Faculty Bibliography

OBJECTIVES/OBJECTIVE:To examine the feasibility of a novel anesthetic option for hip fracture fixation with short cephalomedullary nails. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:An urban, academic level 1 trauma center, a tertiary care academic medical center, and an orthopedic specialty hospitalPatients/Participants: 20 recent and 40 risk-matched (1:1:1 by anesthesia type) historical hip fracture patients. INTERVENTION/METHODS:All patients with an OTA 31.A1-3 IT hip fracture presenting from October 1st 2019 - March 31st, 2020 treated with a short cephalomedullary nail (CMN) underwent a new intraoperative anesthesia protocol using monitored anesthesia care (MAC) and soft-tissue infiltration with local anesthesia (STILA). MAIN OUTCOME MEASUREMENTS/METHODS:Intraoperative measures, postoperative pain scores, narcotic and acetaminophen use, hospital quality measures, and inpatient cost. RESULTS:A total of 60 patients (20 each: MAC, general, spinal) were identified. There were differences among the groups regarding mean minimum and maximum intraoperative heart rate with MAC-STILA protocol demonstrating the best maintenance of normal heart rate parameters (60-100 bpm). For the first 3 hours post-operatively, MAC-STILA patients reported consistently lower pain scores (VAS <1) than spinal or general patients (VAS>1). Through 48 hours postoperatively, MAC-STILA narcotic usage was similar to that of the spinal cohort and approximately five times less than the general cohort. There were no differences in procedural time, length of stay, minor or major complications, inpatient and 30-day mortality, or 30-day readmissions, or post-operative ambulatory distance. There was no difference in inpatient cost among cohorts. CONCLUSIONS:This feasibility study demonstrates safety for the MAC-STILA protocol with comparison to spinal and general anesthesia. The MAC-STILA protocol is a viable option for treatment of OTA 13.A1-3 IT fractures with a short CMN, and may be the preferred method for patients with severe medical co-morbidities or relative contraindications to general and/or spinal anesthesia. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

PURPOSE/OBJECTIVE:This study sought to compare postoperative outcomes and complications between patients with distal humerus fractures treated with open reduction and internal fixation (ORIF) of their non-dominant versus dominant arm. METHODS:A retrospective review of all patients who sustained a distal humerus fracture treated operatively with ORIF at one academic institution between 2011 and 2015 was performed. Measured outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and elbow range of motion. Differences in outcomes between patients who underwent surgery of their dominant upper extremity and those who underwent surgery of their non-dominant extremity were assessed. RESULTS:Sixty-nine patients met inclusion criteria. Forty (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow-up was 14.1 ± 10.5 months, with all patients achieving at least 6 months follow-up. The non-dominant cohort experienced a higher proportion of postoperative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow-up, the non-dominant cohort had lower MEPI scores (P = 0.037) but no difference in elbow arc of motion (P = 0.314). CONCLUSION/CONCLUSIONS:Patients who sustained a distal humerus fracture of their non-dominant arm treated with ORIF experienced more postoperative complications, reported a greater incidence of painful hardware, underwent removal of hardware more often, and had worse functional recovery in this study. Physicians should emphasize the importance of physical therapy and maintaining arm movement especially when the non-dominant arm is involved following distal humerus fracture repair. LEVEL OF EVIDENCE/METHODS:Level III.

