Faculty Bibliography

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.

BACKGROUND:Cost effective implant selection in orthopedic trauma is essential in the current era of managed healthcare delivery. Both locking and non-locking plates have been utilized in the treatment of displaced fractures of the olecranon. However, locking plates are often more costly and may not provide superior clinical outcomes. The primary aim of the present study is to assess the clinical and functional outcomes of olecranon fractures treated with locked and non-locking plate and screw constructs while providing insight into the cost of various implants. METHODS:We performed a retrospective chart review of a single institution database identifying Mayo IIB type olecranon fractures treated surgically from 2003 to 2012. All fractures were treated with either a locked plate or a one-third tubular hook plate construct. Clinical and radiographic outcomes were evaluated. Minimum 6-month follow-up was required. Outcomes were compared between fixation constructs, including rate of union, early failure, postoperative range of motion, and complication rates. Statistical analysis included Pearson's Chi-squared and Fisher's exact test for categorical variables, and the Student's ttest for continuous variables. RESULTS:The one-third tubular construct was equivalent to locking plate constructs with respect to union, post-operative range of motion, and rates of complications. There were no early or late failures. Locking plates were associated with a relative cost increase of $1,263.50 compared to the one-third tubular hook plate per case. CONCLUSION:Surgeons should consider the cost of implants when treating Mayo IIB olecranon fracture. In this cohort, one-third tubular plates provided equivalent outcomes to locked plates with a notable decrease in cost.

Hemiarthroplasty as a treatment for femoral neck fractures is controversial with evolving understanding of its complica - tions. One set of complications relates to the use of cement for these procedures. This case study presents two cases that were complicated by retained cement in the acetabulum that was identified in final intraoperative check with x-rays. In both cases, the incision was reopened and retained fragments were removed. We aim to remind the orthopaedic surgery community that this complication can occur even to the careful, experienced surgeon and to recommend the steps necessary to minimize the risk of its occurrence.

OBJECTIVES: To compare rebound pain and the need for narcotic analgesia following ankle fracture surgery for patients receiving perioperative analgesia through either a continuous infusion or a single injection nerve block. DESIGN: Prospective randomized controlled trial. SETTINGS: Surgeries were performed at two hospitals affiliated with a large urban academic medical center. PATIENTS/PARTICIPANTS: 50 patients undergoing operative fixation of an ankle fracture (AO/OTA Type 44). INTERVENTION: Participants were randomized to receive either a popliteal sciatic nerve block as a single shot (SSB group) or a continuous infusion through an On Q continuous infusion pump (On Q group). MAIN OUTCOME MEASUREMENTS: Visual Analog Scale and Numeric Rating Scale (0-10) pain levels and amount of pain medication taken. RESULTS: For all time points after discharge, mean postoperative pain scores and number of pain pills taken were lower in the On Q group vs. the SSB group. Pain scores were significantly lower in the On Q group at the 12 hour postoperative time point (p = 0.002) and at 2 weeks postoperatively. The number of pain pills taken in the first 72 hours was lower in the On Q group (14.9 vs. 20.0; p = 0.036). Overall, 7/23 patients in the On Q group had their pump malfunction and one patient accidently removed their catheter. CONCLUSIONS: Use of continuously infused regional anesthetic for pain control in ankle fracture surgery significantly reduces "rebound pain" and the need for oral opioid analgesia compared to single-shot regional anesthetic. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopy has been advocated as a possible adjunct to theoperative treatment of tibial plateau fractures. This reviewarticle provides a historical perspective on the developmentof the technique while focusing on its current role inthe management of these injuries. Topics include the possibleutility of employing arthroscopy in the diagnosis andmanagement of associated soft tissue lesions and potentialfor arthroscopic assistance to facilitate achieving fracturereduction without an open arthrotomy. Pertinent literatureis reviewed and discussed, with an emphasis on the datarelated to patient outcomes.

