Faculty Bibliography

OBJECTIVES/OBJECTIVE:What patient characteristics and injury factors predict decreased knee range of motion (ROM) following operative management of tibial plateau fractures? DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Over 11 years, tibial plateau fractures at a single academic institution were prospectively followed. A total of 266 patients were included in this study. INTERVENTION/METHODS:Surgical repair of tibial plateau fractures and secondary interventions due to arthrofibrosis. MAIN OUTCOME MEASURE/METHODS:Clinical outcomes were evaluated using the Short Musculoskeletal Function Assessment (SMFA) and range of motion (ROM) at 3-month, 6-month and long-term follow-up. Secondary outcomes were considered as the need for a subsequent procedure due to arthrofibrosis. RESULTS:At 3-month follow-up, the mean ROM was 113°. By long-term follow-up (mean=17 months), the mean ROM improved to 125°. Independent predictors of decreased knee ROM were the following: At 3-month follow-up, open fractures (P=0.047), application of a knee spanning external fixator (P=0.026), orthopaedic poly trauma (P=0.003), and tibial spine involvement (P=0.043). At long-term follow-up, non-Caucasian ethnicity (P=0.003), increasing age (P=0.003), and a deep infection (P=0.002). Ten patients (3.7%required a secondary procedure for arthrofibrosis. There was a significant improvement in the knee ROM (P<0.001) and functional outcomes (P=0.004) following the intervention. CONCLUSIONS:At long-term follow-up, independent predictors of decreased knee ROM were non-Caucasian ethnicity, increasing age, and sustaining a post-operative complication of a deep infection. Secondary interventions were reliable treatments for arthrofibrosis. LEVEL OF EVIDENCE/METHODS:Prognostic level III.

OBJECTIVES/OBJECTIVE:To determine the effect of osteonecrosis (ON) on the clinical and functional outcome after open reduction and internal fixation of proximal humerus fractures. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Over a 12-year period, 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 sixty-five patients with 166 proximal humerus fractures met inclusion criteria. Eight patients developed radiographic evidence of ON (4.8%). INTERVENTION/METHODS:Surgical repair of proximal humerus fractures. MAIN OUTCOME MEASURE/METHODS:Patients were divided into 2 cohorts; 1 cohort being those diagnosed with ON and the other cohort being those who were not. All patients were prospectively followed and assessed for clinical and functional outcomes at the latest follow-up visit (mean = 22.9 months) using the Disabilities of Arm, Shoulder and Hand survey along with ranges of motion of the injured extremity. RESULTS:Average postoperative forward elevation for patients with ON was worse than those without ON (P = 0.002). Additionally, there was a significant difference in Disabilities of Arm, Shoulder and Hand scores at the latest follow-up between the 2 groups (P = 0.026). There was no difference in external rotation or mean length of follow-up between the 2 groups (P > 0.05). CONCLUSIONS:This study demonstrates the negative effects of ON after open reduction and internal fixation of proximal humerus fractures. Those who develop ON have poorer functional and clinical outcomes as compared with patients without ON. Consequently, the development of ON can be used as a predictor of poor outcomes. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:Determine if a novel inpatient mortality risk assessment tool designed to be calculated in the emergency department (ED) setting can risk stratify patient reported functional outcomes and mortality at one year. DESIGN/METHODS:Prospective cohort SETTING:: Academic level one trauma center PATIENTS:: 685 patients >55 years old who were orthopaedic surgery consults or trauma surgery consults in the ED between 10/1/2014 and 9/30/2015. INTERVENTION/METHODS:Calculation of validated trauma triage score (STTGMA) using each patient's demographics, injury severity, and functional status MAIN OUTCOME MEASUREMENTS:: mortality, EQ-5D questionnaire, and percent return to baseline function since their hospitalization at one-year post hospitalization. RESULTS:45 (6.6%) patients died within the year following hospitalization. Of remaining 639 patients available for follow-up, 247 (38.7%) were successfully contacted. There was no observed difference between patients who were successfully contacted and those who were not. The mean STTGMA score was 2.1 ± 3.6%. Patients reported on average a 76.4 ± 27.5% return to baseline function. When comparing patients between risk groups, there was a significant difference in EQ-5D scores and percent return to baseline. Kaplan-Meier survival curve shows that high risk patients had pronounced decreased survival within the initial days after discharge compared to other cohorts. CONCLUSION/CONCLUSIONS:This study demonstrates that patients identified with the STTGMA tool as having an increased risk of inpatient mortality following trauma correlate with poorer functional outcomes at one year. The STTGMA risk score is also a valuable tool to stratify risk of mortality up to one year following discharge. LEVEL OF EVIDENCE/METHODS:Level IV, Prognostic.

