Faculty Bibliography

Background and aims: This study seeks to determine the effect of spinal anesthesia (SA) on clinical outcomes when compared to general anesthesia (GA) in operatively managed tibial plateau fractures. Methods: Over 8 years, all operative tibial plateau fractures treated by two surgeons were prospectively followed. 113 patients were identified for this study. 30 received SA and 83 received GA. All patients were treated using a similar operative protocol and physiotherapy regimen. Clinical outcomes were compared at 3 months, 6 months and the latest follow-up. These outcomes include Short Musculoskeletal Functional Assessment (SMFA) scores, pain levels, complications and reoperations. Analysis was done using student's t-tests, Chi-squared tests and multivariate linear regression. Results: Using univariate analysis, SMFA scores were improved at 6 months in SA vs. GA patients (beta = -1.14, 95% confidence interval [CI] = -2.06 to -.23, p=0.015), and pain scores were lower in SA vs. GA at 6 months (p =0.004) and at the latest followup (p=0.012). After controlling for group differences, pain scores were found to be lower in SA vs. GA at 3 months (beta = -0.16, 95% CI = -0.24 to 2.02, p=0.048), but not at 6 months or the latest followup. The odds ratio of higher pain scores of a patient who received GAvs SA at 3 months was 3.1 (95% CI, 1.06 to 9.26, p=0.039). Conclusions: In patients who undergo surgical management of a tibial plateau fracture, the use of spinal anesthesia is associated with improved functional scores and decreased pain levels up to 6 months postoperatively

OBJECTIVE: This study aimed at identifying the optimal threshold value to detect cartilage lesions with Standardized dGEMRIC at 3T and evaluate intra- and inter-observer repeatability. DESIGN: We retrospectively reviewed 20 hips in 20 patients. dGEMRIC maps were acquired at 3T along radial imaging planes of the hip and standardized to remove the effects of patient's age, sex and diffusion of gadolinium contrast. Two observers separately evaluated 84 Standardized dGEMRIC maps, both by visual inspection and using an average index for a region of interest in the acetabular cartilage. A radiologist evaluated the acetabular cartilage on morphologic MR images at exactly the same locations. Using intra-operative findings as reference, the optimal threshold to detect cartilage lesions with Standardized dGEMRIC was assessed and results were compared with the diagnostic performance of morphologic MRI. RESULTS: Using z < -2 as threshold and visual inspection of the color-adjusted maps, sensitivity, specificity and accuracy for Observer 1 and Observer 2, were 83%, 60% and 75%, and 69%, 70% and 69%, respectively. Overall performance was 52%, 67% and 58%, when using an average z for the acetabular cartilage, compared to 37%, 90% and 56% for morphologic assessment. The kappa coefficient was 0.76 and 0.68 for intra- and inter-observer repeatability, respectively, indicating substantial agreement. CONCLUSIONS: Standardized dGEMRIC at 3T is accurate in detecting cartilage damage and could improve preoperative assessment in FAI. As cartilage lesions in FAI are localized, visual inspection of the Standardized dGEMRIC maps is more accurate than an average z for the acetabular cartilage.

PURPOSE: The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after hip arthroscopy. METHODS: Over the course of 13 months, four surgeons that routinely perform hip arthroscopy participated in a protocol to screen all patients postoperatively for deep venous thrombosis (DVT) using bilateral venous duplex ultrasound at or about the 2 week postoperative time point. All patients were assessed and stratified for VTE risk prior to surgery. Mechanical intraoperative and postoperative chemoprophylaxis were not administered. Perioperative factors, such as weightbearing status after surgery, traction time, and anesthesia type, were recorded. RESULTS: We identified 139 eligible patients (average age 37.7, SD = 12.0) that underwent hip arthroscopy. The incidence of symptomatic VTE was 1.4 percent (2/139). Of the entire patient pool, 81 obtained a follow-up ultrasound. There were no cases of asymptomatic deep vein thrombosis (DVT). There were two symptomatic venous thromboembolic events noted; one DVT and one pulmonary embolus. One patient had no risk factors; the other was overweight and routinely took oral contraceptives. Amongst the patient co- hort, the mean BMI was 25.9 (SD = 4.8). The mean traction time was 58.9 minutes (SD = 23.1). Most patients (71%) were partial weightbearing after the procedure. CONCLUSION AND CLINICAL RELEVANCE: In patients under- going hip arthroscopy, the rate of postoperative VTE was low, despite the use of prolonged axial traction and surgi- cal proximity to the pelvic veins. Although patients should be counseled preoperatively regarding the risk of VTE, we believe that routine use of pharmacologic prophylaxis is not indicated following hip arthroscopy if patients are properly risk stratified prior to surgery and found to be at low risk for VTE.

