Julius Bishop, MD

All Publications

• Preoperative and Postoperative Therapeutic Anticoagulation in Orthopaedic Surgery Increases the Risk of Bleeding: A Systematic Review and Meta-Analysis. The Journal of the American Academy of Orthopaedic Surgeons Wadhwa, H., Rohde, M. S., Xiao, M., Maschhoff, C., Bishop, J. A., Gardner, M. J., Goodnough, L. H. 2024

  Abstract

  INTRODUCTION: Patients requiring postoperative therapeutic anticoagulation may have increased risk of bleeding complications, infection, and poor wound healing. The purpose of this study was to perform a systematic review and meta-analysis assessing bleeding complication rates among orthopaedic surgery patients receiving perioperative therapeutic anticoagulation.METHODS: A systematic review and meta-analysis was performed in concordance with the Preferred Reporting Items for Systematic Review and Meta Analysis 2020 guidelines. PubMed was queried for articles related to therapeutic anticoagulation in orthopaedic surgery and complications using keywords and medical subject headings. Inclusion/exclusion criteria were any study reporting bleeding complications after orthopaedic surgery among patients on perioperative therapeutic anticoagulation with a minimum 1-year follow-up. Studies were reviewed for heterogeneity and risk of bias. Pooled analysis was done to determine postoperative complication rates among patients on therapeutic anticoagulation.RESULTS: Thirty-seven studies with 3,990 patients were included. Studies were grouped by their surgical subspecialty with 16 from arthroplasty, one foot and ankle, two spine, one sports, 13 trauma, and four upper extremity. Among patients on therapeutic anticoagulation, the pooled rate and 95% confidence intervals of bleeding complications was 8% (5 to 11%) overall, 10% (5 to 15%) in arthroplasty, 6% (3 to 11%) in trauma, and 5% (1 to 30%) in upper extremity. The overall rates (95% CI) of venous thromboembolism (VTE) were 2% (2 to 4%), infection 5% (3 to 10%), and revision surgery 4% (3 to 6%). Upper extremity VTE rates were 0% (0 to 15%), infection 4% (3 to 6%), and revision surgery 4% (3 to 6%). Trauma VTE rates were 4% (2 to 5%), infection 2% (1 to 6%), and revision surgery 3% (2 to 4%). Arthroplasty VTE rates were 2% (1 to 5%), infection 9% (4 to 18%), and revision surgery 4% (2 to 7%).CONCLUSIONS: Therapeutic postoperative anticoagulation may increase the risk of bleeding complications when compared with the general population. Incidence of VTE was similar when compared with historical data.

  View details for DOI 10.5435/JAAOS-D-24-00161

  View details for PubMedID 39254989

• Integrated Dual Lag Screws Have Higher Reoperation Rates for Fixation Failure Than Single Lag Component Cephalomedullary Nails: A Retrospective Study of 2,130 Patients with Intertrochanteric Femoral Fractures. The Journal of bone and joint surgery. American volume Gonzalez, C. A., Van Rysselberghe, N. L., Whittaker, M. J., Ngo, D., Michaud, J. B., Gardner, M. J. 2024

  Abstract

  Previous studies comparing reoperation risk between integrated dual lag screw (IDL) and single lag component (SL) cephalomedullary nails (CMNs) in the treatment of intertrochanteric femoral fractures have demonstrated mixed results. The purpose of this study was to assess the rates of reoperation for fixation failure and all-cause reoperation in a large, multi-institutional cohort of patients with an intertrochanteric fracture treated with an IDL or SL CMN. We hypothesized that there would be no difference between the groups with respect to either of the reoperation rates.Adults (≥18 years old) who sustained an intertrochanteric fracture (AO/OTA 31A1 to 31A3) treated with an IDL or SL CMN between January 2014 and May 2021 at 1 of 13 Level-I trauma centers were included. Patients with <3 months of follow-up or pathologic fractures were excluded. Rates of reoperation were compared with use of the chi-square test and multivariable regression, controlling for age, gender, injury mechanism, fracture pattern, and postoperative neck-shaft angle.A total of 2,130 patients met the inclusion criteria. The median age was 78 years, and 62.5% of patients were female. The cohort consisted of 287 patients (13.5%) with an IDL CMN and 1,843 patients (86.5%) with an SL CMN. A total of 99 patients (4.6%) had a reoperation of any type, of whom 29 (1.4% of all patients) had a reoperation for fixation failure. Compared with patients with an SL CMN, those with an IDL CMN had higher rates (4.2% versus 0.9%; p < 0.001) and odds (odds ratio [OR], 4.95 [95% confidence interval (CI), 2.29 to 10.69]; p < 0.001) of reoperation for fixation failure as well as higher rates (7.3% versus 4.2%; p = 0.021) and odds (OR, 1.83 [95% CI, 1.10 to 3.06]; p = 0.021) of all-cause reoperation.Intertrochanteric femoral fractures treated with an IDL CMN were associated with low but significantly higher rates and significantly higher odds of reoperation for fixation failure and all-cause reoperation compared with those treated with an SL CMN. We suggest caution to surgeons in the use of IDL CMNs for high-risk patients and recommend using SL CMNs for most patients with intertrochanteric femoral fractures.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.23.01152

  View details for PubMedID 39042721

• Outcomes of isolated medial tibial plateau fractures by fracture morphology. Injury Cruz, J. P., Michaud, J. B., Van Rysselberghe, N. L., Walsh, D., Svetgoff, R., Bailey, R., Pirkle, S. B., Megerian, M. F., Harbison, G. J., Becerra, J. A., Sakka, B., Vega, A., Bohlen, H. L., Holloway, A., Finlay, A., Scolaro, J. A., Patterson, J. T., Campbell, S. T., Hebert-Davies, J., Warner, S. J., Goodnough, L. H., Bishop, J. A., Gardner, M. J. 2024; 55 (8): 111662

  Abstract

  To identify a cohort of isolated medial tibial plateau fractures treated with surgical fixation and to categorize them by Moore and Wahlquist classifications in order to determine the rate of complications with each fracture morphology and the predictive value of each classification system. We hypothesized there would be high rates of neurovascular injury, compartment syndrome, and complications overall with a higher incidence of neurovascular injury in Moore type III rim avulsion fractures and Wahlquist type C fractures that enter the plateau lateral to the tibial spines.Patients who presented to six Level I trauma centers between 2010 and 2021 who underwent surgical fixation for isolated medial tibial plateau fractures were retrospectively reviewed. Data including demographics, radiographs, complications, and functional outcomes were collected.One hundred and fifty isolated medial tibial plateau fractures were included. All patients were classified by the Wahlquist classification of medial tibial plateau fractures, and 139 patients were classifiable by the Moore classification of tibial plateau fracture-dislocations. Nine percent of fractures presented with neurovascular injury: 5 % with isolated vascular injury and 6 % with isolated nerve injury. There were no significant differences in neurovascular injury by fracture type (Wahlquist p = 0.16, Moore p = 0.33). Compartment syndrome developed in two patients (1.3 %). The average final range of motion was 0.8-122° with no difference by Wahlquist or Moore classifications (p = 0.11, p = 0.52). The overall complication rate was 32 % without differences by fracture morphology. The overall rate of return to the operating room (OR) was 25 %.Isolated medial tibial plateau fractures often represent fracture-dislocations of the knee and should receive a meticulous neurovascular exam on presentation with a high suspicion for neurovascular injury. No specific fracture pattern was found to be predictive of neurovascular injuries, complications, or final knee range of motion. Patients should be counseled pre-operatively regarding high rates of return to the OR after the index surgery.

  View details for DOI 10.1016/j.injury.2024.111662

  View details for PubMedID 38897069

• Historic indications for fixation of posterior malleolus fractures- where did they come from and where are we now? Injury Hunt, A. A., Maschhoff, C., Van Rysselberghe, N., Gonzalez, C. A., Goodnough, H., Gardner, M., Bishop, J. A. 2024; 55 (6): 111537

  Abstract

  The indications for reduction and fixation of the posterior malleolus component of rotational ankle fractures have been controversial for nearly a century. This study aims to identify the historical basis for surgical intervention and trace trends in management strategies over time.In March 2023, a systematic review of full-text, English-language articles providing indications for surgical fixation of the posterior malleolus component of rotational ankle fractures was performed. Articles underwent title and abstract screening before undergoing full-text review.Historical indications for surgical fixation were size-dependent, with fractures comprising 25 % to 33 % of the plafond recommended for internal fixation. Modern studies suggest that nonoperative management of posterior malleolus fractures below this threshold results in residual malreduction of the articular surface, syndesmotic instability, and an increased need for independent fixation of the syndesmosis.Size-based indications for posterior malleolus fracture fixation are based on Level V evidence from small retrospective case series published nearly one century ago and should be retired. While the size of the posterior malleolus component cannot be ignored, additional factors like fracture morphology and location within the plafond should guide modern surgical indications. Contemporary studies indicate that reduction and fixation of small posterior malleolus fractures (comprising less than 25 % of the articular surface) are associated with improved articular reductions, tibiotalar contact pressures, syndesmotic stability with decreased need for independent fixation of the syndesmosis, and superior postoperative outcomes.

  View details for DOI 10.1016/j.injury.2024.111537

  View details for PubMedID 38657283

• 3D Topographical Scanning for the Detection of Osteoporosis. Journal of frailty, sarcopenia and falls Maschhoff, C. W., Oquendo, Y., Michaud, J. B., Carey, D., Jamero, C., Bishop, J. A., Jin, C., DeBaun, M., Gardner, M. J. 2024; 9 (1): 4-9

  Abstract

  Osteoporosis is associated with greater risk of fracture, which can lead to increased morbidity and mortality. DEXA scans are often inaccessible for patients, leaving many cases of osteoporosis undetected. A portable 3D topographical scan offers an easily accessible and inexpensive potential adjunct screening tool. We hypothesized that 3D scanning of arm and calf circumference and volume would correlate with DEXA T-scores.96 female patients were enrolled. Patients were consented and completed a topographical scan of bilateral arms and lower legs with a mobile 3D scanner for arm and calf circumference and volume in clinic. Patient charts were then retrospectively reviewed for DEXA T-scores.Forearm DEXA T-score was positively correlated with arm circumference (r = 0.49, p<0.01), arm volume (r=0.62, p<0.01), and calf volume (r=0.47, p<0.01). Femoral neck DEXA T-score was positively correlated with calf circumference (r=0.36, p<0.01) and calf volume (r=0.36, p<0.01).Our results showed significant correlations between DEXA T-scores and topographical measurements from mobile device acquired 3D scans, although these were in the "moderate" range. Mobile device-based 3D scanning may hold promise as an adjunct screening tool for osteoporosis when DEXA scanning is not available or feasible for patients, although further studies are needed to elucidate the full potential of its clinical utility. At a minimum, identifying a patient as high risk may promote earlier diagnostic DEXA scanning.