OBJECTIVES/OBJECTIVE:Analyze the effectiveness of a BPCI (Bundle Payments for Care Improvement) initiative for patients who would be included in a future potential Surgical Hip and Femur Fracture Treatment (SHFFT) bundle. DESIGN/METHODS:Retrospective cohort SETTING:: Single Academic Institution PATIENTS/PARTICIPANTS:: Patients discharged with operative fixation of a hip or femur fracture (DRG codes 480-482) between 1/2015-10/2016 were included. A BPCI initiative based upon an established program for BPCI Total Joint Arthroplasty (TJA) was initiated for patients with hip and femur fractures in January 2016. Patients were divided into non-bundle (care before initiative) and bundle (care with initiative) cohorts. INTERVENTION/METHODS:Application of BPCI principles MAIN OUTCOME MEASURES:: Length of stay, location of discharge, readmissions RESULTS:: 116 patients participated in the "institutional bundle," and 126 received care prior to the initiative. There was a trend towards decreased mean length of stay, (7.3 ± 6.3 days vs. 6.8 ± 4.0 days, p=0.457) and decreased readmission within 90 days (22.2% vs. 18.1%, p=0.426). The number of patients discharged home doubled (30.2% vs. 14.3%, p=0.008). There was no difference in readmission rates in bundle vs. non-bundle patients based on discharged home status; however, bundle patients discharged to SNF trended towards less readmissions than non-bundle patients discharged to SNF (37.3% vs. 50.6%, p=0.402). Mean episode cost reduction due to initiative was estimated to be $6,450 using Medicare reimbursement data. CONCLUSION/CONCLUSIONS:This study demonstrates the potential success of a BPCI initiative at one institution in decreasing post-acute care facility utilization and cost of care when used for a hip and femur fracture population. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:1) Demonstrate that a validated trauma triage score for middle-aged and geriatric patients could identify those at high risk for mortality within the first two days of hospitalization and 2) determine the cost of care for this cohort of patients DESIGN:: Prospective cohort study SETTING:: Single Level 1 Trauma Center PATIENTS:: Patients 55 years and older who were evaluated in the emergency department setting by Orthopaedics or who met American College of Surgeons Tier 1-3 criteria 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 statusMain Outcome Measurements: length of stay, inpatient mortality, time between presentation and time of death, and direct variable costs of hospitalization RESULTS:: A total of 1470 consecutive patients (mean age of 72.2±11.9 years) were enrolled in this study, 17 of whom expired within 48 hours of presentation to the emergency department. These patients had a significantly higher trauma triage score than the rest of the cohort with a score of 50.9%±37.2% vs. 3.3%±9.5%, p<0.001 indicating that they had a mean risk of inpatient mortality of over 50%. Mean total cost/day was much higher in the cohort of patients who died within 48 hours of admission compared to all other trauma patients ($49,367±$79,057 vs. $3,966±$2,897 (p=0.031)). CONCLUSION/CONCLUSIONS:To achieve value-based care in this high-risk cohort, targeted cost-savings while improving patient outcomes and/or expediting goals-of-care and end-of-life goals is necessary and the STTGMA score allows for stratification of these patients in both mortality risk and cost profile. LEVEL OF EVIDENCE/METHODS:Prognostic, Level III.

PURPOSE/OBJECTIVE:To describe one center's experience with nonunion of one or both bones of the forearm and report on the functional recovery of patients treated for a single- or 2-bone forearm nonunion. METHODS:We performed a retrospective analysis of 23 patients who presented to our institution over an 11-year period and underwent surgical repair of a forearm nonunion (radius, ulna, or both bones). The main outcome measurements included time to union, visual analog scale pain scores, range of motion, Short Musculoskeletal Function Assessment scores, and postoperative complications. RESULTS:Of the 23 patients, 21 (91.3%) healed their nonunion after a single surgical procedure. All patients ultimately healed their nonunion; 7 patients were healed at 3-month follow-up, 11 healed at 6-month follow-up, and 5 healed at 12-month follow-up. Mean visual analog scale pain scores improved considerably from presentation to latest follow-up. The mean range of motion at the latest follow-up was as follows: elbow 130.9° flexion-extension arc, forearm 78.5° pronation/77.8° supination, and wrist 76.1° palmar flexion/74.3° dorsiflexion. Mean Short Musculoskeletal Function Assessment arm and hand index scores improved significantly from baseline to the latest follow-up. Mean Short Musculoskeletal Function Assessment function, activity, and bothersome indices demonstrated improvement, though this was not statistically significant. Two patients required further surgery to achieve osseous union. One patient sustained an iatrogenic posterior interosseous nerve palsy, which resolved spontaneously. CONCLUSIONS:Repair of forearm nonunion with compression plating and bone grafting provides reliable clinical and functional outcomes. Patients treated surgically for nonunion of one or both of the forearm bones can expect to heal with the potential for considerable improvements in pain and function postoperatively. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Therapeutic IV.

