Faculty Bibliography

BACKGROUND: Instability is a common cause of revision hip arthroplasty and is frequently due to improper component placement and subsequent component impingement. Impingement of the greater trochanter upon the anterior inferior iliac spine (AIIS) has been described as a cause of symptomatic femoroacetabular impingement (FAI), but has never been described as a cause of instability following total hip arthroplasty (THA). CASE REVIEW: We present 2 cases of patients undergoing THA. Each patient was evaluated preoperatively and found to have a prominent AIIS, which was concerning due to it overhanging the anterolateral acetabular lip. Both patients had intraoperative posterior instability of their THA, the cause of which was determined to be impingement of the greater trochanter upon a prominent AIIS. Open resection of the AIIS was performed with subsequent resolution of impingement. LITERATURE REVIEW: AIIS impingement has been reported as a cause of symptomatic FAI. In these case reports, open or arthroscopic resection of the AIIS resulted in resolution of symptoms. Morphologically distinct subtypes of the AIIS have been previously described based upon computed tomography, and some subtypes are associated with a high risk of impingement in the native hip. No previous studies have described this phenomenon in the setting of THA. CLINICAL RELEVANCE: Instability is a common cause of revision THA. Impingement of the greater trochanter upon a prominent AIIS is a previously unreported cause of THA instability which can be addressed with intraoperative resection of the AIIS with good result.

The anterior approach for total hip replacements has recently gained popularity. Some authors report faster recoveries and decreased dislocation rated with no increased risk of complications. However others claim no difference in outcomes when compared to other approaches yet an increase in complication rates. This paper provides a brief history of the approach, discusses various indications and contraindications, preoperative considerations, surgical techniques, and postoperative protocols.

BACKGROUND: Although most humeral nonunions are successfully treated with a single procedure, some humeral nonunions are more difficult to heal and require multiple procedures. Current literature does not provide evidence describing how the prognosis for surgical repair in patients who develop humeral diaphyseal nonunions may be affected by initial operative versus nonoperative treatment. QUESTIONS/PURPOSES: The purpose of this study was to assess whether operative versus nonoperative treatment of acute humeral shaft fractures impacts outcome of subsequent repairs of humeral nonunions (NU) including the need for additional surgery and a comparison of pain relief (Visual Analogue Scale for pain) and functional outcome (Short Musculoskeletal Functional Assessment). METHODS: Thirty-four patients with humeral shaft nonunion were evaluated of which 15 patients had been treated operatively (OF), and 19 patients had been treated nonoperatively (NO) for their initial humerus shaft fracture. All patients underwent plating with autogenous bone graft or allograft +/- bone morphogenic protein (BMP) 2 or 7 as their final NU repair surgery prior to healing. We compared functional outcome and pain for both cohorts and determined risk factors for requiring more than 1 nonunion repair surgery. RESULTS: The mean time of final follow-up was 14.7 +/- 10.4 months. Thirty-three of 34 NUs (97.1%) healed. Patients who underwent OF of their original fracture were more likely to require more than 1 NU repair surgery (66.7 vs. 0%, p < 0.01). Of the 15 patients who underwent initial OF, 33.0% required 1 NU surgery, 33.0% required 2 NU surgeries, and 33.0% required 3 NU surgeries. Patients who underwent initial OF were more likely to require >6 months to achieve union (40.0 vs. 10.5%, p = 0.04). At final follow-up, there was no difference in functional outcome or pain scores. Initial OF was the only independent predictor of needing more than 1 NU repair surgery (OR 70.1 CI 2.8-1762.3) to achieve healing. CONCLUSION: Humeral shaft nonunions following initial operative fixation of the index fracture is more resistant to achieving union when compared to nonunions forming after initial nonoperative treatment. When final healing is achieved, there is no difference in function or pain.