  View details for DOI 10.22540/JFSF-09-004

  View details for PubMedID 38444543

  View details for PubMedCentralID PMC10910256

• The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Cruz, J. P., Salazar, B., van Niekerk, M., Finlay, A. K., Van Rysselberghe, N. L., Goodnough, L. H., Bishop, J. A., Gardner, M. J. 2024

  Abstract

  To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting.This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up.Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating room for stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69).This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

  View details for DOI 10.1007/s00590-024-03843-8

  View details for PubMedID 38403660

  View details for PubMedCentralID 6583215

• Factors Associated With Psychiatry Consultation for Musculoskeletal Trauma Patients. Journal of patient experience Campbell, S. T., Kortlever, J. T., Franciscus, A. M., Ravindranath, D., Ring, D., Bishop, J. A., Science of Variation Group 2024; 11: 23743735241299912

  Abstract

  In an online, survey-based experiment, musculoskeletal surgeon members of the science of variation group (n = 243) and a group of consult-liaison psychiatrists (n = 18) read 5 hypothetical scenarios of patients recovering from musculoskeletal trauma, each containing 5 randomized patient variables, and indicated their recommendation for psychiatry consultation or not. Factors associated with recommendation for psychiatry consultation included younger age, history of a psychiatric disorder, and pre-injury use of antipsychotic medications, and scenarios involving psychosis, suicidality, hallucinations in the setting of substance withdrawal, and questionable capacity for informed consent, but not with sadness alone. Musculoskeletal surgeons can collaborate with psychiatrists to develop comprehensive care for inpatients with musculoskeletal trauma starting with relatively pressing mental health needs and perhaps expanding into treatment of sadness or worry that can manifest as greater symptom intensity and a delayed recovery trajectory.

  View details for DOI 10.1177/23743735241299912

  View details for PubMedID 39544704

• Factors affecting residency selection for underrepresented minorities pursuing orthopaedic surgery. Journal of the National Medical Association Hunt, A. A., Calderon, C., Bishop, J. A. 2023

  Abstract

  The United States is increasingly diverse and there are many benefits to an equally diverse physician workforce. Despite this, the percentage of under-represented minorities in orthopaedic surgery has remained stagnant. The purpose of this study was to describe the characteristics underrepresented minorities pursuing orthopaedic surgery value most when evaluating residency programs.The contact information of current underrepresented minority orthopaedic surgery residents were obtained through professional society databases, residency program coordinators and residency program websites. Individuals were sent a survey through which they evaluated the importance of a variety of program characteristics.The most influential program characteristics were resident happiness and camaraderie, program reputation, geographic location, and relationships between residents and attendings. The least influential characteristics were sub-internship scholarship opportunities for minorities, program affiliation with diversity organizations, word of mouth from others, number of fellows, and centralized training sites.There is a need to diversify the field of orthopaedic surgery, which begins by selecting more diverse trainees. This study demonstrates that underrepresented applicants are most influenced by many of the same characteristics as their well-represented peers. However, diversity-related factors still play an important role in the decision-making process. Many residents highlighted the impact microaggressions and mistreatment played in their residency experience, emphasizing the need for residency programs to focus not only on recruitment, but also on the successes and retention of their residents. Only once this is done will the field of orthopaedic surgery find sustained improvement in its diversification efforts.

  View details for DOI 10.1016/j.jnma.2023.12.006

  View details for PubMedID 38195326

• Incisional negative pressure wound therapy may not protect against post-operative surgical site complications in bicondylar tibial plateau fractures. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Johnson, T. R., Oquendo, Y. A., Seltzer, R., Van Rysselberghe, N. L., Bishop, J. A., Gardner, M. J. 2023

  Abstract

  To determine if incisional negative pressure wound therapy is protective against post-operative surgical site complications following definitive fixation of bicondylar tibial plateau fractures.A retrospective analysis of patients diagnosed with an acute bicondylar tibial plateau fracture (AO/OTA 41-C) undergoing ORIF from 2010 to 2020 was performed. Patients received either a standard sterile dressing (SD) or incisional negative pressure wound therapy (iNPWT). Primary outcomes included surgical site infection, osteomyelitis, and wound dehiscence. Secondary outcomes included non-union and return to the operating room. Multivariate logistic regression analyses were performed.180 patients were included and 22% received iNPWT (n = 40) and 78% received standard dressings (n = 140). iNPWT was more common in active smokers (24.7% vs. 19.3%, p = 0.002) and the SD group was more likely to be lost to follow up (3.6% vs. 0%, p = 0.025). iNPWT was not protective against infection or surgical site complications, and in fact, was associated with higher odds of post-operative infection (OR: 8.96, p = 0.005) and surgical site complications (OR:4.874, p = 0.009) overall. Alcohol abuse (OR: 19, p = 0.005), tobacco use (OR: 4.67, p = 0.009), and time to definitive surgery (OR = 1.21, p = 0.033) were all independent risk factors for post-operative infection.In this series of operatively treated bicondylar tibial plateau fractures, iNPWT did not protect against post-operative surgical site complications compared to conventional dressings. Tobacco use, alcohol abuse, and time to definitive surgery, were independent risk factors for post-operative infection. Further studies are needed to determine if iNPWT offers a protective benefit in exclusively high-risk patients with relevant medical and social history.

  View details for DOI 10.1007/s00590-023-03782-w

  View details for PubMedID 37989870

• Retrograde Intramedullary Nailing Versus Locked Plating for Extreme Distal Periprosthetic Femur Fractures: A Multicenter Retrospective Cohort Study. Journal of orthopaedic trauma Van Rysselberghe, N. L., Seltzer, R., Lawson, T. A., Kuether, J., White, P., Grisdela, P., Daniell, H., Amirhekmat, A., Merchan, N., Seaver, T., Samineni, A., Saiz, A., Ngo, D., Dorman, C., Epner, E., Svetgoff, R., Terle, M., Lee, M., Campbell, S., Dikos, G., Warner, S., Achor, T., Weaver, M. J., Tornetta, P., Scolaro, J., Wixted, J. J., Weber, T., Bellino, M. J., Goodnough, L. H., Gardner, M. J., Bishop, J. A. 2023

  Abstract

  To compare clinical and radiographic outcomes following retrograde intramedullary nailing vs locked plating of "extreme distal" periprosthetic femur fractures, defined as those which contact or extend distal to the anterior flange.METHODS.Retrospective review.Eight academic level I trauma centers.adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMNs or LPs.Outcome Measures and Comparisons: The primary outcome was reoperation to promote healing or to treat infection (re-operation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Compared, were patients treated with rIMNs or LPs.71 patients treated with rIMNs and 224 patients treated with LPs were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 +/- 1.1 vs LP: 6.0 +/- 1.1, p<0.001) and more patients who were allowed to weight-bear as tolerated immediately post-operatively (rIMN: 45%; LP: 9%, p<0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group (p=0.122). There were no significant differences in nonunion (p >0.999), delayed union (p=0.079), fixation failure (p>0.999), infection (p=0.084), or overall reoperation rate (p>0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, p=0.008).Retrograde intramedullary nailing of extreme distal periprosthetic femur fractures has similar complication rates compared to locked plating, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000002730

  View details for PubMedID 38031262

• Interaction of preoperative chemoprophylaxis and tranexamic acid use does not affect transfusion in acetabular fracture surgery. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Wadhwa, H., Rohde, M., Oquendo, Y., Chen, M. J., Tigchelaar, S. S., Bellino, M., Bishop, J., Gardner, M. J. 2023

  Abstract

  PURPOSE: While the effects of tranexamic acid (TXA) use on transfusion rates after acetabular fracture surgery are unclear, previous evidence suggests that holding deep vein thrombosis (DVT) chemoprophylaxis may improve TXA efficacy. This study examines whether holding DVT chemoprophylaxis in patients receiving TXA affects intraoperative and postoperative transfusion rates in acetabular fracture surgery.METHODS: We reviewed electronic medical records (EMR) of 305 patients who underwent open reduction and internal fixation of acetabular fractures (AO/OTA 62) and stratified patients per the following perioperative treatment: (1) no intraoperative TXA (noTXA), (2) intraoperative TXA and no preoperative DVT prophylaxis (opTXA/noDVTP), or (3) intraoperative TXA and preoperative DVT prophylaxis (opTXA/opDVTP). The primary outcomes were need for intraoperative or postoperative transfusion. Risk factors for each primary outcome were assessed using multivariable regression.RESULTS: Intraoperative or postoperative transfusion rates did not significantly differ between opTXA/opDVTP and opTXA/noDVTP groups (46.2% vs. 36%, p=0.463; 15.4% vs. 28%, p=0.181). Median units transfused did not differ between groups (2±1 vs. 2±1, p=0.515; 2±1 vs. 2±0, p=0.099). There was no association between preoperative DVT chemoprophylaxis and TXA with intraoperative or postoperative transfusions. EBL, preoperative hematocrit, and IV fluids were associated with intraoperative transfusions; age and Charlson Comorbidity Index (CCI) were associated with postoperative transfusions.CONCLUSION: Our findings suggest holding DVT prophylaxis did not alter the effect of TXA on blood loss or need for transfusion.

  View details for DOI 10.1007/s00590-023-03763-z

  View details for PubMedID 37865628

• Supplemental fixation of distal femur fractures: a review of biomechanical and clinical evidence CURRENT ORTHOPAEDIC PRACTICE Wadhwa, H., Goodnough, L., Sharma, J., Maschhoff, C. W., Van Rysselberghe, N. L., Bishop, J. A., Gardner, M. J. 2023; 34 (4): 201-207

  View details for DOI 10.1097/BCO.0000000000001209

  View details for Web of Science ID 001017778100011

• Purification and functional characterization of novel human skeletal stem cell lineages. Nature protocols Hoover, M. Y., Ambrosi, T. H., Steininger, H. M., Koepke, L. S., Wang, Y., Zhao, L., Murphy, M. P., Alam, A. A., Arouge, E. J., Butler, M. G., Takematsu, E., Stavitsky, S. P., Hu, S., Sahoo, D., Sinha, R., Morri, M., Neff, N., Bishop, J., Gardner, M., Goodman, S., Longaker, M., Chan, C. K. 2023

  Abstract

  Human skeletal stem cells (hSSCs) hold tremendous therapeutic potential for developing new clinical strategies to effectively combat congenital and age-related musculoskeletal disorders. Unfortunately, refined methodologies for the proper isolation of bona fide hSSCs and the development of functional assays that accurately recapitulate their physiology within the skeleton have been lacking. Bone marrow-derived mesenchymal stromal cells (BMSCs), commonly used to describe the source of precursors for osteoblasts, chondrocytes, adipocytes and stroma, have held great promise as the basis of various approaches for cell therapy. However, the reproducibility and clinical efficacy of these attempts have been obscured by the heterogeneous nature of BMSCs due to their isolation by plastic adherence techniques. To address these limitations, our group has refined the purity of individual progenitor populations that are encompassed by BMSCs by identifying defined populations of bona fide hSSCs and their downstream progenitors that strictly give rise to skeletally restricted cell lineages. Here, we describe an advanced flow cytometric approach that utilizes an extensive panel of eight cell surface markers to define hSSCs; bone, cartilage and stromal progenitors; and more differentiated unipotent subtypes, including an osteogenic subset and three chondroprogenitors. We provide detailed instructions for the FACS-based isolation of hSSCs from various tissue sources, in vitro and in vivo skeletogenic functional assays, human xenograft mouse models and single-cell RNA sequencing analysis. This application of hSSC isolation can be performed by any researcher with basic skills in biology and flow cytometry within 1-2 days. The downstream functional assays can be performed within a range of 1-2 months.

