Faculty Bibliography

INTRODUCTION/BACKGROUND:Autogenous iliac crest bone graft (ICBG) is considered the benchmark graft for nonunion repair. However, ICBG harvest is invasive and may provide reduced benefit to elderly patients. The purpose of this study was to compare the clinical and functional outcomes of ICBG use in fixation of fracture nonunions between elderly and nonelderly patients. METHODS:Over a 13-year period, 242 patients who underwent operative repair of a long bone fracture nonunion and received autogenous ICBG were enrolled in a prospective research registry and followed. Data collected included patient demographics, injury information, and nonunion management. All patients had a minimum of 12 months of postoperative follow-up. Patients at least 65 years of age were classified as elderly, whereas younger patients were classified as nonelderly. Functional outcomes were evaluated at routine intervals postoperatively using the short musculoskeletal function assessment (SMFA) and visual analog scale pain scores. Bony union was determined radiographically. All postoperative complications were recorded. RESULTS:Of the 242 patients included, 44 were elderly and 198 were nonelderly. No differences were found between groups with respect to postoperative pain scores or SMFA scores. Furthermore, time to union, rate of union, and postoperative complication rate did not differ between groups. Multivariate linear regression demonstrated that older age was not associated with time to union, postoperative pain scores, or postoperative SMFA scores after controlling for possible confounding variables. DISCUSSION/CONCLUSIONS:The use of ICBG in nonunion repair among elderly patients is as effective as use in younger patients with a long bone nonunion. Concerns of increased postoperative complications and decreased rate of union in elderly patients receiving ICBG for treatment of fracture nonunion should be alleviated. ICBG remains the benchmark graft for nonunion repair among all age groups.

OBJECTIVES/OBJECTIVE:(1) To assess the correlation of psychosocial factors and long-term outcomes of proximal humerus fractures all in surgical repair; (2) to identify specific psychosocial factors with favorable and unfavorable outcomes; and (3) to assess the correlation between DSM-V mental health diagnoses and long-term Disabilities of Arm, Shoulder, and Hand (DASH) scores. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an institutional review board-approved registry. One hundred eighty-five proximal humerus fractures of 247 met inclusion criteria. INTERVENTION/METHODS:Surgical repair of proximal humerus fractures. MAIN OUTCOME MEASURE/METHODS:All patients were prospectively followed up and assessed for clinical and functional outcomes at latest follow-up visit (mean = 24.8 months) using the DASH questionnaires along with ranges of motion and pain level. Psychosocial factors at 3 months were obtained from the DASH survey. RESULTS:Concomitant diagnosis of depressed mood (P = 0.001), anxiety (P < 0.0005), low energy level (P = 0.003), and fatigue (P = 0.001) correlated significantly with poorer outcome. All 6 psychosocial factors correlated directly and significantly with pain at latest follow-up (P < 0.0005). Multiple regression analysis revealed that the strongest predictor of the overall DASH score was the extent of interference with social life (P = 0.001). CONCLUSION/CONCLUSIONS:Analysis demonstrated that psychological and social factors at 3 months postoperatively have a strong correlation with negative long-term (>1 year) outcomes after proximal humerus fixation. Clinicians may offer psychological support and encourage social support to these patients postoperatively to improve pain and treatment outcomes. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To propose a previous implant fractures (PIFs) classification system with good interobserver reliability. DESIGN/METHODS:Retrospective classification. SETTING/METHODS:Four academic medical centers. PATIENTS/PARTICIPANTS/METHODS:A retrospective review of PIFs treated at 4 academic medical centers over 10 years was performed. Data collected included initial implant and PIF radiographs. There were 103 PIFs in 96 patients during the study period. Seventy-three (70.9%) were about plate/screw (PS) constructs and 30 (29.1%) were about intramedullary (IM) devices. INTERVENTION/METHODS:Assignment of PIF classification. MAIN OUTCOME MEASUREMENTS/METHODS:PIFs were classified based on initial implant (PS or IM) and fracture location with respect to the initial implant (proximal or distal to the implant, at the tip of the construct, or within the construct). Reliability of this scheme was assessed among 5 observers using Fleiss' kappa tests. RESULTS:Of PIFs about plate/screw constructs, 26.0% were proximal/distal to the implant (classification: PS1), 57.5% involved bone between the most proximal/distal screw and the same end of the plate (classification: PS2), and 16.4% involved only bone between the most proximal and distal screws (classification: PS3). Of PIFs about IM, 43.3% were distal to the device (classification: IM1), 46.7% involved bone between the most proximal/distal locking bolt and the same end of the device (classification: IM2), and 10.0% involved only bone between locking bolts (classification: IM3). Interobserver reliability for the classification system was excellent between observers, κ = 0.839, P < 0.0005. CONCLUSIONS:The proposed system offers a simple method to classify and describe fractures that occur about a previously implanted fracture device. Development of a classification system will allow for comparison of treatment modalities between injury types.