OBJECTIVES: The purpose of this study was to investigate the prevalence and longitudinal improvement of patient reported sexual dysfunction following five common non pelvic orthopaedic traumatic conditions. DESIGN: Retrospective analysis of prospectively collected data SETTING:: Academic Medical Center PATIENTS/PARTICIPANTS:: The functional status of 1,324 patients with acute proximal humerus fractures (n=104), acute distal radius fractures (n=396), acute tibial plateau fractures (n=118) acute ankle fractures (n=434), and chronic long bone fracture nonunions (n=272) was prospectively assessed at baseline, three, six, and twelve months post-treatment. Patient reported sexual dysfunction, acquired from validated functional outcomes surveys, was compared to overall patient reported functional outcome for each follow-up visit. Men and women were analyzed separately. RESULTS: Sexual dysfunction at the three month follow-up was reported in 31% of proximal humerus fracture patients, 32% of distal radius fracture patients, 47% of tibial plateau patients, 11% of ankle fracture patients, and 42% of long bone nonunions. By one year follow-up, greater than 80% of patients with all fracture types reported mild or no sexual dysfunction. Women reported a significantly higher degree of sexual dysfunction than men at six months (p=0.003) and twelve months follow-up (p=0.031). CONCLUSIONS: Following treatment of acute and chronic orthopaedic trauma conditions, a considerable number of patients experience sexual dysfunction, with women reporting more dysfunction than men. The results of this study should allow orthopaedic trauma surgeons to counsel patients regarding expectations of sexual function following traumatic orthopaedic conditions. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES:: The aim of our study was to investigate the rate, longitudinal improvement, and risk factors of sleep disturbance following four common orthopaedic traumatic conditions. METHODS:: The functional status of 1,095 patients was prospectively assessed using validated questionnaires for patients with acute proximal humerus (n=111), distal radius (n=440), tibial plateau (n=109), and ankle fractures (n=435). Patient reported sleep difficulty was compared to the overall functional and emotional status of each patient at three, six, and twelve months post-treatment. RESULTS:: Sleep difficulty at three months follow-up was reported in 41% of proximal humerus fracture patients, 25% of distal radius fracture patients, 36% of tibial plateau patients, and 19% of ankle fracture patients. By twelve months follow-up less than 20% of patients with all fracture types reported sleep difficulty. At twelve months follow-up the SF-36 Mental Health category for patients with distal radius fractures (p=0.001) and the Short Musculoskeletal Function Assessment (SMFA) Emotional category for patients with tibial plateau fractures (p=0.024) and ankle fractures (p=<0.001) were independent predictors of poor sleep while the respective functional status categories were not. CONCLUSIONS:: At twelve months follow-up, poor sleep was independently associated with poor emotional status, but not associated with poor functional status. The mental health status of patients with sleep difficulty in the latter stages of fracture healing should be carefully assessed in order to provide the highest level of care. The results of this study should allow orthopaedic trauma surgeons to counsel patients regarding expectations of difficulty sleeping following acute fractures. LEVEL OF EVIDENCE:: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Lower extremity injuries secondary to low-energy gunshot wounds are frequently seen in the civilian populations of urban areas. Although these wounds have fewer complications than high-energy gunshot injuries, the functional and psychological damage is still significant making appropriate timely orthopaedic treatment and follow-up imperative. PURPOSE: The purpose of this study is to present our outcomes in the treatment of low-energy gunshot wounds in a civilian population at an urban, level one trauma center in patients treated by a standard protocol. METHODS: One hundred and thirty three patients who sustained 148 gunshot wound injuries were treated at our level one trauma center between January 1(st), 2009 and October 1(st), 2011. Following IRB approval, we extracted information from medical records regarding hospital course, length of stay and type of operative or non-operative treatment. If available, injury and post-operative radiographs were also reviewed. Patients were contacted by telephone to obtain Short Musculoskeletal Function Assessment (SMFA) surveys, pain on a scale of 0-10 and for the determination of any adverse events related to their shooting. RESULTS: There were 125 men (94.0%) and 8 women (6.0%) with an average age of 27.1 years (range 15.2-56.3). Seventy-six patients (57.1%) did not have any health insurance upon admission. The average length of stay in the hospital was 4.5 days (range 0.0-88.0). Fifty-one gun shots (34.5%) resulted in fractures of the lower extremities. Patients underwent a total of 95 lower extremity-related procedures during their hospitalization. Twenty-two patients (16.5%) experienced a complication related to their gunshot wounds. 38% of the cohort was available for long-term functional assessment At a mean 23.5 months (range 8-48) of follow up, patients reported mean Functional and Bothersome SMFA scores of 19.6 (SD 15.9) and 10.9 (SD 15.6) suggesting that these patients have poorer function scores than the general population. These patients still had pain related to their gunshot injury with an average pain score of 2.16 (range 0-8). CONCLUSIONS: Gunshot injuries to the extremities may involve bone, soft tissue, and neurovascular structures. Execution of appropriate therapeutic methods in such situations is critical for treating surgeons given the potential for complications. At our level one trauma center, gunshot victims were predominantly young, uninsured adult men. Complications included infection, compartment syndrome, and arterial injuries. Functional data collected demonstrated that patients continued to have difficulties with ADL's at long-term follow-up.

Today's increasingly complex health-care landscape requires that physicians take an active role in minimizing health-care costs and expenditures. Judicious choice of implants, a fracture-driven treatment algorithm, capitation models, use of generic fracture implants, and reuse of external fixation constructs all represent mechanisms that can result in substantial savings. In some health-care environments, these cost savings programs may be directly linked to physician reimbursement in the form of gainsharing plans. Evidence-based critical evaluations of implant usage patterns are necessary to help control implant-related health-care spending but are lacking in the current literature. Physicians need to acknowledge their influence and responsibility in this realm and assume an active role to help reduce costs.

In March 2012, an algorithm for the treatment of intertrochanteric fractures of the hip was introduced in our academic department of Orthopaedic Surgery. It included the use of specified implants for particular patterns of fracture. In this cohort study, 102 consecutive patients presenting with an intertrochanteric fracture were followed prospectively (post-algorithm group). Another 117 consecutive patients who had been treated immediately prior to the implementation of the algorithm were identified retrospectively as a control group (pre-algorithm group). The total cost of the implants prior to implementation of the algorithm was $357 457 (mean: $3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052 to 4133)) after its implementation. There was a trend toward fewer complications in patients who were treated using the algorithm (33% pre- versus 22.5% post-algorithm; p = 0.088). Application of the algorithm to the pre-algorithm group revealed a potential overall cost saving of $70 295. The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions. Cite this article: Bone Joint J 2014;96-B:1192-7.