  View details for DOI 10.1038/s41596-023-00836-5

  View details for PubMedID 37316563

  View details for PubMedCentralID 6568007

• Arthroplasty for femoral neck fractures is at risk for under restoration of lateral femoral offset. Hip international : the journal of clinical and experimental research on hip pathology and therapy Shah, H. N., Barrett, A. A., Finlay, A. K., Arora, P., Bellino, M. J., Bishop, J. A., Gardner, M. J., Miller, M. D., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2023: 11207000231169914

  Abstract

  PURPOSE: The aim of the study was to determine the restoration of hip biomechanics through lateral offset, leg length, and acetabular component position when comparing non-arthroplasty surgeons (NAS) to elective arthroplasty surgeons (EAS).METHODS: 131 patients, with a femoral neck fracture treated with a THA by 7 EAS and 20 NAS, were retrospectively reviewed. 2 blinded observers measured leg-length discrepancy, femoral offset, and acetabular component position. Multivariate logistic regression models examined the association between the surgeon groups and restoration of lateral femoral, acetabular offset, leg length discrepancy, acetabular anteversion, acetabular position, and component size, while adjusting for surgical approach and spinal pathology.RESULTS: NAS under-restored 4.8mm of lateral femoral offset (43.9±8.7mm) after THA when compared to the uninjured side (48.7±7.1mm, p=0.044). NAS were at risk for under-restoring lateral femoral offset when compared to EAS (p=0.040). There was no association between lateral acetabular offset, leg length, acetabular position, or component size and surgeon type.CONCLUSIONS: Lateral femoral offset is at risk for under-restoration after THA for femoral neck fractures, when performed by surgeons that do not regularly perform elective THA. This indicates that lateral femoral offset is an under-appreciated contributor to hip instability when performing THA for a femoral neck fracture. Lateral femoral offset deserves as much attention and awareness as acetabular component position since a secondary analysis of our data reveal that preoperative templating and intraoperative imaging did not prevent under-restoration.

  View details for DOI 10.1177/11207000231169914

  View details for PubMedID 37128124

• External Fixator Usage and Delayed MRI Scans: A National Survey Study. The Journal of the American Academy of Orthopaedic Surgeons Van Rysselberghe, N. L., Fithian, A. T., Kim, H. B., Sung, J. C., Chou, B. B., Bishop, J. A., Gardner, M. J., Lucas, J. F., Hecht, G. G. 2023

  Abstract

  To report the current state of institutional protocols regarding the use of MRI in patients with external fixation devices (EFDs) in the United States.National Survey Study.Practicing orthopaedic surgeons frequenting the Orthopaedic Trauma Association website were invited to participate in this study.Sixty-two eligible orthopaedic surgeons completed the survey. No respondents reported any known harmful complications of MRI use with an EFD. Eight respondents (13%) reported at least one early scan termination because of mild warmth or vibration without any lasting complications. Fifty-six respondents (90%) reported delays to care related to MRI-EFD compatibility labeling, and 27 respondents (48%) reported delayed MRI scans in every patient with an EFD who needed one. Twenty-six surgeons (42%) had modified their practice in some way in response to these barriers. Examples include delaying EFD placement until after MRI, relying on CT arthrograms over MRI for surgical planning, and taking patients to the operating room to remove EFDs temporarily and then replace them. Nineteen respondents (31%) had developed formal protocols to address this issue, but having a written protocol was not associated with any decrease in delays (P = 0.119). Eighty-nine percent of respondents thought there was a need for a national consensus guideline on this issue.Despite no previous reports of harmful complications, MRI utilization is frequently delayed or prevented in patients with EFDs in place. This is a pervasive problem nationally, which persists despite the implementation of written institutional protocols. Additional research is needed, potentially at the national level, to address this common issue.V.

  View details for DOI 10.5435/JAAOS-D-21-01023

  View details for PubMedID 36728274

• Optimizing Orthopaedic Trauma Implant Pricing Through a Data-Driven and Surgeon-Integrated Approach. Journal of orthopaedic trauma Seltzer, R., Johnson, J. R., McFarlane, K., Chawla, A., Chamberlain, S., Kohler, M., Sheth, K., Wall, J. K., Bishop, J., Gardner, M., Shea, K. G. 2022

  Abstract

  To determine if market-based pricing could be coupled with surgeon integration into negotiation strategies to achieve lower pricing levels for orthopaedic trauma implants. A secondary aim was to identify specific types of implants that may offer larger opportunities for cost savings.Market pricing levels were reviewed from two industry implant databases. This information was used by surgeons and supply chain management (SCM) at our institution to select appropriate target pricing levels (25th percentile) for commonly used orthopaedic trauma implants. Target price values were provided to the existing 12 vendors utilized by our institution with a clear expectation that vendors meet these thresholds.Benchmark modeling projected a potential savings of 20.0% over our prior annual spend on trauma implants. Following two rounds of negotiation, savings amounted to 23.0% of prior annual spend. Total savings exceeded 1,000,000 USD with 11 of 12 vendors (91.7%) offering net savings. Total percent savings were highest for external fixators, drill bits, and K-wires. Plates and screws comprised the greatest proportion of our prior annual spend and achieved similar savings.A surgeon and supply chain coordinated effort led to major cost savings without a need for consolidation of vendors.

  View details for DOI 10.1097/BOT.0000000000002560

  View details for PubMedID 36728607

• Effectiveness of melatonin treatment for sleep disturbance in orthopaedic trauma patients: A prospective, randomized control trial. Injury Tanner, N., Schultz, B., Calderon, C., Fithian, A., Segovia, N., Bishop, J., Gardner, M. 2022; 53 (12): 3945-3949

  Abstract

  Explore sleep disturbance in postoperative orthopedic trauma patients and determine the impact of melatonin supplementation on postoperative sleep, pain, and quality of life.In this prospective, randomized controlled trial at a Level I trauma center, 84 adult orthopedic trauma patients with operative fracture management were randomized 2-weeks postoperatively to either the melatonin or placebo group. Patients randomized to the melatonin group (42 subjects, mean age 41.8 ± 15.5 years) received 5 mg melatonin supplements. Patients in the placebo group (42 subjects, mean age 41.3 ± 14.0 years) received identical glucose tablets. Both groups were instructed to take the tablets 30 minutes before bed for 4 weeks and received sleep hygiene education and access to the Cognitive Behavioral Therapy for Insomnia (CBT-I) Coach app.Our primary outcome was sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary outcomes were pain measured by the Visual Analog Scale (VAS), quality of life measured by the 36-Item Short Form Survey (SF-36), and opioid use.Patients in both groups had significant sleep disturbance (PSQI ≥ 5) at 2-weeks (83%) and 6-weeks (67%) postoperatively. PSQI improved by 3.3 points (p<0.001) at follow-up, but there was no significant difference between groups (melatonin PSQI = 5.6, placebo PSQI = 6.1, P = 0.615). Compared to placebo, melatonin did not affect VAS, SF-36, or opioid use significantly.Sleep disturbance is prevalent in orthopedic trauma patients. Melatonin treatment did not significantly improve subjective sleep quality, pain, quality of life or opioid use.Therapeutic Level I.

  View details for DOI 10.1016/j.injury.2022.10.011

  View details for PubMedID 36424687

• Do superficial infections increase the risk of deep infections in tibial plateau and plafond fractures? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY Patterson, J. T., O'Hara, N. N., Scharfstein, D. O., Castillo, R. C., O'Toole, R., Firoozabadi, R., METRC 2022

  Abstract

  Open reduction internal fixation of tibial plateau and pilon fractures may be complicated by deep surgical site infection requiring operative debridement and antibiotic therapy. The management of superficial surgical site infection is controversial. We sought to determine whether superficial infection is associated with an increased risk of deep infection requiring surgical debridement after fixation of tibial plateau and pilon fractures.This is a secondary analysis of data from the VANCO trial, which included 980 adult patients with a tibial plateau or pilon fracture at elevated risk of infection who underwent open reduction internal fixation with plates and screws with or without intrawound vancomycin powder. An association of superficial surgical site infection with deep surgical site infection requiring debridement surgery and antibiotics was explored after matching on risk factors for deep surgical site infection.Of the 980 patients, we observed 30 superficial infections (3.1%) and 76 deep infections (7.8%). Among patients who developed a superficial infection, the unadjusted incidence of developing a deep infection within 90 days was 12.8% (95% confidence interval [CI] 1.3-24.2%). However, after a 3:1 match on infection risk factors, the 90-day marginal probability of a deep surgical site infection after sustaining a superficial infection was 6.0% (95% CI  - 6.5-18.5%, p = 0.35).Deep infection after superficial infection is uncommon following operative fixation of tibial plateau and pilon fractures. Increased risk of subsequent deep infection attributable to superficial infection was inconclusive in these data.Prognostic Level II.

  View details for DOI 10.1007/s00590-022-03438-1

  View details for Web of Science ID 000886880000001

  View details for PubMedID 36418579

  View details for PubMedCentralID 5699108

• Effect of Supplemental Perioperative Oxygen on SSI Among Adults with Lower-Extremity Fractures at Increased Risk for Infection A Randomized Clinical Trial JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME O'Toole, R., Joshi, M. G., Carlini, A. R., Huang, Y., Murray, C. K., Bosse, M. J., Scharfstein, D. O., Frca, A., Gary, J. L., Karunakar, M. A., Weaver, M. J., Obremskey, W., McKinley, T. O., Altman, G. T., D'Alleyrand, J. G., Degani, Y., Collins, S., Agel, J., Taylor, T. J., Sikorski, R. A., Stall, A. C., Paryavi, E., O'Hara, N. N., Slobogean, G. P., Amundson, A., Zadnik, M., Castillo, R. C., Westrick, E. R., Salopek, T., Miller, A. N., Tornetta, P., Hsu, J. R., Kempton, L. B., Seymour, R. B., Sims, S. H., Churchill, C., Sietsema, D. L., Gitajn, I., DePalo, P. A., Jones, C. B., Mir, H., Burgos, E. J., Keller, J. M., Heng, M., Mueller, G., Westberg, J. R., Ertl, J., Mullis, L. S., Shively, K. D., Achor, T. S., Choo, A., Munz, J. W., Galpin, M. C., Mullis, B. H., Vallier, H. A., Anglen, J. O., Nascone, J., Sciadini, M. F., Hayda, R., Rodriguez-Buitrago, A., Gardner, M. J., Caroom, C., Jenkins, M. D., Miclau, T., Morshed, S., Belaye, T., Higgins, T. F., Matuszewski, P. E., Aneja, A., Moghadamian, E. S., Wright, R. D., Stringer, P. J., Ahn, J., Teague, D., Ertl, W., Donegan, D. J., Hesketh, P. J., Weinlein, J. C., Kleweno, C. P., Firoozabadi, R., Whiting, P. S., Goodspeed, D. C., Lang, G. J., Simske, N. M., Siy, A. B., Jahangir, A., Stinner, D. J., Tummuru, R. R., Carroll, E. A., Halvorson, J. J., Goodman, J. B., Holden, M. B., DiPasquale, T. G., MacKenzie, E. J., Allen, L. E., Hackman, A., Major Extremity Trauma Res Consort 2022; 104 (14): 1236-1243