PURPOSE/OBJECTIVE:The purpose of this study was to examine hospital quality measures and the long-term functional outcomes associated with lateral compression type 1 [LC1] pelvic ring injuries. METHODS:A query was performed from December 2011 to September 2020 at two institutions within one hospital system for patients with a pelvic fracture diagnosis. Chart review was performed on admitted patients to determine demographic information, medical co-morbidities (to calculate Charlson Co-morbidity Index), in-hospital complications, length of stay [LOS], discharge disposition, and 30-day readmission rates. All patients included were treated nonoperatively. An attempt was made to contact all patients for long-term follow-up to assess current functional status with a Short Musculoskeletal Function Assessment [SMFA]. RESULTS:Two-hundred and eighty-six patients were included, with 172 (65.9%) patients admitted and analyzed with respect to hospital quality measures. Patients admitted were older (83 vs 80 years, p = 0.015) with more medical co-morbidities (p = 0.001) than those discharged from the emergency department. The average LOS was 5.7 ± 3.7 days and 31 (18%) experienced in-hospital complications. The inpatient mortality rate was 1.2%, and the 30-day readmission rate was 8.1%. When comparing admitted patients without concomitant injuries, admitted patients with concomitant injuries, and non-admitted patients, admitted patients with concomitant injuries were found to have more medical co-morbidities (p = 0.001). Forty-three patients were available for long-term follow-up (average 36.6 ± 7.3 months), with an average SMFA score of 29.0 ± 25.7. CONCLUSIONS:Patients admitted for LC1 pelvic fractures are likely to be older with more medical co-morbidities, and up to 1/5th will experience inpatient complications. Although inpatient mortality remains low, this injury pattern can lead to significant functional disability that persists for several years after injury.

OBJECTIVE:This study examines the role of electronic learning platforms for medical knowledge acquisition in orthopedic surgery residency training. This study hypothesizes that all methods of medical knowledge acquisition will achieve similar levels of improvement in medical knowledge as measured by change in orthopedic in-training examination (OITE) percentile scores. Our secondary hypothesis is that residents will equally value all study resources for usefulness in acquisition of medical knowledge, preparation for the OITE, and preparation for surgical practice. DESIGN/METHODS:9 ACGME accredited orthopedic surgery programs participated with 95% survey completion rate. Survey ranked sources of medical knowledge acquisition and study habits for OITE preparation. Survey results were compared to OITE percentile rank scores. PARTICIPANTS/METHODS:386 orthopedic surgery residents SETTING: 9 ACGME accredited orthopaedic surgery residency programs RESULTS: 82% of participants were utilizing online learning resources (Orthobullets, ResStudy, or JBJS Clinical Classroom) as primary sources of learning. All primary resources showed a primary positive change in OITE score from 2018 to 2019. No specific primary source improved performance more than any other sources. JBJS clinical classroom rated highest for improved medical knowledge and becoming a better surgeon while journal reading was rated highest for OITE preparation. Orthopedic surgery residents' expectation for OITE performance on the 2019 examination was a statistically significant predictor of their change (decrease, stay the same, improve) in OITE percentile scores (p<0.001). CONCLUSIONS:Our results showed that no specific preferred study source outperformed other sources. Significantly 82% of residents listed an online learning platform as their primary source which is a significant shift over the last decade. Further investigation into effectiveness of methodologies for electronic learning platforms in medical knowledge acquisition and in improving surgical competency is warranted.

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.

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.

