Faculty Bibliography

We retrospectively compared the outcomes of early functional weight-bearing after use of 2 different approaches (minimally invasive, standard) for surgical repair of the Achilles tendon. We reviewed the cases of 63 consecutive patients who underwent repair of an acute closed Achilles tendon rupture and had follow-up of at least 6 months. Of these 63 patients, 33 were treated with a minimally invasive posterolateral approach (minimal group), and 30 were treated with a standard posteromedial approach (standard group). Two weeks after surgery, each patient was allowed to weight-bear as tolerated in a controlled ankle movement boot with a 20 degrees heel wedge. At 6 weeks, the patient was placed in a regular shoe with a heel lift. We examined range of motion and incidence of reruptures, sural nerve injuries, and wound complications at 6 weeks and 3 months and calf strength at 6 months. Neither group had any reruptures. Mean incision length was 2.5 cm (minimal group) and 7.2 cm (standard group). One patient (3.2%) in the minimal group and 6 patients (20%) in the standard group developed a superficial wound infection. Four (12.9%) of 31 minimal patients and no standard patients developed a sural nerve deficit. There were statistically significant differences between the groups' wound complication rates (P = .04) and nerve injury rates (P = .043). At final follow-up, the groups did not differ in their functional outcomes (ability to perform a single heel raise, American Orthopaedic Foot and Ankle Society scores). Used after a minimally invasive posterolateral or standard posteromedial approach, early functional weightbearing is an effective and safe method for treating acute ruptures of the Achilles tendon, and it has a lower rate of soft-tissue complications. A standard posteromedial approach has a higher rate of wound complications, and a minimally invasive posterolateral approach has a higher rate of sural nerve injury.

BACKGROUND: Bisphosphonate therapy for osteoporosis has been associated with atypical femoral fractures. To date, there have been few reports in the literature regarding the preoperative and postoperative courses of patients who have sustained bisphosphonate-associated complete atypical femur fractures. OBJECTIVES/PURPOSES: The purposes of this study were to (1) characterize the preoperative course of patients who eventually presented with bisphosphonate-associated complete atypical femur fractures (duration of bisphosphonate treatment, pain history, risk of converting a nondisplaced fracture to a complete fracture); (2) evaluate the percentage of patients who achieved radiographic union of those fractures after treatment; and (3) determine the patients' recovery of function using the Short Musculoskeletal Functional Assessment. METHODS: Thirty-three patients with 41 atypical, low-energy femur fractures associated with >/= 5 years of bisphosphonate use were treated with intramedullary nailing between 2004 and 2011 at one center. The main outcome measurements were Short Musculoskeletal Functional Assessment for function and radiographic evaluation for fracture healing. Patients had been treated with bisphosphonates for an average of 8.8 years (range, 5-20 years) before presentation. RESULTS: Patients reported a mean of 6 months of pain before presentation (range, 1-8 months). Sixty-six percent of patients with surgically treated complete fractures became pain-free and 98% were radiographically healed by 12 months. Sixty-four percent of patients who underwent intramedullary nailing reported a functional return to baseline within 1 year. Patients who reported major functional limitations at latest followup listed pain and apprehension as the major causes of their limitation. CONCLUSIONS: Patients with surgically treated bisphosphonate-associated complete femur fractures achieved generally reliable although delayed fracture healing if malaligned, and nearly two-thirds of patients returned to self-reported baseline function within 1 year. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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.

SUMMARY: Once you have completed your fellowship and have started a new job, there are many competing demands for your time and attention. This article focuses on how to try and balance your work and personal life and provides some suggestions and recommendations to help one do so. Some of these are general and applicable to most life circumstances and some are specific to a particular situation.