  Abstract

  Supplemental perioperative oxygen is a low-cost intervention theorized to reduce the risk of surgical site infections, but its effect among patients undergoing surgery for a tibial plateau, tibial pilon, or calcaneal fracture is unknown. We aimed to determine the effectiveness of a high fraction of inspired oxygen (FiO 2 , 80%) versus low FiO 2 (30%) in reducing surgical site infections in these patients.A randomized controlled trial was conducted at 29 U.S. trauma centers. We enrolled 1,231 patients who were 18 to 80 years of age and had a tibial plateau, tibial pilon, or calcaneal fracture and were thought to be at elevated risk for infection based on their injury characteristics. Patients were randomized to receive 80% FiO 2 (treatment group) or 30% FiO 2 (control group) in the operating room and for up to 2 hours in the recovery room. The primary outcome was a composite of either deep surgical site infection (treated with surgery) or superficial surgical site infection (treated with antibiotics alone) within 182 days following definitive fixation. Secondary outcomes included these surgical site infections at 90 and 365 days after surgery.The modified intention-to-treat analysis included 1,136 patients with 94% of expected follow-up through 182 days. Surgical site infection occurred in 40 (7.0%) of the patients in the treatment group and 60 (10.7%) of the patients in the control group (relative risk [RR], 0.65; 95% confidence interval [CI], 0.45 to 0.96; risk difference [RD], -3.8%; 95% CI, -7.2% to -0.4%; p = 0.03). The treatment intervention demonstrated a similar effect at 90 days (RR, 0.59; 95% CI, 0.37 to 0.93) and 365 days (RR, 0.62; 95% CI, 0.44 to 0.87). Secondary analyses demonstrated that the effect was driven by a reduction in superficial surgical site infections.Among tibial plateau, pilon, or calcaneal fracture patients at elevated risk for surgical site infection, a high perioperative FiO 2 lowered the risk of surgical site infection. The findings support the use of this intervention, although the benefit appears to mostly be in reduction of superficial infections.Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.21.01317

  View details for Web of Science ID 000827774800007

  View details for PubMedID 35775284

• Drilling the cement mantle in well-fixed periprosthetic femur fractures is not associated with arthroplasty-related complications. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Van Rysselberghe, N. L., DeBaun, M. R., Sanchez, M., Wadhwa, H., Pfaff, K. E., Bellino, M. J., Gardner, M. J., Bishop, J. A. 2022

  Abstract

  OBJECTIVE: To determine if screw fixation across a cement mantle is safe and effective during plate fixation of well-fixed periprosthetic femur fractures.DESIGN: Retrospective cohort study.SETTING: Academic Level I Trauma Center.PATIENTS: Twenty-eight patients with AO/OTA 32A[B1] or 32A[C] periprosthetic femur fractures treated with open reduction and internal plate and screw fixation after cemented or uncemented hip arthroplasty.INTERVENTION: Screw placement into the cement mantle during internal fixation.OUTCOME MEASUREMENTS: Primary outcome was revision arthroplasty for aseptic loosening. Secondary outcomes included radiographic evidence of aseptic loosening, infection, nonunion, implant failure, and overall reoperation rate.RESULTS: There were 28 patients who met inclusion criteria. A total of 9 patients had screws placed in the cement mantle while the remaining 19 patients had screws placed around an uncemented stem. At a mean of 3.7-year follow-up, there were no cases of revision arthroplasty or aseptic loosening in either group. There were no significant differences in rates of infection, nonunion, implant failure, or reoperation rate between patients who had screw placement into a cement mantle vs around an uncemented stem.CONCLUSION: Drilling into the cement mantle during fixation of a periprosthetic femur fracture around a well-fixed cemented hip stem appears safe and effective. When possible, surgeons can consider bicortical screws around a cemented stem, given the biomechanical advantages over unicortical screw or cerclage fixation. Larger prospective trials confirming the safety of this technique are warranted prior to routine implementation.LEVEL OF EVIDENCE: III.

  View details for DOI 10.1007/s00590-022-03308-w

  View details for PubMedID 35788424

• Mini-fragment plating of olecranon fractures is comparable to precontoured small-fragment plating. Journal of orthopaedics Wadhwa, H., Oquendo, Y. A., Goodnough, L. H., DeBaun, M. R., Bishop, J. A., Gardner, M. J. 2022; 30: 41-45

  Abstract

  Introduction: Though long-term functional outcomes of olecranon fracture plate fixation are favorable, postoperative implant irritation commonly leads to elective removal. We hypothesized that mini-fragment plates will decrease implant removal compared to precontoured plates.Methods: Patients with isolated olecranon fracture (AO/OTA 2U1-B1) treated with plate fixation were retrospectively reviewed. Patients were stratified into groups based on whether they underwent open reduction and internal fixation with a (1) surgeon contoured mini-fragment or (2) precontoured olecranon-specific plate. Rates of symptomatic implants and implant removal were compared.Results: 98 and 32 patients were treated with precontoured and mini-fragment plates, respectively. Baseline demographics and comorbidities were similar. Mean follow-up was 20.6 months. There were no differences in rates of postoperative complication (22/98, 22.4% vs. 5/32, 15.6%; p=0.41) or reoperation (37/98, 37.8% vs. 8/32, 25%; p=0.19). Symptomatic implants were common in the precontoured cohort (44/98, 44.9% vs. 7/32, 21.9%; p<0.05). Implant removal rates were 36.7% and 18.8%, respectively (p=0.06).Discussion/conclusion: Olecranon fracture stabilization with mini-fragment plate is associated with lower rates of symptomatic implants, with no difference in postoperative complications or reoperations. Mini-fragment plating is a safe and promising alternative to precontoured plating.

  View details for DOI 10.1016/j.jor.2022.02.009

  View details for PubMedID 35241886

• Musculoskeletal Educational Resources for the Aspiring Orthopaedic Surgeon. JB & JS open access Wadhwa, H., Van Rysselberghe, N. L., Campbell, S. T., Bishop, J. A. 2022; 7 (1)

  Abstract

  Musculoskeletal (MSK) education is underemphasized in medical school curricula, which can lead to decreased confidence in treating MSK conditions and suboptimal performance on orthopaedic surgery elective rotations or subinternships. Given the low amount of formalized education in MSK medicine, students aiming to learn about orthopaedic surgery must gain much of their foundational knowledge from other resources. However, there are currently no centralized introductory educational resources to fill this need. We provide a framework for navigating the different types of resources available for trainees and highlight the unaddressed needs in this area.

  View details for DOI 10.2106/JBJS.OA.21.00113

  View details for PubMedID 35651664

• Countersinking the Lag Screw or Blade During Cephalomedullary Nailing of Geriatric Intertrochanteric Femur Fractures: Less Collapse and Implant Prominence Without Increased Cutout Rates. The Journal of the American Academy of Orthopaedic Surgeons Henry Goodnough, L., Wadhwa, H., Tigchelaar, S. S., Pfaff, K., Heffner, M., van Rysselberghe, N., DeBaun, M. R., Gardner, M. J., Bishop, J. A. 1800; 30 (1): e83-e90

  Abstract

  INTRODUCTION: The lag screw or helical blade of a cephalomedullary nail facilitates controlled collapse of intertrochanteric proximal femur fractures. However, excessive collapse results in decreased hip offset and symptomatic lateral implants. Countersinking the screw or helical blade past the lateral cortex may minimize subsequent prominence, but some surgeons are concerned that this will prevent collapse and result in failure through cutout. We hypothesized that patients with countersunk lag screws or helical blades do not experience higher rates of screw or blade cutout and have less implant prominence after fracture healing.METHODS: A retrospective review of 175 consecutive patients treated with cephalomedullary nails for AO/OTA 31A1-3 proximal femur fractures and a minimum 3-month follow-up and 254 patients with a 6-week follow-up at a single US level I trauma center. Patients were stratified based on countersunk versus noncountersunk lag screw or helical blade in a cephalomedullary nail. The primary outcome was the cutout rate at minimum 3 months, and the secondary outcome was radiographic collapse at minimum 6 weeks.RESULTS: Cutout rates were no different in patients with countersunk and noncountersunk screws and blades, and countersinking was associated with less collapse and less implant prominence at 6 weeks.DISCUSSION: Surgeons can countersink the lag screw or blade when treating intertrochanteric proximal femur fractures with a cephalomedullary nail without increasing failure rates and with the potential benefits of less prominent lateral implants and decreased collapse.

  View details for DOI 10.5435/JAAOS-D-20-01029

  View details for PubMedID 34932507

• Cross-species comparisons reveal resistance of human skeletal stem cells to inhibition by non-steroidal anti-inflammatory drugs. Frontiers in endocrinology Goodnough, L. H., Ambrosi, T. H., Steininger, H. M., Butler, M. G., Hoover, M. Y., Choo, H., Van Rysselberghe, N. L., Bellino, M. J., Bishop, J. A., Gardner, M. J., Chan, C. K. 2022; 13: 924927

  Abstract

  Fracture healing is highly dependent on an early inflammatory response in which prostaglandin production by cyclo-oxygenases (COX) plays a crucial role. Current patient analgesia regimens favor opioids over Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) since the latter have been implicated in delayed fracture healing. While animal studies broadly support a deleterious role of NSAID treatment to bone-regenerative processes, data for human fracture healing remains contradictory. In this study, we prospectively isolated mouse and human skeletal stem cells (SSCs) from fractures and compared the effect of various NSAIDs on their function. We found that osteochondrogenic differentiation of COX2-expressing mouse SSCs was impaired by NSAID treatment. In contrast, human SSCs (hSSC) downregulated COX2 expression during differentiation and showed impaired osteogenic capacity if COX2 was lentivirally overexpressed. Accordingly, short- and long-term treatment of hSSCs with non-selective and selective COX2 inhibitors did not affect colony forming ability, chondrogenic, and osteogenic differentiation potential in vitro. When hSSCs were transplanted ectopically into NSG mice treated with Indomethacin, graft mineralization was unaltered compared to vehicle injected mice. Thus, our results might contribute to understanding species-specific differences in NSAID sensitivity during fracture healing and support emerging clinical data which conflicts with other earlier observations that NSAID administration for post-operative analgesia for treatment of bone fractures are unsafe for patients.

  View details for DOI 10.3389/fendo.2022.924927

  View details for PubMedID 36093067

• A prescribing protocol decreases the rate of chronic opioid use in orthopaedic trauma patients: a prospective quality improvement study CURRENT ORTHOPAEDIC PRACTICE Fithian, A. T., Chavez, G., Nathan, K., Campbell, S. T., Bishop, J. A., Gardner, M. J. 2021; 32 (6): 555-558

  View details for DOI 10.1097/BCO.0000000000001052

  View details for Web of Science ID 000711965500004

• To Fix or Revise: Differences in Periprosthetic Distal Femur Fracture Management Between Trauma and Arthroplasty Surgeons. The Journal of the American Academy of Orthopaedic Surgeons Van Rysselberghe, N. L., Campbell, S. T., Goodnough, L. H., Amanatullah, D. F., Gardner, M. J., Bishop, J. A. 2021

  Abstract

  INTRODUCTION: This study sought to determine the effect of trauma fellowship training on the surgical decision to fix or revise to distal femoral replacement in periprosthetic distal femur fractures.METHODS: An anonymous online survey including nine cases of geriatric periprosthetic distal femur fractures was distributed through the Orthopaedic Trauma Association website. Respondents were asked whether they would recommend fixation or revision to distal femoral replacement. Fractures were classified by the location relative to the anterior flange (proximal or distal) and the presence or absence of comminution. Recommendations were compared between type of fellowship completed (trauma, arthroplasty, or both), practice setting, and number of periprosthetic distal femur fractures treated monthly.RESULTS: One hundred fifty-one surgeon survey responses were included. Completion of a trauma fellowship was associated with a higher likelihood of recommending fixation for any periprosthetic distal femur fracture compared with arthroplasty training (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.97 to 3.29; P < 0.0001). Disagreement was significant for comminuted proximal (OR 6.90, 95% CI 3.24 to 14.68; P < 0.0001), simple distal (OR 20.90, 95% CI 6.41 to 67.71; P < 0.001), and comminuted distal fractures (OR 2.47, 95% CI 1.66 to 3.68; P < 0.0001). Dual fellowship-trained surgeons were less likely to recommend fixation than surgeons who completed a trauma fellowship alone (OR 0.60, 95% CI 0.39 to 0.93; P = 0.027) and more likely to recommend fixation than surgeons who completed an arthroplasty fellowship alone (OR 1.70, 95% CI 1.13 to 2.63; P = 0.012). Surgeons who treat three or more periprosthetic distal femur fractures monthly showed a significant preference for fracture fixation compared with lower volume surgeons (OR 2.45, 95% CI 1.62 to 3.68; P < 0.0001).DISCUSSION: Fellowship-trained trauma surgeons show a notable preference for fracture fixation over distal femoral replacement for periprosthetic distal femur fractures, as compared with arthroplasty-trained surgeons. Additional research is needed to clarify surgical indications that maximize outcomes for these injuries.