INTRODUCTION/BACKGROUND:Periprosthetic fracture nonunions represent a rare problem in orthopaedic practice, although their incidence has increased with the increased frequency of joint replacement surgery. This video demonstrates the use of a linked nail-plate construct to repair a distal femoral periprosthetic fracture nonunion. METHODS:The patient is a 93-year-old woman who is 1-year status-post a left distal femoral periprosthetic fracture with known delayed healing. She presents with a low energy trauma and hardware failure. The patient was indicated for operative fixation using a linked nail-plate construct given the patient's previous hardware failure, advanced age, and poor bone quality. RESULTS:This video demonstrates the linked nail-plate technique for the repair of a distal femoral periprosthetic fracture nonunion. Anatomical reduction and stable fixation with bone graft was performed with excellent results. There were no intraoperative or postoperative complications and no issues related to metallurgy. CONCLUSIONS:In this video, we present the case of an atrophic distal femoral periprosthetic nonunion treated with a linked nail-plate construct with autologous bone graft. Although femoral periprosthetic fracture nonunions are a rare occurrence, they can be successfully treated with operative intervention aimed at compression plating with supplemental bone grafting.

INTRODUCTION/BACKGROUND:Approximately half of all hip fractures are intertrochanteric femur fractures. This video demonstrates the technique of repair of an unstable intertrochanteric hip fracture using a cephalomedullary device. METHODS:The patient is an 88-year-old woman presenting with an intertrochanteric hip fracture secondary to a low-energy injury. The patient was indicated for surgery due to the unstable nature of the fracture. RESULTS:This video demonstrates the cephalomedullary nailing technique for the repair of an unstable intertrochanteric hip fracture after a low-energy injury. Anatomical reduction and stable fixation were obtained with this technique. CONCLUSIONS:The case demonstrates a cephalomedullary technique of intertrochanteric fracture fixation using a cephalomedullary nail. The technique has significant advantages including minimal intraoperative blood loss, shorter operative times, potential for more biological healing with a load-sharing device, and low infection rate.

INTRODUCTION/BACKGROUND:Monteggia fractures are rare, although complex elbow injuries. Bado II Monteggia fractures are characterized by posterior dislocation of the radial head and concurrent fracture of the proximal or middle third of the ulna. This video demonstrates the open reduction and internal fixation of a complex Bado II Monteggia fracture dislocation. METHODS:The patient is a 65-year-old woman with a Bado II Monteggia fracture after a low-energy fall from standing height. Given the extent of comminution and the instability of the elbow, the patient was indicated for surgical fixation. RESULTS:This video demonstrates a locking plate technique for repair of a comminuted fracture of the proximal ulna. Anatomical reduction of ulnohumeral and radiocapitellar joints and stable fixation with bone grafting of the fracture are achieved with a medial 2.0/2.4-mm plate and a dorsal precontoured variable-angle locking plate. Demonstration of radial head arthroplasty is provided as an alternative for utilization in cases with a radial head fracture. CONCLUSIONS:Anatomical reduction and fixation of complex Monteggia fracture dislocations can be achieved with adherence to standard aspects of bony reconstruction. In this video we present the case of a Bado II Monteggia fracture surgically repaired with a locking plate construct.