INTRODUCTION: Femoral neck fractures in the elderly comprise a significant number of orthopedic surgical cases at a major trauma center. These patients are immediately incapacitated, and surgical fixation can help increase mobility, restore independence, and reduce morbidity and mortality. However, operative treatment carries its own inherent risks including infections, deep vein thromboses, and intraoperative cardiovascular collapse. Cerebrovascular stroke is a relatively uncommon occurrence after hip fractures. METHODS: We present 2 cases with unusual postoperative medical complication after cemented hip hemiarthroplasty for femoral neck fracture that will serve to illustrate an infrequent but very serious complication. RESULTS: Case 1 was a 73-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, he developed neurological deficits, and a postoperative noncontrast head computed tomography showed a right medial thalamic infarct. Case 2 was an 82-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, the patient became hemodynamically unstable. A postoperative noncontrast head computed tomography showed a large evolving left middle cerebral artery stroke. CONCLUSIONS: General anesthesia in the setting of decreased cardiac function (decreased ejection fraction and output) carries the risk for ischemic injury to the brain from decreased cerebral perfusion. Risk factors including advanced age, history of coronary artery disease, atherosclerotic disease, and atrial fibrillation increase the risk for perioperative stroke. Furthermore, it is known that during the cementing of implants, microemboli can be released, which must be considered in patients with preoperative heart disease. As a result, consideration of using a noncemented implant or cementing without pressurizing in this clinical scenario should be an important aspect of the preoperative plan in an at-risk patient. Further studies are needed that can elucidate a causal relationship.

The benefits of bisphosphonates are well documented, but prolonged use has been associated with atypical femur fractures. Radiographic markers for fracture predisposition could potentially aid in safer medication use. In this case-control designed study, we compared hip radiographic parameters and the demographic characteristics of chronic bisphosphonate users who sustained an atypical femoral fracture with a group of chronic bisphosphonate users who did not sustain an atypical femur fracture and also a group who sustained an intertrochanteric hip fracture. Radiographic parameters included were neck-shaft angle (NSA), hip-axis length (HAL) and center-edge angle (CE). Multivariate regression was used to evaluate the relationship between radiographic measures and femur fracture. Receiver-operating characteristic analysis determined cut-off points for neck-shaft angle and risk of atypical femur fracture. Ultimately, pre-fracture radiographs of 53 bisphosphonate users who developed atypical fracture were compared with 43 asymptomatic chronic bisphosphonate users and 64 intertrochanteric fracture patients. Duration of bisphosphonate use did not statistically differ between users sustaining atypical fracture and those without fracture (7.9 [+/-3.5] vs. 7.7 [+/-3.3] years, p=0.7). Bisphosphonate users who fractured had acute/varus pre-fracture neck-shaft angles (p<0.001), shorter hip-axis length (p<0.01), and narrower center-edge angles (p<0.01). Regression analysis revealed associations between neck-shaft angle (OR=0.89 [95% CI=0.81-0.97; p=0.01), center edge angle (OR=0.89 [95% CI=0.80-0.99]; p=0.03), and BMI (OR=1.15 [95% CI=1.02-1.31; p=0.03) with fracture development. ROC curve analysis (AUC=0.67 [95% CI=0.56-0.79]) determined that a cut-off point for neck-shaft angle <128.3 degrees yielded 69% sensitivity and 63% specificity for development of atypical femoral fracture. Ultimately, an acute/varus angle of the femoral neck, high BMI, and narrow center-edge angle were associated with development of atypical femur fracture in long-term bisphosphonate users. Patients on long-term bisphosphonates should be regularly radiographically evaluated in order to assess for potential risk of atypical fracture.

BACKGROUND: The purpose of this study was to compare the functional outcomes and quality of life of older and younger patients with similarly treated distal femur fractures. METHODS: We conducted an assessment of 57 patients who sustained distal femur fractures (Orthopaedic Trauma Association Type 33B, C) and underwent surgical treatment at our academic medical center. Patients were divided into 2 groups for analysis: an elderly cohort of patients aged 65 or older and a comparison cohort of patients younger than age of 65. A retrospective review of demographics, preoperative ambulatory status, radiographic data, and physical examination data was collected from the medical records. Follow-up functional data were collected via telephone at a mean of 2.5 years (range 6 months-8 years) using a Short Musculoskeletal Functional Assessment (SMFA). All patients underwent standard operative treatment of either nail or plate fixation. RESULTS: There was no statistical difference in gender, fracture type, surgical technique, surgeon, or institution where the surgery was performed. The percentage of patients with healed fractures at 6-months follow-up was not significantly different between the cohorts. The elderly cohort had slightly worse knee range of motion at 3, 6, and 12 months postoperatively but there was not a statistically significant difference between the groups. The SMFA Daily Activity, Functional, and Bother indices were significantly worse in the older cohort (P < .01, P = .01, P = .02, respectively). However, there was no significant difference in the SMFA Emotional or Mobility indices. CONCLUSION: Despite lower quality of life and functional scores, this study suggests that relatively good clinical outcomes can be achieved with surgical fixation of distal femoral fractures in the elderly patients. Age should not be used as a determinate in deciding against operative treatment of distal femur fractures in the elderly patients.