  View details for DOI 10.5435/JAAOS-D-20-00968

  View details for PubMedID 34288890

• Biomechanically superior treatments do not translate into improved outcomes in randomized controlled trials. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Xiong, G. X., Kang, J. R., Sharma, J., Finlay, A., Gardner, M. J., Bishop, J. A. 2021

  Abstract

  PURPOSE: Significant time and resources are devoted to conducting orthopaedic biomechanics research; however, it is not known how these studies relate to their subsequent clinical studies. The purpose of the present study was to determine whether biomechanically superior treatments were associated with improved clinical outcomes as determined by analogous randomized controlled trials (RCTs).METHODS: A systematic review was conducted to find RCTs that tested a research question based on a prior biomechanical study. PubMed and SCOPUS databases were queried for orthopaedic randomized controlled trials, and full text articles were reviewed to find RCTs which cited biomechanical studies with analogous comparison groups. A random-effects multi-level logistic regression model was conducted examining the association between RCT outcome and biomechanics outcome, adjusting for multiple outcomes nested within study.RESULTS: In total, 20,261 articles were reviewed yielding 21 RCTs citing a total of 43 analogous biomechanical studies. In 7 instances (16.2%), the RCT and a cited biomechanical study showed concordant results (i.e. the superior treatment in the RCT was also the superior construct in the biomechanical study). RCT outcome was not associated with biomechanical outcome (beta=-1.50, standard error=0.78, p=.05).CONCLUSION: This study assessed 21 orthopaedic RCTs with 43 corresponding biomechanical studies and found no association between superior biomechanical properties of a given orthopaedic treatment and improved clinical outcomes. Favourable biomechanical properties alone should not be the primary reason for selecting one treatment over another. Furthermore, RCTs based on biomechanical studies should be carefully designed to maximize the chance of providing clinically relevant insights.

  View details for DOI 10.1007/s00590-021-03051-8

  View details for PubMedID 34176011

• Antibiotic resistance: still a cause of concern? OTA international : the open access journal of orthopaedic trauma DeBaun, M. R., Lai, C., Sanchez, M., Chen, M. J., Goodnough, L. H., Chang, A., Bishop, J. A., Gardner, M. J. 2021; 4 (3 Suppl)

  Abstract

  Antibiotic resistance remains a global public health concern with significant patient morbidity and tremendous associated health care costs. Drivers of antibiotic resistance are multifaceted and differ between developing and developed countries. Under evolutionary pressure, microbes acquire antibiotic tolerance through a variety of mechanisms at the cellular level. Patients after orthopaedic trauma are vulnerable to drug-resistant pathogens, particularly after open fractures. Traumatologists practicing appropriate antibiotic prophylaxis and treatment regimens mitigate infection and propagation of antibiotic resistance.

  View details for DOI 10.1097/OI9.0000000000000104

  View details for PubMedID 37609480

  View details for PubMedCentralID PMC10441676

• Tranexamic acid does not affect intraoperative blood loss or in-hospital outcomes after acetabular fracture surgery. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Wadhwa, H., Tigchelaar, S. S., Chen, M. J., Koltsov, J. C., Bellino, M. J., Bishop, J. A., Gardner, M. J. 2021

  Abstract

  PURPOSE: Tranexamic acid (TXA) reduces need for transfusion in total joint arthroplasty, though findings in acetabular surgery are conflicting. We compared outcomes after acetabular fracture surgery with or without perioperative intravenous (IV) TXA administration.METHODS: We performed a retrospective review of 305 patients with acetabular fractures that underwent open reduction and internal fixation (ORIF). Eighty-nine patients received TXA, and 216 did not. The primary outcome was rates of intraoperative and postoperative allogeneic blood transfusion.RESULTS: Baseline demographics and characteristics were similar. Time from injury to surgery and estimated blood loss were comparable. Operative time (p<0.01) and intraoperative IV fluids (p<0.01) were greater in the non-TXA group. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively did not differ. Mean differences in preoperative and postoperative hemoglobin and hematocrit, hospital length of stay, and perioperative complications also did not differ. In a multivariable regression model, age 60-70years, Charlson Comorbidity Index, Injury Severity Score, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approaches and intraoperative transfusion requirement were independently associated with postoperative transfusion.CONCLUSION: In this study, perioperative IV TXA did not decrease blood loss, need for transfusion, or improve in-hospital outcomes of acetabular fracture surgery. Age 60-70, CCI, ISS, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approach and need for intraoperative transfusion were independently associated with postoperative transfusion. Further prospective trials are warranted to confirm these findings.

  View details for DOI 10.1007/s00590-021-02985-3

  View details for PubMedID 33891154

• Hypotensive Anesthesia does not reduce Transfusion Rates during and after Acetabular Fracture Surgery. Injury Wadhwa, H., Chen, M. J., Tigchelaar, S. S., Bellino, M. J., Bishop, J. A., Gardner, M. J. 2021

  Abstract

  BACKGROUND: Acetabular fracture open reduction and internal fixation (ORIF) is generally associated with high intraoperative blood loss. Hypotensive anesthesia has been shown to decrease blood loss and intraoperative transfusion in total joint arthroplasty and posterior spinal fusion. In this study, we assessed the effect of reduction in intraoperative mean arterial pressures (MAPs) during acetabular fracture surgery on intraoperative blood loss and need for transfusion.METHODS: Three hundred and one patients with acetabular fractures who underwent ORIF at an academic Level 1 trauma center were retrospectively reviewed. Patients were separated based on mean intraoperative MAPs (<60 mmHg, 60-70 mmHg, >70 mmHg). Thirteen patients had mean intraoperative MAP <60 mmHg, 95 had MAP 60-70 mmHg, and 193 had MAP >70 mmHg. Rates of intraoperative and postoperative allogeneic blood transfusion were compared.RESULTS: Mean intraoperative MAPs were significantly different between groups (p < 0.0001). Time from injury to surgery, estimated blood loss, operative time and intraoperative IV fluids were comparable. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively were similar between groups. Mean differences in preoperative and postoperative hemoglobin and hematocrit were also similar. There was no difference in hospital length of stay or perioperative complications between the groups. Multivariate logistic regression analysis demonstrated that body mass index > 30 (p < 0.05) and anterior surgical approach (p < 0.01) were independently associated with intraoperative transfusion and an anterior surgical approach (p < 0.001) was independently associated with postoperative transfusion.CONCLUSION: Decreased intraoperative MAP during acetabular fracture surgery does not reduce blood loss or need for transfusion. On the other hand, no increased end-organ ischemia was seen with hypotensive anesthesia.LEVEL OF EVIDENCE: Therapeutic Level III.

  View details for DOI 10.1016/j.injury.2021.03.059

  View details for PubMedID 33832703

• Research methodologic quality varies significantly by subspecialty: An analysis of AAOS meeting abstracts. Journal of clinical orthopaedics and trauma Souza, K. E., Chan, J. Y., Campbell, S. T., Bishop, J. A. 2021; 15: 37–41

  Abstract

  Background: The purpose of this study was to compare the level of evidence and study type of clinical abstracts accepted to the 2017 AAOS Annual Meeting based on subspecialty.Methods: All clinical abstracts presented at the 2017 AAOS Annual Meeting were assessed by two independent raters for LOE and study type. Nonparametric statistics and chi-square test were used to compare LOE and study types between subspecialties.Results: A total of 1083 abstracts met inclusion criteria. There was a significant difference in LOE of abstracts by subspecialty (p<0.001). Shoulder/elbow, adult reconstruction knee, hand/wrist, and sports had the highest percentage of level I and II studies. The type of study also varied significantly by subspecialty (p=0.005).Discussion: Methodologic quality of clinical studies presented at the 2017 AAOS Annual Meeting differed significantly among subspecialties. Orthopedic researchers should look to the fields producing the highest quality studies in an effort to improve methodological quality.

  View details for DOI 10.1016/j.jcot.2020.11.001

  View details for PubMedID 33717914

• White-Light Body Scanning Captures Three-Dimensional Shoulder Deformity After Displaced Diaphyseal Clavicle Fracture. Journal of orthopaedic trauma DeBaun, M. R., Lai, C., Schultz, B. J., Oquendo, Y. A., Campbell, S. T., Goodnough, L. H., Bishop, J. A., Gardner, M. J. 2021; 35 (4): e142–e147

  Abstract

  OBJECTIVE: We sought to determine if white-light three-dimensional (3D) body scanning can identify clinically relevant shoulder girdle deformity after displaced diaphyseal clavicle fracture (DCF).METHODS: Adult patients with DCF (OTA/AO 15A) were prospectively enrolled. Four subcutaneous osseous landmarks were used to measure shoulder girdle morphology of the injured and uninjured shoulder. Measurements were made both manually with a tape measure and digitally with a white-light 3D scanner. Bilateral radiographs were obtained, and clavicle length was recorded. Quick-Disabilities of the Arm, Shoulder, and Hand surveys were administered at injury and at 6 and 12 weeks.RESULTS: Twenty-two patients were included in the study. At the initial visit, all patients had significant differences in deformity measurements between injured and uninjured shoulders as measured by 3D scanning. There was no difference between shoulders measured using manual measurements. At 6 and 12 weeks, shoulder asymmetry was significantly less in patients treated with surgery compared with nonoperative patients as measured by the 3D scanner alone. Clavicle shortening measured on 3D scanning had weak and moderate positive correlations to radiographs (R = 0.27) and manual measurements (R = 0.53), respectively. Patients treated with surgery had significant functional improvements by 6 weeks, and a similar improvement was not seen until 12 weeks in nonsurgical patients.CONCLUSION: White-light 3D scanning was able to identify and monitor clinically relevant shoulder girdle deformity after DCF. This tool may become a useful adjunct to clinical examination and radiographic assessment, when determining clinically relevant deformity thresholds. In the future, quantifying and understanding shoulder deformity may inform clinical decision making in these patients.LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000001957