INTRODUCTION/BACKGROUND:The purpose of this study is to evaluate the relationship between patients' own health expectations and treatment outcomes following surgical repair of proximal humerus fractures. HYPOTHESIS/OBJECTIVE:Patients' health expectations will correlate with treatment outcomes following surgical repair of proximal humerus fractures. MATERIAL AND METHODS/METHODS:Over a 14-year period, 247 patients with a displaced proximal humerus fracture who underwent ORIF with locking compression plates were prospectively followed at one academic institution. Minimum follow-up period was 12 months. Patient-reported functional outcome data for the latest follow up visit (12 months and greater) was obtained from Disabilities of Arm, Shoulder, and Hand (DASH) questionnaires. Survey responses regarding health expectations were recorded at 3-month follow-up and converted to dichotomous variables. Two groups were identified: the high expectations and the low expectations groups. Statistical analysis comparing the two groups and their functional and clinical outcomes was performed using the independent t-test, using p<0.05 for significance. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to further statistically characterize the relationship between health expectations at 3 months and long-term outcomes. RESULTS:One hundred and eighty-five (75.0%) patients available for analysis with a mean follow-up length of 24.8 months. The cohort included 124 (67%) females and 61 (33%) males and the average age at time of injury was 59.5 years. Eighty-six (46.5%) patients had low expectations for their overall health and 99 (53.5%) patients had high expectations for their health. No significant differences were seen between groups in regards to age, gender, follow-up length, Charlson Comorbidity Index (CCI), smoking and tobacco use, fracture pattern (OTA and Neer classifications), early complications (p>0.05), fracture healing, and avascular necrosis. The mean DASH score at the latest follow up for patients with low expectations was 31.42±22.8 whereas the mean for those with high expectations was 16.76±20.2 (p<0.0005). The mean forward flexion of the shoulder for patients with low expectations was 137.8±31.5 degrees as compared to 148.5±26.3 degrees (p<0.05). The positive predictive value of good expectations correlating with good outcomes was 71.7%. DISCUSSION/CONCLUSIONS:Patients with high expectations for their health early following injury had better outcomes in the long term. These high expectations also appeared to have an optimal influence on range of shoulder motion. This data suggests attitudinal and psychological factors that affect patient health expectations early on in the course of treatment may also influence patients' functional and clinical outcomes. LEVEL OF EVIDENCE/METHODS:II; Retrospective Study.

OBJECTIVES/OBJECTIVE:To evaluate the outcomes of patients who underwent soft tissue flap coverage during treatment of a tibia fracture nonunion. DESIGN/METHODS:Retrospective analysis on prospectively collected data. SETTING/METHODS:Academic medical center. PATIENTS/PARTICIPANTS/METHODS:157 patients were treated for a fracture nonunion following a tibia fracture over a 15-year period. Sixty-six had sustained an open tibial fracture initially and 25 of these patients underwent soft tissue flaps for their open tibia fracture nonunion. INTERVENTION/METHODS:Manipulation of soft tissue flaps, either placement or elevation for graft placement in ununited previously open tibial fractures. MAIN OUTCOME MEASUREMENTS/METHODS:Bony healing, time to union, ultimate soft tissue status, postoperative complications, and functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA). This group was compared to a group of open tibial fracture nonunions that did not undergo soft tissue transfer. RESULTS:Bony healing was achieved in 24/25 patients (96.0%) who received flaps at a mean time to union of 8.7 ± 3.3 months compared to 39/41 patients (95.1%) at a mean 7.5 ± 3.2 months (p > 0.05) in the non-coverage group. Healing rate and time to union did not differ between groups. At latest follow-up, the flap coverage group reported a mean SMFA index of 17.1 compared to an SMFA index of 27.7 for the non-coverage group (p = 0.037). CONCLUSIONS:Utilization of soft tissue flaps in the setting of open tibia shaft nonunion repair surgery are associated with a high union rate (>90%). Coverage with or manipulation of soft tissue flaps did not result in improved bony healing rate or time to union compared to those who did not require flaps. However, soft tissue flap coverage was associated with higher functional scores at long-term follow-up. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

SUMMARY:There are a variety of treatment options available for proximal humerus fractures, including nonoperative management, open reduction internal fixation with screws, locking plates, intramedullary nailing, or suture fixation, and arthroplasty, including hemiarthroplasty and total shoulder replacements. Fracture characteristics, including the number of fracture parts and involvement of the humeral head and glenoid and the patient's functional status and postoperative goals help dictate the optimal choice. Although the indications for hemiarthroplasty as treatment for severe proximal humerus fractures have narrowed, the authors believe that there is a still a place for this technique in practice.

SUMMARY:A 58-year-old woman with a proximal 1/3 humeral shaft nonunion presented 2 years after initial injury. We present a technique for nonunion repair, including nonunion site preparation, direct compression of the fracture site using plate osteosynthesis, and iliac crest bone graft harvest and utilization. The purpose of this video is to review humeral shaft nonunion literature and describe our management technique.