BACKGROUND: Previous studies have demonstrated the efficacy of popliteal block anesthesia in decreasing post - operative narcotic administration, nausea, and length of stay in patients undergoing foot and ankle surgeries. The purpose of this study was to compare the amount of narcotic medication administered, the need for anti-emetic medica - tion, PACU length of stay, and discharge status in patients treated surgically for ankle fractures who received popliteal blocks with those who received general anesthesia alone. METHODS: All patients being treated with open reduction and internal fixation for ankle fractures were randomized to receive either general anesthesia (GETA) or popliteal block. Postoperatively, data was collected on the duration of time in the PACU before discharge to home or to a hospital floor. Additional information was collection on the amount of anti-emetic and pain medication in the PACU. RESULTS: Fifty-one patients agreed to participate in the study. There was no significant difference between the two groups with regards to the need for anti-emetic medication, the amount of pain medication received in the PACU, or amount of time spent in the PACU. Patients who received a popliteal block were no more likely to be discharged to home from the PACU than those who received general anesthesia. DISCUSSION: While previous studies have demonstrated the efficacy of popliteal block in decreasing anti-emetic and pain medication administration in the PACU, we found no difference in the amount of medication administered. We found that popliteal block patients were no more likely to be discharged to home than those who received general anesthesia.

BACKGROUND: Rotational injuries are the most common and usually classified as per the Lauge Hansen classification; with the most common subgroup being the supination external rotation (SER) mechanism. Isolated fractures of the distal fibula (SE2) without associated ligamentous injury are usually treated with a splint or brace and the patient may be allowed to weight bear as tolerated. This study reports the functional outcomes following a stable, low energy, rotational ankle fracture supination external rotation (SER2) when compared to unstable SER4 fractures treated operatively. MATERIALS AND METHODS: 64 patients who were diagnosed and treated nonoperatively for a stable SER2 ankle fracture were followed prospectively. In the comparison group, 93 operatively treated fibular fractures were extracted from a prospectively collected database and evaluated comparison. Baseline characteristics obtained by trained interviewers at the time of injury included: Patient demographics, short form-36, short musculoskeletal functional assessment (SMFA) and American Orthopedic Foot and Ankle Society (AOFAS) questionnaires. Patients were followed at 3, 6 and 12 months postsurgery. Additional information obtained at each followup point included any complications or evidence on fracture healing. Data were analyzed by the Student's t-test and theFisher's Exact Test to compare demographic and functional outcomes between the two cohorts. P < 0.05 was considered to be significant. RESULTS: The average of patients' age in the stable fracture cohort was 43 versus 45 in the SER4 group. Nearly 64% of the patient population was female when compared with 37% in the operative group. In the SER2 by 6 months all patients had returned to baseline functional status. There were 18 delayed unions (all healed by 6 months). Based on the functional outcome scores all patients had returned to preoperative level. In comparison, SE4 patients had less functional recovery at 3 and 6 months (P < 0.05) based on the SMFA scores and at 3, 6 and 12 months based on the AOFAS (P < 0.001) scores. There was no difference in pain levels between the two groups at all time points. There were three nonunions in the SE4 group and six delayed unions. CONCLUSIONS: An SER2 ankle fracture is a relatively benign injury with functional limitations resolving by 3 months while the need for surgical fixation in SER ankle fractures appears to affect lower extremity function to a greater degree for a longer time period. Patients should be counseled as to these expected outcomes.

External fixation for definitive or initial management of tibial fractures has a long history, with pin-to-bar external fixation being the standard of care for definitive management of tibial fractures. However, the use of this method lessened because of the increased popularity of intramedullary nailing and drawbacks associated with external fixation. This method is still commonly in use in the military environment and can be used for temporary stabilization of tibial fractures, especially in the setting of periarticular injuries. These fixators also may be useful for salvage of open and/or infected fractures that are unsuitable for internal fixation.

CASE/METHODS:We present a case of a patient who sustained overlapping dislocation of the pubic symphysis (ODPS), which required an open reduction as well as anterior and posterior pelvic ring fixation. CONCLUSION/CONCLUSIONS:This case report is a valuable addition to the current literature on ODPS because we believe it to be the first report describing a patient who required both anterior and posterior fixation because of pelvic instability.