Faculty Bibliography

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 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

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.

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.

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.

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.

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.

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.

OBJECTIVES: The purpose of this study was to determine what patient and injury factors are associated with the presence of a meniscus tear in tibial plateau fractures. We also sought to compare functional outcome, pain scores, and range of motion between patient groups with and without meniscal injury. MATERIALS AND METHODS: A total of 99 patients with 101 acute tibial plateau fractures were included in the study cohort. Patients were divided into two groups: those with and without meniscus tears at the time of initial injury. Statistical analysis with Student's t-test for continuous variables and chi square test for categorical variables was performed to compare those with and without a meniscal tear. Logistic regression was performed to identify the variables that predicted the presence of a meniscus tear and repeated ANOVA measures were used to assess functional outcome scores. RESULTS: Fifty-four patients with 56 tibial plateau fractures (55%) were found to have an associated meniscal tear. The average amount of joint depression in this group was 12.3 mm (range: 2.0 to 29.5 mm). The remaining 45 patients with 45 fractures (45%) had an average depression of 5.4 mm (range: 0.0 to 12.8 mm). Degree of tibial plateau depression was the only significant predictor of meniscal injury. CONCLUSIONS: Our findings suggest that amount of depression in tibial plateau fractures is a significant predictor of the occurrence of a meniscus tear with an odds ratio of 1.36. We also found no significant difference in the functional outcome, pain scores, and knee range of motion between the group with and without meniscus tears at the longest follow-up interval. These findings suggest that acute repair of meniscal injury following traumatic fracture of the tibial plateau could produce functional results similar to those patients that did not sustain a meniscus tear.