-assisted closure reticulated open-cell foam dressings is an effective adjunct for temporary wound closure and results in enhanced flap tissue survival. Methods: A retrospective review was performed in 13 consecutive patients with a lower extremity surgical wound and exposed hardware, joint, tendon or bone who received the two-stage wound closure treatment. Primary endpoints included time to closure, total wound duration, and wound closure status upon discharge. Results: Mean time from the initial procedure until definitive closure was 4 days (range, 2-8 days). Mean wound duration before the procedure was 54 days (range, 5-120 days). All 13 wounds had delayed primary closure or random pattern flap upon discharge and remained closed throughout the length of follow-up. Conclusions: Temporarily implanted vacuum-assisted closure may be a safe and effective adjunctive therapy when applied to the undersurface of newly developed flaps

This report questions the cost and effectiveness of routinely sending explanted hardware to pathology for evaluation. Forty-six consecutive patients who had symptomatic hardware removed were enrolled in this study. Pathology reports following hardware removal were obtained, and charts were reviewed for these patients. The pathology department was contacted for related departmental procedure codes, and hospital billing records were obtained regarding the cost of the procedure. In all cases, the pathology reports gave the gross diagnosis of 'hardware' and the gross description included the measurements of the internal fixation hardware removed. In no case did the report alter the plan of the attending physician. The healthcare system may benefit by subspecialty review of the current practice of sending internal fixation devices to pathology for evaluation. We recommend a single radiographic view along with proper documentation in the postoperative report to confirm the removal of internal fixation hardware in lieu of pathologic evaluation

BACKGROUND: Ethnic disparities have been demonstrated in the treatment of chronic diseases, such as diabetes and heart disease. It is unclear if similar ethnic disparities appear with respect to recovery following fracture care. METHODS: We retrospectively reviewed 496 individuals (253 whites, 100 blacks, and 143 Latinos) with a fracture of the distal part of the radius. Assessment of physical function and pain was conducted at three, six, and twelve months following treatment. The Disabilities of the Arm, Shoulder and Hand (DASH) score was used to assess physical function, and a visual analog scale was used to assess pain. Multiple linear regression was used to model physical function and pain across ethnicity while controlling for age, sex, mechanism of injury, level of education, type of fracture, type of treatment (operative or nonoperative), and Workers' Compensation status. RESULTS: Both blacks and Latinos exhibited poorer physical function and greater pain than whites did at most follow-up points. Latinos reported more pain at each follow-up point in comparison with blacks and whites (p < 0.001 at three, six, and twelve months). These significant differences remained after controlling for Workers' Compensation status, which was also strongly associated with both pain and function. CONCLUSIONS: These findings suggest that recovery is different between ethnic groups following a fracture of the distal part of the radius. These ethnic disparities may result from multifactorial sociodemographic factors that are present both before and after fracture treatment

Obesity has been increasing steadily in the US population over the past 50 years. In trauma patients, obesity is associated with higher morbidity and mortality. There are reported increases in the incidence of cardiovascular, pulmonary, venous thromboembolic, and infectious complications in obese trauma patients. Obese patients who sustain high-energy traumatic injuries often sustain orthopedic injuries to the pelvis or lower extremities. Obese orthopedic trauma patients may be at higher risk for nerve injuries secondary to positioning, intraoperative complications, loss of reduction after surgery, increased intraoperative estimated blood loss, and increased operative times. Orthopedic surgeons must be aware of these results when treating these fractures in obese trauma patients

OBJECTIVES: It is well recognized that operative treatment of a fracture of the distal humerus requires handling of the ulnar nerve, which can cause nerve dysfunction; however, the incidence of postoperative ulnar nerve dysfunction is not well studied. Our purpose was to determine the incidence of ulnar nerve dysfunction after open reduction and internal fixation of distal humerus fractures and identify factors associated with its development. DESIGN: Retrospective cohort study from two university-based institutions. PATIENTS: The medical records of 69 patients with a minimum of 12 months follow-up (median, 15 months; range, 12-72 months) after open reduction and plate and screw fixation of a bicolumnar fracture of the distal humerus (Orthopaedic Trauma Association Types 13A and C) that did not have preoperative ulnar nerve dysfunction were reviewed retrospectively. INTERVENTION: Surgical repair of a distal humerus fracture with or without ulnar nerve transposition. MAIN OUTCOMES: Ulnar nerve function was graded immediately postoperatively and at final follow-up according to a modified system of McGowan. Those with and without ulnar neuropathy were analyzed for differences in final position of the nerve (anterior versus in the cubital tunnel), open injury, multiple procedures, ipsilateral injury, and demographic factors. RESULTS:: The incidence of immediately postoperative ulnar nerve dysfunction documented in the medical record was seven of 69 patients (10.1%) (McGowan grades: 1 [57%], 2 [43%], 3 [0%]). The incidence of ulnar nerve dysfunction at final follow-up was 16% (11 of 69 patients) (McGowan grades: 1 [72%], 2 [28%], 3 [0%]). No demographic, injury, or treatment factors were associated with a risk of postoperative ulnar nerve dysfunction. CONCLUSION: There is a substantial incidence of postoperative ulnar nerve dysfunction after open reduction and plate and screw fixation of the distal humerus, which is likely underestimated by this retrospective analysis. Prospective studies using careful preoperative nerve evaluation and systematic postoperative nerve assessment are likely to identify an even higher incident of postoperative ulnar nerve dysfunction. Transposition was not protective in this analysis

