Faculty Bibliography

BACKGROUND: The implementation of Section 405 of the New York State Public Health Code and the adoption of similar policies by the Accreditation Council for Graduate Medical Education in 2002 restricted resident work hours to eighty hours per week. The effect of these policies on operative volume in an orthopaedic surgery residency training program is a topic of concern. The purpose of this study was to evaluate the effect of the work-hour restrictions on the operative experiences of residents in a large university-based orthopaedic surgery residency training program in an urban setting. METHODS: We analyzed the operative logs of 109 consecutive orthopaedic surgery residents (postgraduate years 2 through 5) from 2000 through 2006, representing a consecutive interval of years before and after the adoption of the work-hour restrictions. RESULTS: Following the implementation of the new work-hour policies, there was no significant difference in the operative volume for postgraduate year-2, 3, or 4 residents. However, the average operative volume for a postgraduate year-5 resident increased from 274.8 to 348.4 cases (p = 0.001). In addition, on analysis of all residents as two cohorts (before 2002 and after 2002), the operative volume for residents increased by an average of 46.6 cases per year (p = 0.02). CONCLUSIONS: On the basis of the findings of this study, concerns over the potential adverse effects of the resident work-hour polices on operative volume for orthopaedic surgery residents appear to be unfounded

BACKGROUND: Ankle fracture-dislocations require urgent reduction to protect the soft tissues, to minimize articular injury, and to allow swelling to decrease. Conscious sedation is commonly used to provide analgesia for closed reduction of this injury. We hypothesized that an intra-articular block of the ankle would provide similar analgesia and the ability to reduce the ankle with a lower risk than conscious sedation. METHODS: Between September 2005 and January 2007, forty-two patients with an ankle fracture-dislocation presented to our emergency department and were enrolled in a prospective randomized study. The patients were given either conscious sedation or an intra-articular lidocaine block for the reduction and for the application of a plaster splint. After the reduction maneuver, the patients used a visual analog pain scale to rate the level of pain before, during, and after the procedure, from 1 (no pain) to 10 (severe pain). The senior authors reviewed the injury and reduction radiographs to confirm the reduction of the ankle joint. RESULTS: Twenty-one patients were randomized to each group. There was no difference in demographic data or fracture patterns between the groups. Both the sedation and the block reduced the pain to a similar degree. The pain reduction (the initial pain level minus the level of pain after medication was given or injected) was an average (and standard deviation) of 4.6 +/- 3.3 for the block group and 4.2 +/- 3.5 for the sedation group (p = 0.64). The average change in the level of pain between the initial presentation and during the reduction was 3.6 +/- 3.8 for the block group and 4.1 +/- 3.3 for the sedation group. Overall, there was no difference in analgesia provided by these two methods (p = 0.71). An acceptable reduction was achieved for forty-one of the forty-two patients with one failure in the sedation group. The average time for ankle reduction and stabilization in a splint was 81.5 minutes for the sedation group and 63.8 minutes for the block group. CONCLUSIONS: Compared with conscious sedation, an intra-articular lidocaine block provides a similar degree of analgesia and sufficient analgesia to achieve closed reduction of ankle fracture-dislocations