  View details for PubMedID 32910627

• Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial. JAMA surgery Major Extremity Trauma Research Consortium (METRC), O'Toole, R. V., Joshi, M., Carlini, A. R., Murray, C. K., Allen, L. E., Huang, Y., Scharfstein, D. O., O'Hara, N. N., Gary, J. L., Bosse, M. J., Castillo, R. C., Bishop, J. A., Weaver, M. J., Firoozabadi, R., Hsu, J. R., Karunakar, M. A., Seymour, R. B., Sims, S. H., Churchill, C., Brennan, M. L., Gonzales, G., Reilly, R. M., Zura, R. D., Howes, C. R., Mir, H. R., Wagstrom, E. A., Westberg, J., Gaski, G. E., Kempton, L. B., Natoli, R. M., Sorkin, A. T., Virkus, W. W., Hill, L. C., Hymes, R. A., Holzman, M., Malekzadeh, A. S., Schulman, J. E., Ramsey, L., Cuff, J. A., Haaser, S., Osgood, G. M., Shafiq, B., Laljani, V., Lee, O. C., Krause, P. C., Rowe, C. J., Hilliard, C. L., Morandi, M. M., Mullins, A., Achor, T. S., Choo, A. M., Munz, J. W., Boutte, S. J., Vallier, H. A., Breslin, M. A., Frisch, H. M., Kaufman, A. M., Large, T. M., LeCroy, C. M., Riggsbee, C., Smith, C. S., Crickard, C. V., Phieffer, L. S., Sheridan, E., Jones, C. B., Sietsema, D. L., Reid, J. S., Ringenbach, K., Hayda, R., Evans, A. R., Crisco, M. J., Rivera, J. C., Osborn, P. M., Kimmel, J., Stawicki, S. P., Nwachuku, C. O., Wojda, T. R., Rehman, S., Donnelly, J. M., Caroom, C., Jenkins, M. D., Boulton, C. L., Costales, T. G., LeBrun, C. T., Manson, T. T., Mascarenhas, D. C., Nascone, J. W., Pollak, A. N., Sciadini, M. F., Slobogean, G. P., Berger, P. Z., Connelly, D. W., Degani, Y., Howe, A. L., Marinos, D. P., Montalvo, R. N., Reahl, G. B., Schoonover, C. D., Schroder, L. K., Vang, S., Bergin, P. F., Graves, M. L., Russell, G. V., Spitler, C. A., Hydrick, J. M., Teague, D., Ertl, W., Hickerson, L. E., Moloney, G. B., Weinlein, J. C., Zelle, B. A., Agarwal, A., Karia, R. A., Sathy, A. K., Au, B., Maroto, M., Sanders, D., Higgins, T. F., Haller, J. M., Rothberg, D. L., Weiss, D. B., Yarboro, S. R., McVey, E. D., Lester-Ballard, V., Goodspeed, D., Lang, G. J., Whiting, P. S., Siy, A. B., Obremskey, W. T., Jahangir, A. A., Attum, B., Burgos, E. J., Molina, C. S., Rodriguez-Buitrago, A., Gajari, V., Trochez, K. M., Halvorson, J. J., Miller, A. N., Goodman, J. B., Holden, M. B., McAndrew, C. M., Gardner, M. J., Ricci, W. M., Spraggs-Hughes, A., Collins, S. C., Taylor, T. J., Zadnik, M. 2021: e207259

  Abstract

  Importance: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist.Objective: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections.Design, Setting, and Participants: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers.Interventions: A standard infection prevention protocol with (n=481) or without (n=499) 1000 mg of intrawound vancomycin powder.Main Outcomes and Measures: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence.Results: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P=.06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P=.02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P=.78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections.Conclusions and Relevance: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin.Trial Registration: ClinicalTrials.gov Identifier: NCT02227446.

  View details for DOI 10.1001/jamasurg.2020.7259

  View details for PubMedID 33760010

• Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures. Journal of clinical orthopaedics and trauma Bosch, L. C., Nathan, K., Lu, L. Y., Campbell, S. T., Gardner, M. J., Bishop, J. A. 2021; 14: 65–68

  Abstract

  Background: The purpose of this study was to compare outcomes after hip fracture surgery between DNR/DNI and full code cohorts to determine whether DNR/DNI status is an independent predictor of complications and mortality within one year. A significant number of geriatric hip fracture patients carry a code status designation of DNR/DNI (Do-Not-Resuscitate/Do-Not-Intubate). There is limited data addressing how this designation may influence prognosis.Methods: A retrospective chart review of all geriatric hip fractures treated between 2002 and 2017at a single level-I academic trauma center was performed. 434 patients were eligible for this study with 209 in the DNR/DNI cohort and 225 in the full code cohort. The independent variable was code-status and dependent variables included patient demographics, surgery performed, American Society of Anesthesiologists, score, Charlson Comorbidity Index, significant medical and surgical complications within one year of surgery, duration of follow-up by an orthopaedic surgeon, duration of follow-up by any physician, and mortality within 1 year of surgery. One-year complication rates were compared, and multiple logistic regression analyses were performed to analyze the relationship between independent and dependent variables.Results: The DNR/DNI cohort experienced significantly more surgical complications compared to the full code cohort (14.8% vs 7.6%, p=0.024). There was a significantly higher rate of medical complications and mortality in the DNR/DNI cohort (57.9% vs 36%, p<0.001 and 19.1% vs 3.1%, p=0.037, respectively). In the regression analysis, DNR/DNI status was an independent predictor of a medical complication (odds ratio 2.33, p=0.004) and one-year mortality (odds ratio 9.69, p<0.001), but was not for a surgical complication (OR 1.95, p=0.892).Conclusions: In our analysis, DNR/DNI code status was an independent risk factor for postoperative medical complications and mortality within one year following hip fracture surgery. The results of our study highlight the need to recognize the relationship between DNR/DNI designation and medical frailty when treating hip fractures in the elderly population.

  View details for DOI 10.1016/j.jcot.2020.09.021

  View details for PubMedID 33717898

• Cephalomedullary helical blade is independently associated with less collapse in intertrochanteric femur fractures than lag screws. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Goodnough, L. H., Wadhwa, H., Tigchelaar, S. S., Pfaff, K., Heffner, M., Van Rysselberghe, N., DeBaun, M. R., Bishop, J. A., Gardner, M. J. 2021

  Abstract

  OBJECTIVES: Excessive fracture site collapse and shortening in intertrochanteric femur fractures alter hip biomechanics and patient outcomes. The purpose of the study was to compare extent of collapse in cephalomedullary nails with blades or lag screws. We hypothesized that there would be no difference in collapse between helical blades and lag screws.DESIGN: Retrospective cohort study.SETTING: Single U.S. Level I Trauma Center.PATIENTS: 171 consecutive patients treated with cephalomedullary nails with either lag screw or blade for AO/OTA 31A1-3 proximal femur fractures and minimum 3-month follow-up.INTERVENTION: Lag screw or helical blade in a cephalomedullary nail.OUTCOME MEASURES: The primary outcome was fracture site collapse at 3months.RESULTS: There was a significantly higher proportion of reverse-oblique and transverse intertrochanteric femur fractures (31-A3) in the lag screw group (15/42 vs 25/129). A3 patterns were associated with more collapse. There was significantly less collapse in the blade group (median 4.7mm, inter-quartile range 2.5-7.8mm) than the screw group (median 8.4 mmm, inter-quartile range 3.7-11.2mm, p 0.006). Median collapse was no different between blades and screws when comparing stable and unstable patterns. However, blades were independently associated with 2.5mm less collapse (95%CI -4.2, -0.72mm, p 0.006) and lower likelihood of excessive collapse (>10mm at 3months, OR 0.3, 95% CI 0.13-0.74, p 0.007), regardless of fracture pattern.CONCLUSIONS: Helical blades are independently associated with significantly less collapse than lag screws in intertrochanteric proximal femur fractures, after adjusting for unstable fracture patterns. In fracture patterns at risk for collapse, surgeons can consider use of a helical blade due to its favorable sliding properties compared to screws.

  View details for DOI 10.1007/s00590-021-02875-8

  View details for PubMedID 33587180

• Low profile fragment specific plate fixation of lateral tibial plateau fractures - A technical note. Injury Chen, M. J., Frey, C. S., Salazar, B. P., Gardner, M. J., Bishop, J. A. 2021

  Abstract

  PURPOSE: Precontoured plates used to stabilize lateral tibial plateau (LTP) fractures are limited in their ability to raft particular areas of the reconstructed articular surface. These implants also do not fit every individual's bony anatomy and can lead to soft tissue irritation. The purpose of this study was to evaluate fragment specific plate fixation of LTP fractures using generic small and mini fragment constructs.METHODS: This was a retrospective case series of LTP fractures treated with small fragment tubular and/or mini fragment plate constructs at a single Level I trauma center. Postoperative complications were recorded. Final radiographs were analyzed to determine union and interval subsidence of the articular surface and/or loss of reduction.RESULTS: All 19 LTP fractures healed without loss of reduction or implant failure. There was minimal interval subsidence of the LTP in all patients. There were no complications or reoperations for symptomatic implant removal within the given follow-up period.CONCLUSION: Fragment specific fixation of LTP fractures using small and mini fragment plates creates a lower profile construct that reliably maintains fracture reduction to union.

  View details for DOI 10.1016/j.injury.2020.12.037

  View details for PubMedID 33423771

• Short versus long cephalomedullary nailing of intertrochanteric fractures: a meta-analysis of 3208 patients. Archives of orthopaedic and trauma surgery Cinque, M. E., Goodnough, L. H., Md, B. J., Fithian, A. T., DeBaun, M. n., Lucas, J. F., Md, M. J., Bishop, J. A. 2021

  Abstract

  The purpose of the study was to compare treatment outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures.A systematic review of perioperative outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures was performed. The following databases were used: using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019). The queries were performed in June 2019.The following search term query was used: "Intramedullary Nail AND Intertrochanteric Fracture OR "Long OR Short Nail AND intertrochanteric Fracture." Studies were excluded if they were "single-arm" studies (i.e., reporting on either long or short CMN but not both), or did not report at least one of the outcomes being meta-analyzed. Furthermore, cadaveric studies, animal studies, basic science articles, editorial articles, surveys and studies were excluded.Two investigators independently reviewed abstracts from all identified articles. Full-text articles were obtained for review if necessary, to allow further assessment of inclusion and exclusion criteria. Additionally, all references from the included studies were reviewed and reconciled to verify that no relevant articles were missing from the systematic review.Short nails were associated with statistically significantly less estimated blood loss and operative time compared to long nails. There were no significant differences in transfusion rates, implant failures or overall re-operation rates between implant lengths. Similarly, there was no significant difference in peri-implant fracture between implant lengths.Overall, the available clinical evidence supports the use of short cephalomedullary nails for the majority of intertrochanteric femur fractures.Meta-analysis; Level III, therapeutic.