INTRODUCTION: Much has been studied with reference to methicillin resistant Staphylococcus aureus (MRSA) and methicillin sensitive S. aureus (MSSA) colonization and associated outcomes and comorbidities. In the area of Orthopedic surgery, literature predominantly comes from the field of arthroplasty. Little is known about outcomes of fracture and Orthopedic trauma patients in the setting of S. aureus colonization. We believe that MRSA/MSSA colonization in and of itself may be a weak marker for generally poor protoplasm, potentially with complex medical history including previous hospitalization or rehab placement. This milieu of risk factors may or may not contribute to poorer outcomes after fracture and fracture nonunion surgery. The purpose of this study is to determine if nasal swabbing for S. aureus (MRSA or MSSA) carriage can predict operative culture, complications, or outcomes following fracture nonunion surgery. METHODS: Sixty-two consecutive patients undergoing surgery for fracture nonunion were prospectively followed. Data analyses were performed using grouped MRSA and MSSA carriers (Staphylococcus carriers: SC). Outcomes analyzed included time to healing, need for additional surgery, and persistent nonunion. RESULTS: Twenty-six percent of patients (16/62) were identified as MSSA carriers, an additional 6.5% (4/62) carried MRSA. Follow-up of at least 12-months was obtained on 90% (56/62) of patients. White blood cell counts, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values did not differ between SCs and non-carriers pre-operatively. Carriers were just as likely as non-carriers to culture positively for any pathogen at the time of surgery. Although SC's were three times as likely as non-carriers to grow S. aureus (15% vs. 5%), this difference did not reach statistical significance (p=0.3). Post-operative wound complications, antibiotic use, pain at follow-up and progression to healing did not differ between groups. CONCLUSIONS: Ultimately, pre-operative nasal swabbing for S. aureus is a simple and non-invasive diagnostic tool with prognostic implications in patients undergoing fracture nonunion surgery. This study found that MRSA and MSSA colonized patients with fracture nonunion of long bones do not have an increased association with positive cultures or a predisposition towards greater post-operative infectious complications.