Open knee joint injuries are potentially devastating injuries if not properly diagnosed and treated. Current diagnostic techniques, such as the saline load test (SLT), are based on outdated literature. Diagnosis of traumatic arthrotomies via the presence of intra-articular air on computed tomography (CT) scan has recently been shown to be 100% sensitive and specific to detect these injuries. Additionally, open knee joint injuries have a high rate of associated periarticular fractures (51%). The workhorse open surgical approach to the knee is the medial parapatellar approach; however, arthroscopic irrigation and debridement (I&D) should be considered in the setting of small puncture wounds (e.g., gunshot wounds). Antibiotic therapy following I&D of an open knee joint injury includes 24 to 48 hours of intravenous antibiotics. Oral antibiotic therapy can be administered afterwards for 3 to 5 days if the original injury was grossly contaminated. Ultimately, a unified management algorithm for open knee joint injuries based on current literature should be followed to ensure appropriate diagnosis and treatment of this potentially devastating injury.

INTRODUCTION: Operative fixation of displaced inferior pole patella fractures has now become the standard of care. This study aims to quantify clinical, radiographic and functional outcomes, as well as identify complications in a cohort of patients treated with non-absorbable braided suture fixation for inferior pole patellar fractures. These patients were then compared to a control group of patients treated for mid-pole fractures with K-wires or cannulated screws with tension band wiring. METHODS: In this IRB approved study, we identified a cohort of patients who were diagnosed and treated surgically for a displaced patella fracture. Demographic, injury, and surgical information were recorded. All patients were treated with a standard surgical technique utilizing non-absorbable braided suture woven through the patellar tendon and placed through drill holes to achieve reduction and fracture fixation. All patients were treated with a similar post-operative protocol and followed up at standard intervals. Data were collected concurrently at follow up visits. For purpose of comparison, we identified a control cohort with middle third patella fractures treated with either k-wires or cannulated screws and tension band technique. Patients were followed by the treating surgeon at regular follow-up intervals. Outcomes included self-reported function and knee range of motion compared to the uninjured side. RESULTS: Forty-nine patients with 49 patella fractures identified retrospectively were treated over 9 years. This cohort consisted of 31 females (63.3%) and 18 males (36.7%) with an average age of 57.1 years (range 26 - 88 years). Patients had an average BMI of 26.48 (range 19 - 44.08). Thirteen patients with inferior pole fractures underwent suture fixation and 36 patients with mid-pole fractures underwent tension band fixation (K-wire or cannulated screws with tension band). In the suture cohort, one fracture failed open repair (7.6%), which was revised again with sutures and progressed to union. Of the 36 fractures repaired with a tension band fixation, 11 underwent secondary surgery due to hardware pain or fixation failure (30.6%). At one year, no difference was seen in knee range of motion between cohorts. All fractures healed radiographically. Those patients who required reoperation or removal of hardware had significantly diminished range of motion about their injured knee (p > 0.005). CONCLUSIONS: Patients who sustain inferior pole patella fractures have limited options for fracture fixation. Suture repair is clinically acceptable, yielding similar results to patella fractures repaired with metal implants. Importantly, patients undergoing suture repair appear to have fewer hardware related postoperative complications than those receiving wire fixation for midpole fractures.

BACKGROUND: The quality of reduction of the syndesmosis is an important factor in the outcome of ankle fractures associated with a syndesmotic injury. The purpose of this study was to directly compare the accuracy of syndesmotic reductions obtained using intraoperative standard fluoroscopic techniques against reductions obtained using three-dimensional imaging of the Iso-C3D fluoroscope. METHODS: We prospectively reviewed imaging studies of patients who were diagnosed as having preoperative or intraoperative evidence of syndesmotic diastasis (on the basis of the fluoroscopic Cotton test and/or a manual external rotation stress test) who underwent syndesmotic fixation at one of two level-I trauma centers. Center A used intraoperative computed tomography (CT) imaging to assess reduction (