  View details for DOI 10.1007/s00402-021-03752-z

  View details for PubMedID 33484311

• Distal Femur Replacement versus Open Reduction and Internal Fixation for Treatment of Periprosthetic Distal Femur Fractures: Systematic Review and Meta-Analysis. Journal of orthopaedic trauma Wadhwa, H. n., Salazar, B. P., Goodnough, L. H., Van Rysselberghe, N. L., DeBaun, M. R., Wong, H. N., Gardner, M. J., Bishop, J. A. 2021

  Abstract

  To compare complications and functional outcomes of treatment with primary distal femoral replacement (DFR) versus open reduction and internal fixation (ORIF).PubMed, Embase, and Cochrane databases were searched for English language studies up to May 19, 2020, identifying 913 studies.Studies that assessed complications of periprosthetic distal femur fractures with primary DFR or ORIF were included. Studies with sample size ≤5, mean age <55, nontraumatic indications for DFR, ORIF with non-locking plates, native distal femoral fractures, or revision surgeries were excluded. Selection adhered to PRISMA criteria.Study quality was assessed using previously reported criteria. There were 40 Level IV studies, 17 Level III studies, and 1 Level II study.Fifty-eight studies with 1,484 patients were included in the meta-analysis. Complications assessed (Incidence Rate Ratio (IRR) (95%CI): 0.78 (0.59-1.03)) and reoperation or revision (IRR (95%CI): 0.71 (0.49-1.04)) were similar between the DFR and ORIF cohorts. Mean knee range of motion (ROM) was greater in the ORIF cohort (DFR: 90.47 vs. ORIF: 100.36, p < 0.05). Mean Knee Society Score (KSS) (DFR: 79.41 vs. ORIF: 82.07, p = 0.35) and return to preoperative ambulatory status were similar (IRR (95%CI): 0.82 (0.48-1.41)).In comparing complications among patients treated for periprosthetic distal femur fracture with DFR or ORIF, there was no difference between the groups. There were also no differences in functional outcomes, although knee ROM was greater in the ORIF group. This systematic review and meta-analysis highlights the need for future prospective trials evaluating the outcomes of these divergent treatment strategies.Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000002141

  View details for PubMedID 34001801

• ICD-10 codes do not accurately reflect ankle fracture injury patterns. Injury Seltzer, R. A., Van Rysselberghe, N. L., Fithian, A. T., LaPrade, C. M., Sharma, J., Oquendo, Y. A., Michaud, J. B., DeBaun, M. R., Gardner, M. J., Bishop, J. A. 2021

  Abstract

  To determine the accuracy of International Classification of Disease Version 10 (ICD-10) coding for ankle fracture injury patterns.Retrospective cohort study PATIENTS: 97 adult patients with fractures about the ankle (rotational ankle fracture or distal tibia fracture) from 2016 to 2020, selected by stratified random sampling.Assignment of an ICD-10 code representative of a rotational ankle fracture, pilon fracture, or unspecified fracture of the lower leg.Injury radiographs were reviewed by three authors to determine the correct code. Agreement between the correct code and the electronic medical record (EMR) assigned code was determined using kappa's statistic in the aggregate as well as percent agreement, sensitivity, specificity, and positive predictive value (PPV) between individual codes.59 of 97 cases (60.8%) demonstrated discordance between the existing EMR and surgeon-assigned codes. Aggregate agreement between all codes was fair (K = 0.26). Lateral malleolus fracture codes demonstrated the highest PPV (0.91, 95% CI 0.72-0.99), while the lowest PPV was found for "other fractures of the lower leg" (0.05, 95% CI 0.0-0.24) and "other fracture of the fibula" (0.0, 95% CI 0.0-0.15). Generalized "other fracture" codes comprised 45% of EMR codes compared to only 6% of assigned codes (p < 0.001). EMR codes were specific but not sensitive.There is substantial discordance between existing EMR and surgeon-assigned ICD-10 codes for ankle fractures. Database research that relies on ICD-10 coding as a surrogate for primary clinical data should be interpreted with caution and institutions should make efforts to increase the accuracy of their coding.

  View details for DOI 10.1016/j.injury.2021.10.005

  View details for PubMedID 34654551

• Incidence and Management of Articular Impaction in Geriatric Olecranon Fractures. The Journal of the American Academy of Orthopaedic Surgeons Wadhwa, H. n., Goodnough, L. H., Finlay, A. K., DeBaun, M. R., Campbell, S. T., Hecht, G. n., Lucas, J. F., Bishop, J. A., Gardner, M. J. 2021

  Abstract

  Olecranon fractures are common in the elderly. Articular impaction is encountered occasionally, but the incidence and outcomes after treatment of this injury pattern have not been well characterized.We evaluated a cohort of geriatric olecranon fractures to determine the incidence of articular impaction and describe a technique for open reduction and internal fixation.Of the 63 patients in our series, 31 had associated intraarticular impaction (49.2%). Patients with articular impaction did not have significantly different rates of postoperative complications (11/31, 35.5% versus 10/31, 32.3%; P = 1.00) or revision surgery (10/31, 32.3% versus 8/31, 25.8%; P = 0.780) compared with those without articular impaction.Articular impaction is a common feature of geriatric olecranon fractures. Surgeons must maintain a high index of suspicion and have a surgical plan in place for managing this component of the injury.

  View details for DOI 10.5435/JAAOS-D-20-01293

  View details for PubMedID 33999874

• Distal femoral fine wire traction assisted retrograde nailing of the femur. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Chen, M. J., Avedian, R. S., Gardner, M. J., Bishop, J. A. 2021

  Abstract

  Here we describe the surgical technique for using distal femoral fine wire traction during retrograde femoral nailing and present case examples. This technique allows for hands-free distraction across the fracture site to restore length and alignment, while not interfering with the preparation and insertion of the retrograde femoral nail. Distal femoral fine wire traction is a useful adjunctive technique to restore length and effect an indirect reduction in femur fractures being stabilized with a retrograde nail.

  View details for DOI 10.1007/s00590-021-02897-2

  View details for PubMedID 33575843

• Management of the posterior wall fracture in associated both column fractures of the acetabulum. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Chen, M. J., Hollyer, I. n., Wadhwa, H. n., Tigchelaar, S. S., Van Rysselberghe, N. L., Bishop, J. A., Bellino, M. J., Gardner, M. J. 2021

  Abstract

  The primary aim of this study was to compare clinical outcomes in patients with associated both column (ABC) acetabular fractures with fracture of the posterior wall (PW), in which the PW underwent reduction and fragment-specific fixation versus those that were treated with column fixation alone. Secondary aims were to assess PW fracture incidence and morphology, as well as to compare radiographic outcomes including fracture healing and interval displacement of the PW in those that did and did not undergo fragment-specific fixation of the PW.This was a retrospective series of ABC acetabular fractures treated at a single Level I trauma center. Separate fractures of the PW were identified, and associated features were assessed. Associated both column fractures that underwent reduction and fragment-specific fixation of the PW where then compared to ABC fractures with PW involvement that underwent column reconstruction alone. Radiographic and clinical outcomes were compared.Fractures of the PW occurred in 55.7% of ABC fractures and were associated with central displacement of the femoral head. The majority of PW fractures were large and involved the acetabular roof. All PW fractures healed without displacement by 3 months, regardless of whether or not reduction and stabilization was performed. Mid-term outcomes at 1-year were similar regardless of whether or not the PW was reduced and stabilized, with regards to Tönnis grade, Merle d'Aubigné-Postel score, and conversion to total hip arthroplasty.Reduction and fragment-specific fixation of the PW component of ABC acetabular fractures did not improve outcomes in this small comparative study. Posterior wall fractures associated with ABC patterns are frequently large-sized fragments that involve the acetabular roof and are rendered stable after reconstruction of the columns.

  View details for DOI 10.1007/s00590-020-02850-9

  View details for PubMedID 33386470

• Gluteus Minimus Debridement During Acetabular Fracture Surgery Does Not Prevent Heterotopic Ossification - A Comparative Study. Journal of orthopaedic trauma Chen, M. J., Tigchelaar, S. S., Wadhwa, H. n., Frey, C. S., Bishop, J. A., Gardner, M. J., Bellino, M. J. 2021

  Abstract

  To compare rates of heterotopic ossification (HO) after acetabular fracture surgery, through a posterior approach, with and without gluteus minimus muscle (GMM) debridement.Retrospective comparative study.Single academic Level I trauma center.Ninety-four patients in the GMM preserved group and 42 patients in the GMM debrided group met inclusion criteria.GMM preservation or debridement during acetabular fracture surgery through a single-posterior approach.Primary outcomes were incidence and severity of HO. Reoperation for HO excision was assessed. Other risk factors for severe HO (Brooker class III-IV) were secondarily assessed using multivariable logistic regression analyses. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Significance was set at p-value ≤ 0.05.There was no difference in the incidence or severity of HO between the debrided and preserved groups. Rates of reoperation for HO excision were comparable. American Society of Anesthesiologists (ASA) physical status class (OR = 3.3), head injury (OR = 4.6), and abdominal injury (OR = 4.5) were associated with severe HO.GMM debridement was not associated with a decreased incidence of HO after acetabular fracture surgery. ASA class is a novel risk factor associated with severe HO formation.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000002061

  View details for PubMedID 33480642

• Late Venous Thoracic Outlet Syndrome After Anatomic Fixation of a Diaphyseal Clavicle Fracture: A Case Report. JBJS case connector Fogel, N., Lee, J. T., Bishop, J. A. 2021; 11 (1)

  Abstract

  CASE: We report the case of a 29-year-old man with a displaced mid-diaphyseal clavicle fracture that healed in anatomic position without fracture callus after surgical treatment but developed symptoms of late venous thoracic outlet syndrome (TOS) 19 months postoperatively. He was diagnosed with proximal subclavian vein thrombosis and was treated with urgent thrombolysis and staged first rib resection with resolution of symptoms.CONCLUSIONS: Late venous TOS is a potential complication of clavicle fracture, even in the setting of anatomic reduction and primary bone healing. This entity has previously only been described in the setting of nonunion and malunion.

  View details for DOI 10.2106/JBJS.CC.20.00243

  View details for PubMedID 33690240

• Artificial Neural Networks Predict 30-Day Mortality After Hip Fracture: Insights From Machine Learning. The Journal of the American Academy of Orthopaedic Surgeons DeBaun, M. R., Chavez, G., Fithian, A., Oladeji, K., Van Rysselberghe, N., Goodnough, L. H., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  OBJECTIVES: Accurately stratifying patients in the preoperative period according to mortality risk informs treatment considerations and guides adjustments to bundled reimbursements. We developed and compared three machine learning models to determine which best predicts 30-day mortality after hip fracture.METHODS: The 2016 to 2017 National Surgical Quality Improvement Program for hip fracture (AO/OTA 31-A-B-C) procedure-targeted data were analyzed. Three models-artificial neural network, naive Bayes, and logistic regression-were trained and tested using independent variables selected via backward variable selection. The data were split into 80% training and 20% test sets. Predictive accuracy between models was evaluated using area under the curve receiver operating characteristics. Odds ratios were determined using multivariate logistic regression with P < 0.05 for significance.RESULTS: The study cohort included 19,835 patients (69.3% women). The 30-day mortality rate was 5.3%. In total, 47 independent patient variables were identified to train the testing models. Area under the curve receiver operating characteristics for 30-day mortality was highest for artificial neural network (0.92), followed by the logistic regression (0.87) and naive Bayes models (0.83).DISCUSSION: Machine learning is an emerging approach to develop accurate risk calculators that account for the weighted interactions between variables. In this study, we developed and tested a neural network model that was highly accurate for predicting 30-day mortality after hip fracture. This was superior to the naive Bayes and logistic regression models. The role of machine learning models to predict orthopaedic outcomes merits further development and prospective validation but shows strong promise for positively impacting patient care.

  View details for DOI 10.5435/JAAOS-D-20-00429

  View details for PubMedID 33315645

• Iatrogenic Compartment Syndrome After Delayed Primary Closure of the Tibial Fracture-Related Leg Fasciotomy Wound: A Case Report. JBJS case connector Karamian, B. A., Bishop, J. A. 2020; 10 (4)

  Abstract

  CASE: Compartment syndrome can occur after tibial fracture and requires prompt diagnosis and immediate fasciotomy. Because of post-traumatic swelling, delayed primary wound closure can be difficult requiring significant tension on the skin. Closing the skin in this setting theoretically puts the patient at risk of elevated compartment pressures, although compartment syndrome has never been reported in these circumstances. We describe a case of compartment syndrome that developed after delayed primary skin closure of a single incision 4-compartment fasciotomy wound after tibial fracture.CONCLUSION: This is the first published description of compartment syndrome after delayed primary closure of a leg fasciotomy wound.

