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.

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.

Background Displaced tibial plateau fractures often require surgical treatment and plate and screw constructs are the most common method of fixation. There has been increased usage of locking plate technology for both complex and simple fracture patterns without any evidence demonstrating their advantage. Purpose The purpose of this study was to compare the clinical use of locked versus nonlocked plating for repair of displaced Schatzker type-II (OTA Type 41B) tibial plateau fractures. Methods Seventy-seven consecutive patients treated operatively with one of two types of plate and screw constructs in a nonrandomized fashion for Schatzker type II tibial plateau fractures and they were prospectively followed over a 5-year period. A total of 35 (45.5%) patients were treated using a locked plate and screw construct and 42 (54.5%) patients were treated with a nonlocked plate and screw construct. All patients received the same pre- and postoperative care and there was no difference in plate morphology and length between cohorts. Clinical outcomes were assessed using Short Musculoskeletal Functional Assessment (SMFA) scores, Visual Analogue Score for pain, and knee ranges of motion. Radiographic outcome was assessed with plain radiographs at all follow-up points. Implant costs for both types of constructs were calculated from hospital purchasing records. Results Patients were assessed at a mean period of 18.5 months (range: 12-72 months). There was no difference in demographic factors, physical examination parameters, radiographic outcomes, and SMFA scores between cohorts. In terms of cost, the cost of locked construct was $905 more than the nonlocked construct. Conclusion Based on clinical outcomes and cost per implant, we found no evidence to support the routine use of locked plating for simple split depression fractures of the lateral tibial plateau. The use of standard nonlocked, precontoured implants provides adequate fixation for these fracture patterns.

Background Isolated medial tibial plateau injuries are uncommon and underdescribed in the literature. As such, the range of fracture severity and outcomes in comparison to more frequently described tibial plateau fractures are lacking. Method To assess outcomes of this rare injury, we compared two cohorts of patients. Overall, 27 patients who sustained 27 isolated medial plateau (Schatzker type IV) fractures and 81 patients with 81 split depression lateral plateau (Schatzker type II) fractures were compared. The outcomes were stratified by injury mechanism energy and assessed with radiographs, clinical and arthroscopic examinations, and functional status with the short musculoskeletal function assessment questionnaire (SMFA). Results Overall, 52% of Schatzker type IV fractures versus 71% of Schatzker type II were associated with high-energy injuries. Schatzker type IV fractures were more often nondisplaced and amenable to being managed, nonoperatively, 22 versus 6%, with excellent results. Schatzker type II fractures had a corresponding higher proportion of postoperative articular step off greater than 12 mm and poorer 12-month SMFA scores. Schatzker type IV fractures were more often treated with an external fixator than Schatzker type II fractures (22 vs. 1%). Within Schatzker type IV fractures, high- versus low-energy injuries did not differ significantly with regards to initial articular step off (4.2 vs. 5.1 mm), ligamentous and meniscal injury, or SMFA outcomes. Conclusions Isolated medial plateau fractures had low- and high-energy patterns with differing management and outcomes. Schatzker type IV fractures overall were associated with lower energy mechanisms, less initial articular step off, and better functional outcomes than Schatzker II comparisons in this cohort. Level of Evidence: The level of evidence is 4.

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.