BACKGROUND: This study was performed to evaluate when patients recover sufficiently to drive an automobile after operative repair of various other lower extremity fractures. METHODS: A computerized driving simulator was developed and tested. Three groups of individuals were compared: (1) 12 healthy, volunteers tested once to establish normal mean values for variables tested (group I); (2) 22 patients with right-sided long bone lower extremity fractures (9 femur, 13 tibial shaft) tested at 6 weeks, 9 weeks, and 12 weeks after operative repair (group II); and 35 patients with right-sided articular fractures (12 plateau, 4 pilon, 12 calcaneus, 7 acetabulum) tested at 12 weeks, 15 weeks, and 18 weeks after operative repair (group III). Individuals were tested under a series of driving scenarios (city, suburban, and highway). Short musculoskeletal functional assessment scores were recorded at the time of each driving test and compared with results of the driving test. Analyses were performed to determine the relationship between time from initiation of weight bearing on the right lower extremity and brake travel time (BTT). RESULTS: For group I, BTT was 302 +/- 90; for group II, BTT was 444 msec +/- 153 msec, 377 msec +/- 127 msec, and 359 msec +/- 116 msec at 6 weeks, 9 weeks, and 12 weeks after surgery; and for group III, BTT was 412 msec +/- 161 msec, 343 msec +/- 112 msec, and 339 msec +/- 116 msec at 12 weeks, 15 weeks, and 18 weeks after surgery. Short musculoskeletal functional assessment scores improved with respect to function and bother indexes, but did not correlate with improvement in BTT (r = 0.36, p = 0.07, and r = 0.31, p = 0.12, respectively). CONCLUSION: BTT was significantly reduced until 6 weeks after initiation of weight bearing in both long bone and articular fractures of the right lower extremity

OBJECTIVES: External fixation is frequently used for provisional and/or definitive stabilization of open and closed fractures and dislocations involving the lower extremity. There is some concern, however, that application of an external fixator with subsequent reduction of the fractures with distraction may precipitate the development of compartment syndrome. The hypothesis of this study was that application of external fixation and restoration of limb length would have no effect on the compartment pressures. DESIGN: Prospective cohort study. SETTING: Academic medical center, 2 level 1 trauma centers. PATIENTS: Between October 2003 and May 2006, 25 patients who met inclusion criteria and underwent immediate knee-spanning external fixation. INTERVENTION: All 4 compartments of the injured leg were measured with a Solid-State Transducer Intra Compartment device or an arterial line set-up during the temporizing procedure at 4 different time points. In addition, at the time each pressure reading was taken, the patient's diastolic pressure was recorded from the anesthesia monitor. MAIN OUTCOME MEASUREMENT: Elevation of compartment pressure at any of 4 distinct time points during the procedure. Each of the compartments was measured and recorded 4 times: (1) after the patient had been draped but before any fixation or reduction of the fracture, (2) immediately after the insertion of the fixator pins, (3) immediately after reduction of the fracture, and (4) 5 minutes after the reduction. A threshold of less than 30 mm Hg differential from diastolic pressure in conjunction with clinical examination was set as an indication for 4-compartment fasciotomy. RESULTS:: Twenty-five patients with a mean age of 52 years (range, 21-69 years) were enrolled in the study. Injuries included proximal tibial fractures (Orthopaedic Trauma Association types, 41) in 21 patients; knee fracture-dislocation (Moore type II) in 2 patients, and knee (femoro-tibial) dislocations in 2 patients. Two fractures were open, and all other injuries were closed. Fasciotomy was required in 3 cases at initial compartment measurement. In the remaining 22, there were no significant trends toward increased compartment pressures as a result of external fixation placement and knee reduction. There were 9 patients (41%) who had a transient DeltaP < 30 mm Hg at some point during surgery. No patient had a DeltaP < 30 mm Hg sustained through the conclusion of the procedure, and no compartments were released in any of these patients. None of the patients in the study developed compartment syndrome after surgery, and no sequelae of compartment syndrome were noted at minimum 6-month follow-up. CONCLUSIONS: Application of knee-spanning external fixation as a temporary measure for stabilization of high-energy proximal tibial fractures and dislocations may result in transient elevation of intracompartmental pressure of the leg. Although DeltaP may fall below the threshold of 30 mm Hg, this does not appear to lead to compartment syndrome

