Faculty Bibliography

PURPOSE/OBJECTIVE:Chronic use of selective serotonin reuptake inhibitors (SSRIs) for the treatment of depression has been linked to an imbalance in bone metabolism leading to osteoporosis. More recently, the use of SSRIs in murine models has been shown to delay bone healing both in vivo and in vitro by decreasing the osteoblastic differentiation and mineralization. The purpose of this study was to evaluate whether or not chronic use of SSRI's in nonunion patients increases their time to union after surgical intervention. METHODS:We retrospectively analyzed 343 patients in a nonunion database to determine which patients were on SSRI medication. Of these patients, 139 could be contacted and of those 102 were not taking SSRIs and 37 were taking SSRIs. Patient's time to union from nonunion surgical intervention between each cohort at our institution was recorded as the primary outcome. Patient's medical comorbidities that could affect union rates such as diabetes and smoking status were also noted. Baseline Short Musculoskeletal Function Assessment (SMFA) index for bother and function were recorded from the time of nonunion surgery as well as last follow-up. RESULTS:Compared to recent census data, we found significantly more patients in the nonunion cohort using SSRIs (26.6%) than patients in the general population using any type of antidepressant (11%). There was no significant difference in the patients' baseline characteristics other than patients on SSRI treatment had a higher body mass index (BMI) and age (p = 0.048 and p = 0.043, respectively). There was no significant difference noted in the fracture types (p = 0.2063). Patients on SSRIs had a higher SMFA bother index and function index on follow-up (p = 0.0103, p = 0.0147). Patients in the SSRI group had a mean time to union from nonunion surgery of 6.1 months compared to 6.0 in patients without SSRI usage (p = 0.74). These did not reach statistical significance when subcohort analysis for long bone fractures was performed for the femur, tibia, and humerus. CONCLUSION/CONCLUSIONS:To our knowledge, this is the first clinical study to investigate the effects of SSRIs on fracture healing. While in vivo and in vitro murine models have shown that SSRIs can have a deleterious effect on osteoblastic activity, our retrospective analysis did not show a significant difference in time to union between patients with chronic SSRI use and patients who have not been on SSRIs. However, this investigation did show a higher incidence of SSRI use in the nonunion cohort when compared to the general population. In the context of the recent animal model study, this may point to a negative effect of SSRI use on the acute fracture healing process.

SUMMARY/CONCLUSIONS:We present the case of a 53-year-old male laborer who slipped and fell on ice and had acute right shoulder pain. Plain radiographs and a computed tomography scan of the scapula were obtained that demonstrated a comminuted and displaced extra-articular scapula body fracture with approximately 2 cm of medialization of the glenoid. The anatomy, examination, diagnosis, and surgical approach options are reviewed. In this case, open reduction and internal fixation of the scapula is performed through a modified Judet approach. At the 3-month postoperative visit, radiographs demonstrated a healed scapula fracture. The patient was allowed to return to work as a laborer. A modified Judet approach can be performed for surgical fixation of comminuted and displaced extra-articular scapula body fractures with excellent clinical results.

SUMMARY/CONCLUSIONS:A case of a 27-year-old man with a right-sided largely infra-foveal femoral head fracture dislocation with posterior wall acetabular fracture repaired via a Kocher-Langenbeck approach is presented. This is an atypical approach for fixation of the femoral head and acetabulum used because of the size and displacement of both the posterior wall fracture and the femoral head fracture. Indications for fixation of both the femoral head and the acetabulum include a displaced acetabular fracture with: (1) a fracture of the weight-bearing portion of the femoral head and/or (2) a fracture of the femoral head that engages the anterior or posterior wall. Overall, midterm outcomes are expected to be excellent to good if anatomic reduction and a concentrically stable hip joint is restored.

SUMMARY/CONCLUSIONS:We present the case of a 49-year-old male pedestrian struck by a car while cycling, sustaining a displaced anterolateral tibial plateau fracture and a large coronal plane fracture of the posterolateral plateau involving approximately one-third of the anterior posterior dimension of the articular surface. The posterolateral approach without a fibular osteotomy allows direct access to the posterolateral plateau and avoids complications associated with a fibular head osteotomy. The combined anterolateral and posterolateral approach to the proximal tibia without fibular osteotomy is a viable technique to achieve biomechanically sound fixation for lateral tibial plateau fractures that involve the anterolateral and posterolateral aspects of the tibial plateau.

SUMMARY/CONCLUSIONS:This is the case of a 12-year-old boy presented with a displaced radial and ulnar shaft fracture. Historically, these fractures were managed conservatively with closed reduction and cast immobilization; however, there has been an increasing trend toward operative fixation. Malalignment is an indication for operative fixation of pediatric both bone forearm fractures. Flexible nailing was performed in this case because of the small incisions, minimal tissue disruption, shorter operative time, and ease of implant removal. Five years postoperatively, the patient's fracture was healed. Patient presented with an excellent clinical outcome including full range of motion and no pain. He had full strength of his arm and no deficits.