BACKGROUND: We investigated the radiographic parameters that may predict distal radial ulnar joint (DRUJ) instability in surgically treated radial shaft fractures. In our clinical experience, there are no previously reported radiographic parameters that are universally predictive of DRUJ instability following radial shaft fracture. MATERIALS AND METHODS: Fifty consecutive patients, ages 20-79 years, with unilateral radial shaft fractures and possible associated DRUJ injury were retrospectively identified over a 5-year period. Distance from radial carpal joint (RCJ) to fracture proportional to radial shaft length, ulnar variance, and ulnar styloid fractures were correlated with DRUJ instability after surgical treatment. RESULTS: Twenty patients had persistent DRUJ incongruence/instability following fracture fixation. As a proportion of radial length, the distance from the RCJ to the fracture line did not significantly differ between those with persistent DRUJ instability and those without (p = 0.34). The average initial ulnar variance was 5.5 mm (range 2-12 mm, SD = 3.2) in patients with DRUJ instability and 3.8 mm (range 0-11 mm, SD = 3.5) in patients without. Only 4/20 patients (20 %) with DRUJ instability had normal ulnar variance (-2 to +2 mm) versus 15/30 (50 %) patients without (p = 0.041). CONCLUSION: In the setting of a radial shaft fracture, ulnar variance greater or less than 2 mm was associated with a greater likelihood of DRUJ incongruence/instability following fracture fixation.

BACKGROUND: Prior studies have suggested that Asian patients and women may be more likely to sustain atypical femoral fractures in association with bisphosphonate use. However, they do not account for confounders such as asymptomatic patients who are long-term bisphosphonate users or patients sustaining osteoporotic fractures. QUESTIONS/PURPOSES: The purpose of this study was to determine the differences in sex and racial association with atypical femoral fractures by comparing demographic characteristics of patients who sustained an atypical bisphosphonate-associated fracture with patients on long-term bisphosphonates without fractures and with patients who sustained osteoporotic fractures. METHODS: Three groups from prospective registries were identified: (1) patients with atypical femur fractures associated with long-term bisphosphonate use (BFF) (n = 54); (2) patients on long-term bisphosphonates but with no associated fractures (BNF) (n = 119); and (3) patients with osteoporotic proximal femur fractures not associated with bisphosphonates (PFF) (n = 216). Age, sex, and self-reported race/ethnicity were documented and compared. Multivariate and univariate analyses were done as well as age- and sex-stratified analyses. RESULTS: Age and sex distributions of the BFF and BNF patients were similar. There was a higher percentage of Asian patients in the BFF group (17%) than in the BNF group (3%; p = 0.004) as well as Hispanics (13% versus 3% in BNF; p = 0.011). Patients in the BFF group were younger than those in the PFF group (67.5 versus 78.4 years; p < 0.001) and had fewer males (7% versus 14%; p < 0.001). CONCLUSIONS: These data suggest that Asians are at higher risk for atypical bisphosphonate-associated fractures. We recommend closer followup in Asian patients who are taking bisphosphonates. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

INTRODUCTION: Previous reports in the literature from Europe and Asia cite an increased burden on the local emergency departments and orthopaedic services during the operational period of the ice skating rinks. This retrospective observational study was undertaken in order to report the incidence, characteristic, and severity of injuries during a full season at a large urban ice skating rink, as well as to quantify the added burden the ice skating rink places on the local emergency department and the orthopaedic service. METHODS: All patients seen at our emergency room who sustained an injury at the neighboring "free" ice rink were identified over the 4-month period when it was open. The data collected included type of injury, demographics, and need for surgical treatment. RESULTS: Over this period, 118 patients were seen in our ED (of the 135 referrals from the ice rink logbook); Of these, 43 (38%) required an orthopaedic consult and were evenly divided into upper (22) and lower extremity injuries (21). Sixty-seven percent of the patients were adults, and the most common fractures were ankle and distal radius fractures. There were two open fractures of the distal radius seen in the older patients (both in patients > 50). Overall 32% of patients needed operative treatment. Of the non-orthopaedic injuries, the most common was head injury (25%). CONCLUSIONS: An ice-rink may be "free" but adds sig- nificant burden to the healthcare system, and these costs should be factored in by both the sponsoring body and the healthcare system for treatment of these additional patients.