OBJECTIVES/OBJECTIVE:To evaluate the clinical and functional outcomes after operative repair of nonunited lower extremity fractures initially repaired outside the developed Western world. DESIGN/METHODS:Retrospective analysis of prospectively collected data. SETTING/METHODS:Academic medical center. PATIENTS/PARTICIPANTS/METHODS:From September 2004 through February 2017, 227 patients who underwent operative repair of a lower extremity fracture nonunion were prospectively enrolled in a research registry. All patients underwent previous fracture surgery and had at least 12 months of postoperative follow-up. INTERVENTION/METHODS:Repair of lower extremity fracture nonunion. MAIN OUTCOME MEASUREMENTS/METHODS:Postoperative complications, reoperation rate, time to union, and functional outcomes were assessed using the Short Musculoskeletal Function Assessment and Visual Analog Scale pain scores. Univariate and multivariate analyses were performed to evaluate the differences in patients who underwent initial fracture repair outside the developed Western world as opposed to within the United States. RESULTS:Twenty-one patients (9.3%) underwent initial fracture repair outside the developed Western world. These patients had a greater incidence of infected nonunions (47.6% vs. 23.3%; P = 0.015) and failure of a previous implant at the time of presentation (52.4% vs. 22.8%; P = 0.003) than those initially managed within the United States. This cohort also experienced a greater rate of postoperative complications after nonunion repair (23.8% vs. 6.3%; P = 0.016). The geographic location of initial fracture repair was not associated with postoperative Short Musculoskeletal Function Assessment scores or Visual Analog Scale pain scores after controlling for possible confounding variables. CONCLUSIONS:Patients who present with a nonunited lower extremity fracture initially repaired outside the developed Western world experience a high rate of postoperative complications after fracture nonunion repair but can expect good short- and long-term functional outcomes. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To investigate the ability of a validated geriatric trauma risk prediction tool to stratify hospital quality metrics and inpatient cost for middle-aged and geriatric patients admitted from the ED for operative treatment of an ankle fracture. DESIGN/METHODS:Prospective cohort study SETTING:: Single Academic Medical Center PATIENTS:: Patients aged 55 and older who sustained a rotational ankle fracture and were treated operatively during their index hospitalization INTERVENTION:: Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), using patient's demographic, injury severity, and functional status. Patients were stratified into groups based on scores to create a minimal-, low-, moderate-, and high-risk cohort. MAIN OUTCOME MEASUREMENTS/METHODS:length of stay, complications, need for ICU/SDU level care, discharge location, and index admission costs RESULTS:: Fifty ankle fracture patients met inclusion criteria. Mean length of stay was 7.8 ± 5.2 days with a significant difference among the four risk groups (4.6 day difference between low and high risk). 73.1% of minimal risk patients were discharged home compared to 0% of high-risk patients. There was no difference in complication rate or in need for ICU level care between groups. However, high-risk patients had a mean total inpatient cost two times greater than that of minimal risk patients. CONCLUSION/CONCLUSIONS:The STTGMA tool is able to meaningfully stratify older ankle fracture patients requiring operative fixation with regards to hospital quality metrics and cost. This information may allow for efficient targeted reductions in costs while optimizing outcomes. LEVEL OF EVIDENCE/METHODS:Prognostic, Level III.

Background/UNASSIGNED:The purpose of this study is to evaluate the ability of preoperative and postoperative radiographic union scores for tibia fractures (RUST) to predict treatment success of tibia fracture nonunion. Materials and methods/UNASSIGNED:Patients presenting for operative treatment of tibia fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months. Preoperative and 12 week postoperative radiographs were reviewed and scored using the RUST criteria. Postoperative time to union was determined by clinical and radiographic measures. Multivariate regressions were conducted to predict time to union using preoperative and postoperative RUST while controlling for treatment method. Receiver operating characteristic (ROC) curve was conducted to determine the accuracy of preoperative RUST in predicting failure of treatment. Results/UNASSIGNED:Sixty-eight patients with aseptic tibia fracture nonunion treated operatively were identified. Sixty-one patients achieved union. Mean preoperative RUST was 7.5 (SD 1.4). Mean postoperative RUST was 9.2 (SD 1.4). Multivariate linear regressions demonstrated that preoperative (p = 0.043) and postoperative (p = 0.007) RUST are significant predictors of time to union after tibia fracture nonunion surgery. ROC curve demonstrated preoperative RUST below 7 was a good predictor of developing persistent tibia fracture nonunion (AUC = 0.83, Sensitivity = 1.000, Specificity = 0.745). Conclusions/UNASSIGNED:RUST preoperatively and postoperatively predicts outcome after nonunion surgery. RUST can be used as part of the complete clinical picture to shape patient expectations and guide treatment.

CASE/METHODS:An 65-year-old immunocompetent female developed a Leclercia adecarboxylata infection following the repair of closed olecranon fracture. L. adecarboxylata is associated with polymicrobial infections, infections in immunocompromised patients and penetrating or open wounds. Following speciation, intravenous ceftriaxone was started. Two weeks later, the patient presented with leukopenia and neutropenia. Per infectious disease recommendations, the patient was switched to intravenous ertapenem with resolution of both infection and neutropenia. The olecranon fracture went on to heal fully. CONCLUSIONS:This case describes a rare postoperative monomicrobial infection with L. adecarboxylata in an immunocompetent host following musculoskeletal trauma and identifies L. adecarboxylata as a potential emerging hospital-acquired pathogen following orthopedic surgery.