Hip dislocations are uncommon injuries that result from high-energy mechanisms. These patients require careful trauma evaluation to rule out concomitant injuries. Early closed or open reduction that is performed within 6 hours and close radiological follow-up is recommended to obtain the best possible results. It is also essential to educate the patient regarding the potential sequelae and follow them for evidence of osteonecrosis and posttraumatic arthritis

BACKGROUND: There is much debate regarding the optimal treatment of displaced, unstable distal radial fractures in the elderly. The purpose of this retrospective review was to compare outcomes for elderly patients with a displaced distal radial fracture who were treated with or without surgical intervention. METHODS: This case-control study examined ninety patients over the age of sixty-five who were treated with or without surgery for a displaced distal radial fracture. All fractures were initially treated with closed reduction and splinting. Patients who failed an acceptable closed reduction were offered surgical intervention. Patients who did not undergo surgery were treated until healing with cast immobilization. Patients who underwent surgery were treated with either plate-and-screw fixation or external fixation. Baseline radiographs and functional scores were obtained prior to treatment. Follow-up was conducted at two, six, twelve, twenty-four, and fifty-two weeks. Clinical and radiographic follow-up was completed at each visit, while functional scores were obtained at the twelve, twenty-four, and fifty-two-week follow-up evaluations. Outcomes at fixed time points were compared between groups with standard statistical methods. RESULTS: Forty-six patients with a mean age of seventy-six years were treated nonoperatively, and forty-four patients with a mean age of seventy-three years were treated operatively. Other than age, there was no difference with respect to baseline demographics between the cohorts. At twenty-four weeks, patients who underwent surgery had better wrist extension (p = 0.04) than those who had not had surgery. At one year, this difference was not seen. No difference in functional status based on the Disabilities of the Arm, Shoulder and Hand scores and pain scores at any of the follow-up points was seen between the groups. Grip strength at one year was significantly better in the operative group. Radiographic outcome was superior for the patients in the operative group at each follow-up interval. There was no difference between the groups with regard to complications. CONCLUSIONS: Our findings suggest that minor limitations in the range of wrist motion and diminished grip strength, as seen with nonoperative care, do not seem to limit functional recovery at one year. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence

OBJECTIVES:: A delayed union or a nonunion of a fracture is a potentially adverse complication. Understanding the mechanisms of nonunion development may lead to improved treatment modalities. Proteases such as the matrix metalloproteinases play important roles in bone remodeling and repair, in which an imbalance or a nonfunctioning enzyme may lead to defects in bone healing (nonunion). The purpose of this pilot study was twofold: first to define an mRNA expression profile of all the matrix metalloproteinases (MMPs), a disintegrin and metalloproteinases with thrombospondin motif (ADAMTS) enzymes, and their inhibitors (TIMPs) within fracture nonunion tissue, and second to compare this profile with mineralized fracture callus. METHODS:: Using a systematic real-time polymerase chain reaction, we screened the gene expression profiles of all members of the MMPs, ADAMTS, and their inhibitor TIMPs on human fracture nonunion tissue and matched mineralized callus tissue. Significant results were further analyzed using Western immunoblotting, immunohistochemistry, and in vitro protein interaction assays with bone morphogenetic protein-2. RESULTS:: This analysis confirmed MMP-7 and MMP-12 as two unidentified enzymes expressed in fracture nonunion tissue. Both MMP-7 and MMP-12 mRNAs were significantly elevated in nonunion tissue when compared with local mineralized callus from the same site (P < 0.001); the elevated protein levels of interest were visualized through immunoblotting and immunohistochemistry. In addition, these two MMPs were found to directly bind to and degrade bone morphogenetic protein-2 in vitro. CONCLUSION:: Collectively, our findings indicate that tissue present at the site of hypertrophic nonunions commonly expresses significantly higher levels of MMP-7 and MMP-12 in relation to mineralized fracture callus. Both were found to directly inactivate bone morphogenetic protein-2 in vitro, the best established growth factor in bone formation and repair