Partial articular fractures of the distal humerus commonly involve the capitellum and may extend medially to involve the trochlea. As the complex nature of capitellar fractures has become better appreciated, treatment options have evolved from closed reduction and immobilization and fragment excision to a preference for open reduction and internal fixation. The latter is now recommended to achieve stable anatomic reduction, restore articular congruity, and initiate early motion. More complex fracture patterns require extensile surgical exposures. The fractures are characterized by metaphyseal comminution of the lateral column and have associated ipsilateral radial head fracture. With advanced instrumentation, elbow arthroscopy may be used in the management of these articular fractures. Though limited to level IV evidence, clinical series reporting outcomes following open reduction and internal fixation of fractures of the capitellum, with or without associated injuries, have demonstrated good to excellent functional results in most patients when the injury is limited to the radiocapitellar compartment. Clinically significant osteonecrosis and heterotopic ossification are rare, but mild to moderate posttraumatic osteoarthrosis may be anticipated at midterm follow-up

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group

The role of medical, social, and functional covariates on mortality after hip fracture was examined over a 16-year period. A total of 1109 patients with hip fractures were included in a prospective database. The inclusion criteria were patients who were age 65 years or older, ambulatory prior to fracture, cognitively intact, living in their own home at the time of the fracture, and had sustained a nonpathological femoral neck or intertrochanteric chip fracture. Data were analyzed using a Cox proportional hazards model. Mortality was compared with a standardized population, and standardized mortality ratios were calculated for 1, 2, 3, 5, and 10 years,respectively. The 1-, 2-, 5- and 10-year mortality rates were 11.9%, 18.5%, 41.2%, and 75.3%, respectively.The predictors of mortality were advanced age, male gender, high American Society of Anesthesiologists (ASA)classification, the presence of a major postoperative complication, a history of cancer, chronic obstructive pulmonary disorder, a history of congestive heart failure,ambulating with an assistive device, or being a household ambulator prior to hip fracture. The increased mortality risk was highest during the first year after hip fracture and returned to the risk of the standard population 3 years postoperatively. Males who are 65 to 84 years had the highest mortality risk

Locked plate technology has evolved in an effort to overcome the limitations associated with conventional plating methods, primarily for improving fixation in osteopenic bone. The development of screw torque and plate-bone interface friction is unnecessary with locked plate designs, significantly decreasing the amount of soft tissue dissection required for implantation, preserving the periosteal blood supply, and facilitating the use of minimally invasive percutaneous bridging fixation techniques. The locked plate is a fixed-angle device because angular motion does not occur at the plate screw interface. The use of locked plate technology allows the orthopaedic surgeon to manage fractures with indirect reduction techniques while providing stable fracture fixation. The secure 'feel' of locked plates, ease of application, and the low incidence of complications noted in early clinical reports have contributed to the proliferation of this technology. Along with reports of clinical successes, as the use of fixed angle/locked plates has increased, clinical failures are being noticed. This review will focus on the biomechanics of locked plate technology, appropriate indications for its use, laboratory and clinical comparisons to conventional plating techniques, and potential mechanisms of locked plate failure that have been observed

Treatment of intertrochanteric hip fracture is based on patient medical condition, preexisting degenerative arthritis, bone quality, and the biomechanics of the fracture configuration. A critical review of the evidence-based literature demonstrates a preference for surgical fixation in patients who are medically stable. Stable fractures can be successfully treated with plate-and-screw implants and with intramedullary devices. Although unstable fractures may theoretically benefit from load-sharing intramedullary implants, this result has not been demonstrated in the current evidence-based literature

During the past 10 years, there has been a worldwide effort in all medical fields to base clinical health care decisions on available evidence as described by thorough reviews of the literature. Hip fractures pose a significant health care problem worldwide, with an annual incidence of approximately 1.7 million. Globally, the mean age of the population is increasing, and the number of hip fractures is expected to triple in the next 50 years. One-year mortality rates currently range from 14% to 36%, and care for these patients represents a major global economic burden. Surgical options for the management of femoral neck fractures are closely linked to individual patient factors and to the location and degree of fracture displacement. Nonsurgical management of intracapsular hip fractures is limited. Based on a critical, evidence-based review of the current literature, we have found minimal differences between implants used for internal fixation of displaced fractures. Cemented, unipolar hemiarthroplasty remains a good option with reasonable results. In the appropriate patient population, outcomes following total hip arthroplasty are favorable and appear to be superior to those of internal fixation