SUMMARY/CONCLUSIONS:We present the surgical technique for arthrodesis of the subtalar and calcaneocuboid joints of a Sanders type IV calcaneal fracture nonunion via a distraction bone block arthrodesis technique with tricortical iliac crest allograft combined with reamer/irrigator/aspirator autograft from the patient's femur. A lateral extensile approach to the calcaneus was used for the exposure, which allowed the surgeon to follow the stepwise complex surgical plan outlined here. Calcaneal nonunions are difficult to treat, but good outcomes can be achieved if proper technique with bone grafting is used.

PURPOSE/OBJECTIVE:To assess longer-term (> 5 years) function and outcome in patients treated with anatomic locking plates for proximal humerus fractures. METHODS:This retrospective cohort study was conducted at an urban, academic level 1 trauma center and an orthopedic specialty hospital. Patients treated operatively for proximal humerus fractures with an anatomic locking plate by three orthopedic trauma surgeons and two shoulder surgeons from 2003 to 2015 were reviewed. Patient demographics and injury characteristics, disabilities of the arm, shoulder, and hand (DASH) scores, complications, secondary surgeries, and shoulder range of motion were compared at 1 year and at latest follow-up. RESULTS:Seventy-five of 173 fractures were eligible for analysis. At a minimum 5 years and a mean of 10.0 ± 3.2 years following surgery, DASH scores did not differ from one-year compared to long-term follow-up (16.3 ± 17.4 vs. 15.1 ± 18.2, p = 0.555). Shoulder motion including: active forward flexion (145.5 vs. 151.5 degrees, p = 0.186), internal rotation (T10 vs. T9, p = 0.204), and external rotation measurements (48.4 vs. 57.9, p = 0.074) also did not differ from one year compared to long-term follow-up. By one year, all fractures had healed. After 1-year post-operatively, four patients underwent reoperation, but none for AVN or screw penetration. CONCLUSIONS:Patient-reported functional outcome scores and shoulder range of motion are stable after one year following proximal humerus fracture fixation, and outcomes do not deteriorate thereafter. After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms.

Although surgical procedures have been occurring as early at 6500 BC, the modern sense of the operating room (OR) did not exist until more recently. As aseptic techniques and surgical procedures began to evolve, so too did the OR table. The OR table began to transition from a static, wooden table to a dynamic table with the ability to position patients for a variety of procedures. With the advent of intraoperative imaging for orthopaedic procedures, OR tables have adapted and allow for imaging of bony anatomy by using radiolucent materials. These changes have led to the development of numerous OR tables, each with their own sets of advantages and disadvantages. There is currently no summary of the development, indications, benefits, and disadvantages of the various OR tables available to orthopaedic surgeons in the literature. The purpose of this review is to provide a comprehensive review of orthopaedic operating tables for both the junior orthopaedic resident and experienced attending surgeon.

INTRODUCTION/BACKGROUND:The purpose of this study was to evaluate the outcomes of fracture nonunion repair with autogenous iliac crest bone graft (ICBG) under regional anesthesia alone or in combination with other techniques compared to other anesthesia techniques. MATERIALS AND METHODS/METHODS:Overall, 137 patients were identified who underwent ICBG as part of a repair of a long bone fracture nonunion between January 1, 2013 and October 1, 2020. Surgical and anesthetic records were reviewed to classify patients by anesthesia type. General, spinal, and regional anesthetics were used as either the primary anesthetic or as a combination of regional nerve block with general or spinal anesthesia. RESULTS:Administration of regional anesthesia alone or in combination with general or spinal anesthesia (RA) and general or spinal anesthesia only (GS) groups differed in nonunion site distribution (p < 0.001). RA patients were discharged the same day more often than GS patients (30.9% vs 10.0%, p = 0.009) and experienced fewer postoperative complications (p = 0.021). The RA group achieved union sooner than the GS group (by 5.3 ± 3.2 months vs. by 6.8 ± 3.2 months, p = 0.006). Mean morphine equivalent dose was similar between groups (p = 0.23). Regional anesthesia use increased from 2013 to 2020, and same day discharge surgeries simultaneously increased over the same time period. CONCLUSION/CONCLUSIONS:Regional anesthesia use increased in nonunion repair surgery with ICBG from 2013 to 2020. This was associated with an increase in same day discharge, sooner time to union, and decreased postoperative complications. There was not a need for increased opioid prescription in patients that underwent regional anesthesia.