OBJECTIVES/OBJECTIVE:To assess the role self-reported treatment for a psychiatric diagnosis may play in long-term functional outcomes after operatively managed tibial plateau fractures. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Over an 11-year period, patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an IRB-approved registry. A total of 245 patients were included in the study. Twenty-one patients reported treatment for a psychiatric diagnosis. INTERVENTION/METHODS:Surgical repair of tibial plateau fractures. MAIN OUTCOME MEASURE/METHODS:Patients were divided into 2 cohorts; 1 cohort being those who self-reported receiving treatment of a psychiatric diagnosis (PI); the other group being those who did not self-report receiving treatment of a psychiatric diagnosis (NPI). Three-month, 6-month, and long-term outcomes (mean = 18 months) were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, and postoperative complications (infection, VTE, nonunion, and necessity for secondary operations). RESULTS:Pain scores were higher in patients who self-reported receiving treatment for a psychiatric diagnosis (P = 0.012). Long-term functional outcomes as measured by the SFMA were demonstrated to be worse in patients who self-reported treatment for a psychiatric diagnosis (P = 0.034). No differences existed between groups in regards to postoperative complications. Multiple linear regression analysis revealed that being treated for diagnosis of a mental health illness was an independent predictor of worse functional outcomes at long-term follow-up [B = 8.874, 95% confidence interval (CI) = 0.354-17.394, P = 0.041]. CONCLUSIONS:Mental health plays a crucial role in long-term outcomes after operative fixation of tibial plateau fractures. Patients who have been diagnosed with a mental health illness have significantly worse outcomes at long-term follow-up. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To assess clinical and hospital quality outcomes of patients receiving the previously reported Reduced Effective Dose Using Computed Tomography In Orthopaedic iNjury (REDUCTION) imaging protocol. DESIGN/METHODS:Retrospective Chart review SETTING:: Level I Trauma Center and affiliated Tertiary Care Hospital CenterPatients/Participants: fifty patients who received this protocol for acute traumatic fracture evaluation and met inclusion criteria were compared to a cohort of fifty patients matched for age and fracture type who previously received conventional CT scanning for acute traumatic fracture evaluation. INTERVENTION/METHODS:Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) protocol for diagnostic fracture evaluation. MAIN OUTCOME MEASURES/METHODS:Estimated effective radiation doses were calculated and compared using Digital Imaging and Communications in Medicine (DICOM) information from all included studies. Patient outcomes between groups were compared with time to fracture union as the primary outcome. Secondary outcome measures included: presence of complication defined as infection, malunion, nonunion, failure of non-operative treatment, painful implants, and implant failure. Other secondary quality outcomes that were recorded included readmission within 30 days and hospital length of stay. Functional quality measures included joint range of motion. Statistical analyses were conducted to identify significant differences between cohorts (significance designated as p<0.05). RESULTS:Patient characteristics between cohorts were not significantly different with respect to age, gender, body mass index, comorbidities, injury mechanism or injury location. Fractures of the elbow, hip, knee, and foot/ankle were evaluated. Mean clinical follow-up was 9.5 ± 4.9 months for the REDUCTION cohort and 12.4 ± 5.3 months for conventional CT cohort. Mean estimated effective dose for all REDUCTION scans was 0.15 milliSieverts (mSv) as compared to 1.50 mSv for the conventional CT cohort (p=0.037). Pre-operative diagnosis was confirmed intra-operatively in 49/50 cases in the REDUCTION cohort compared to 48/50 cases in the conventional CT cohort (p=0.79). Outcomes including time to union, range of motion, complications, readmission, treatment failure, reoperation, and length of stay were not significantly different between groups. CONCLUSIONS:The REDUCTION protocol represents an ultra low dose CT scan developed for minimizing radiation exposure to patients presenting with traumatic fractures. This protocol resulted in a ten-fold reduction in radiation exposure. No difference in clinical or hospital quality outcomes was detected between patients who received this protocol as compared to those receiving automated dose CT scans. The REDUCTION protocol is a safe and effective method of performing CT scans for extremity fractures with significantly reduced radiation risk. LEVEL OF EVIDENCE/METHODS:Retrospective Case-Control Study, Level III Evidence.

BACKGROUND:Nondisplaced and minimally displaced fractures of the radial head and neck are common injuries, yet the role of physical therapy (PT) in their treatment is unclear. The aim of this trial was to assess the need for formal PT following a simple fracture of the radial head or neck. METHODS:Patients who had a nondisplaced or minimally displaced fracture of the radial head or neck and presented to 1 of 2 providers were enrolled prospectively between January 2014 and August 2016. Patients were randomized to receive outpatient PT or perform self-directed home exercise. The follow-up intervals were 6 weeks, 3 months, 6 months, and at least 1 year. The outcome measures were Disabilities of the Arm, Shoulder and Hand (DASH) scores; pain; time to clinical healing; and range of motion. Demographic data were analyzed using the Mann-Whitney U test and Fisher exact test. Independent-samples t tests were utilized to compare outcome measures. RESULTS:Fifty-one patients were enrolled in the study. The average follow-up was 16.6 months. Twenty-five patients were randomized to a home-exercise cohort, and 26 patients were randomized to a formal-outpatient-PT cohort. There were no significant differences in demographics between cohorts. At 6 weeks, the home-exercise cohort had better function as indicated by a significantly lower mean DASH score compared with the PT cohort (p = 0.021). At 3 months, 6 months, and final follow-up, there were no significant differences between cohorts for any outcome measure. CONCLUSIONS:Patients who performed home exercises after sustaining a nondisplaced or minimally displaced fracture of the radial head or neck demonstrated better early function at 6 weeks compared with patients who received formal PT. After 6 weeks, there were no significant differences in outcomes. These data suggest that prescribing PT for patients who have an isolated nondisplaced or minimally displaced fracture of the radial head or neck is not cost-effective and that instructing the patient to perform self-directed exercises will be followed by a similar outcome. LEVEL OF EVIDENCE/METHODS:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.