  View details for DOI 10.2106/JBJS.CC.20.00440

  View details for PubMedID 33512921

• Lateral Distractor Use During Internal Fixation of Tibial Plateau Fractures Has Minimal Risk of Iatrogenic Peroneal Nerve Palsy. Journal of orthopaedic trauma Chen, M. J., Salazar, B. P., Tigchelaar, S. S., Frey, C. S., DeBaun, M. R., Goodnough, L. H., Bellino, M. J., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  OBJECTIVES: To determine the incidence of iatrogenic peroneal nerve palsy after application of an intraoperative lateral distractor during open reduction and internal fixation (ORIF) of tibial plateau fractures (TPF).DESIGN: Retrospective review.SETTING: Single academic Level I trauma center.PATIENTS: One hundred and forty-seven patients met criteria and were included in the study.INTERVENTION: Patients with unicondylar and bicondylar TPFs underwent ORIF and received application of an intraoperative lateral distractor to aid in visualization and reduction of the impacted lateral plateau.MAIN OUTCOME MEASUREMENTS: Incidence of iatrogenic peroneal nerve palsy.RESULTS: There was a 2.0% incidence of iatrogenic peroneal nerve symptoms (three of 147 patients), the majority of which were incomplete sensory deficits. There was no association with staged external fixation, regional anesthesia, or tourniquet use.CONCLUSION: Use of an intraoperative lateral distractor is safe and has a low incidence of iatrogenic peroneal nerve palsy if applied carefully.LEVEL OF EVIDENCE: Prognostic level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000001875

  View details for PubMedID 33165211

• Can upstream patient education improve fracture care in a digital world? Use of a decision aid for the treatment of displaced diaphyseal clavicle fractures. Journal of orthopaedic trauma Lai, C. H., DeBaun, M. R., Van Rysselberghe, N., Abrams, G. D., Kamal, R. N., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  BACKGROUND: The increasing proportion of telemedicine and virtual care in orthopaedic surgery presents an opportunity for upstream delivery of patient facing tools, such as decision aids. Displaced diaphyseal clavicle fractures (DDCF) are ideal for a targeted intervention as there is no superior treatment, and decisions are often dependent on patient preference. A decision aid provided prior to consultation may educate a patient and minimize decisional conflict similarly to in-person consultation with an orthopaedic traumatologist.METHODS: Patients with DDCF were enrolled into two groups. The usual care group participated in a discussion with a trauma fellowship trained orthopaedic surgeon. Patients in the intervention group were administered a DDCF decision aid designed with International Patient Decision Aid Standards. Primary comparisons were made based on decisional conflict score. Secondary outcomes included treatment choice, pain score, QuickDASH, and opinion toward cosmetic appearance.RESULTS: A total of 41 patients enrolled. Decisional conflict scores were similar and low between the two groups: 11.8 (usual care) and 11.4 (decision aid). There were no differences in secondary outcomes between usual care and the decision aid.DISCUSSION: Our decision aid for the management of DDCF produces a similarly low decisional conflict score to consultation with an orthopaedic trauma surgeon. This decision aid could be a useful resource for surgeons who infrequently treat this injury or whose practices are shifting toward telemedicine visits. Providing a decision aid prior to consultation may help incorporate patient values and preferences into the decision-making process between surgery and non-operative management.LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000001916

  View details for PubMedID 33105455

• Delayed Union of a Diaphyseal Forearm Fracture Associated With Impaired Osteogenic Differentiation of Prospectively Isolated Human Skeletal Stem Cells. JBMR plus Goodnough, L. H., Ambrosi, T. H., Steininger, H., DeBaun, M. R., Abrams, G. D., McAdams, T. R., Gardner, M. J., Chan, C. K., Bishop, J. A. 2020; 4 (10): e10398

  Abstract

  Delayed union or nonunion are relatively rare complications after fracture surgery, but when they do occur, they can result in substantial morbidity for the patient. In many cases, the etiology of impaired fracture healing is uncertain and attempts to determine the molecular basis for delayed union and nonunion formation have been limited. Prospectively isolating skeletal stem cells (SSCs) from fracture tissue samples at the time of surgical intervention represent a feasible methodology to determine a patient's biologic risk for compromised fracture healing. This report details a case in which functional in vitro readouts of SSCs derived from human fracture tissue at time of injury predicted a poor fracture healing outcome. This case suggests that it may be feasible to stratify a patient's fracture healing capacity and predict compromised fracture healing by prospectively isolating and analyzing SSCs during the index fracture surgery. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

  View details for DOI 10.1002/jbm4.10398

  View details for PubMedID 33103027

• Dual mini-fragment plate fixation for Neer type-II and -V distal clavicle fractures. OTA international : the open access journal of orthopaedic trauma Chen, M. J., Salazar, B. P., Bishop, J. A., Gardner, M. J. 2020; 3 (3): e078

  Abstract

  Contemporary methods for open reduction and internal fixation of displaced distal clavicle fractures have excellent rates of union and high rates of reoperation for symptomatic implant removal. The authors describe their preferred surgical technique and case series of patients with Neer Type-II and -V distal clavicle fractures treated with lower profile dual mini-fragment plates using interdigitating screws placed into the distal segment to enhance fixation.

  View details for DOI 10.1097/OI9.0000000000000078

  View details for PubMedID 33937703

• Contouring Plates in Fracture Surgery: Indications and Pitfalls. The Journal of the American Academy of Orthopaedic Surgeons Bishop, J. A., Campbell, S. T., Graves, M. L., Gardner, M. J. 2020; 28 (14): 585-595

  Abstract

  Effective fracture surgery requires contouring orthopaedic implants in multiple planes. The amount of force required for contouring is dependent on the amount and type of material contained within the plane to be altered. The type of contouring used depends on the desired plate function; for example, buttress mode often requires some degree of undercontouring, whereas compression plating may require prebending. Other reasons to contour a plate include matching patient anatomy either to maximize fixation options or to reduce implant prominence. Precontoured plates can be convenient and help to facilitate soft-tissue friendly techniques but have the potential to introduce malreduction if the plate position and fit are not carefully monitored.

  View details for DOI 10.5435/JAAOS-D-19-00462

  View details for PubMedID 32692093

• Surgical and Nonoperative Management of Olecranon Fractures in the Elderly: A Systematic Review and Meta-Analysis. Journal of orthopaedic trauma Chen, M. J., Campbell, S. T., Finlay, A. K., Duckworth, A. D., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  OBJECTIVES: The aim of this comparative effectiveness study was to perform a meta-analysis of adverse events and outcomes in closed geriatric olecranon fractures, without elbow instability, after treatment with surgical or nonoperative management.DATA SOURCES: PubMed, Web of Science, and Embase databases.STUDY SELECTION: Articles were included if they contained clinical data evaluating outcomes in patients ≥65 years of age with closed olecranon fractures, without elbow instability, treated surgically, or with nonoperative management.DATA EXTRACTION: Data regarding patient age, olecranon fracture type, fracture union, adverse events, reoperation, elbow range of motion, and surgeon and patient reported outcome measures were recorded according to intervention. The interventions included for analysis were tension band wire (TWB) fixation, plate fixation, or nonoperative management.DATA SYNTHESIS: Separate random effects meta-analyses were conducted for each outcome according to intervention. Prevalence and 95% confidence intervals (CI) were calculated for dichotomous variables, while weighted means and CI were calculated for continuous variables.CONCLUSIONS: Comparable outcomes were achieved with surgical or nonoperative management of olecranon fractures in geriatric patients. Surgical intervention carried a high risk of reoperation regardless of whether plate or TBW fixation was used. Functional nonunion can be anticipated if nonoperative treatment is elected in low-demand elderly patients.LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000001865

  View details for PubMedID 32569071

• Distal Femur Replacement versus Surgical Fixation for the Treatment of Geriatric Distal Femur Fractures: A Systematic Review. Journal of orthopaedic trauma Salazar, B. P., Babian, A. R., DeBaun, M. R., Githens, M. F., Chavez, G. A., Goodnough, H., Gardner, M. J., Bishop, J. A. 2020

  Abstract

  OBJECTIVES: The management of geriatric distal femur fractures is controversial, and both primary distal femur replacement (DFR) or surgical fixation (SF) are viable treatment options. The purpose of this study was to compare patient outcomes after these treatment strategies.DATA SOURCES: PubMed, Embase, and Cochrane databases were searched for English language papers up to April 24, 2020, identifying 2,129 papers.STUDY SELECTION: Studies evaluating complications in elderly patients treated for distal femur fractures with either immediate DFR or surgical fixation were included. Studies with mean patient age <55 years, nontraumatic indications for DFR, or SF with non-locking plates were excluded.DATA EXTRACTION: Two studies provided Level II or III evidence while the remaining 28 studies provided Level IV evidence. Studies were formally evaluated for methodologic quality using established criteria. Treatment failure between groups was compared using an incidence rate ratio.DATA SYNTHESIS: Treatment failure was defined for both surgical fixation and arthroplasty as complications requiring a major reoperation for reasons such as mechanical failure, nonunion, deep infection, aseptic loosening, or extensor mechanism disruption. There were no significant differences in complication rates or knee range of motion between SF and DFR.CONCLUSION: SF and DFR for the treatment of geriatric distal femur fractures demonstrate similar overall complication rates. Given the available evidence, no strong conclusions on the comparative effectiveness between the two treatments can be definitively made. More rigorous prospective research comparing SF versus DFR to treat acute geriatric distal femur fractures is warranted.LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000001867

  View details for PubMedID 32569072

• Geriatric fragility fractures are associated with a human skeletal stem cell defect. Aging cell Ambrosi, T. H., Goodnough, L. H., Steininger, H. M., Hoover, M. Y., Kim, E., Koepke, L. S., Marecic, O., Zhao, L., Seita, J., Bishop, J. A., Gardner, M. J., Chan, C. K. 2020: e13164

  Abstract

  Fragility fractures have a limited capacity to regenerate, and impaired fracture healing is a leading cause of morbidity in the elderly. The recent identification of a highly purified bona fide human skeletal stem cell (hSSC) and its committed downstream progenitor cell populations provides an opportunity for understanding the mechanism of age-related compromised fracture healing from the stem cell perspective. In this study, we tested whether hSSCs isolated from geriatric fractures demonstrate intrinsic functional defects that drive impaired healing. Using flow cytometry, we analyzed and isolated hSSCs from callus tissue of five different skeletal sites (n=61) of patients ranging from 13 to 94years of age for functional and molecular studies. We observed that fracture-activated amplification of hSSC populations was comparable at all ages. However, functional analysis of isolated stem cells revealed that advanced age significantly correlated with reduced osteochondrogenic potential but was not associated with decreased in vitro clonogenicity. hSSCs derived from women displayed an exacerbated functional decline with age relative to those of aged men. Transcriptomic comparisons revealed downregulation of skeletogenic pathways such as WNT and upregulation of senescence-related pathways in young versus older hSSCs. Strikingly, loss of Sirtuin1 expression played a major role in hSSC dysfunction but re-activation by trans-resveratrol or a small molecule compound restored in vitro differentiation potential. These are the first findings that characterize age-related defects in purified hSSCs from geriatric fractures. Our results provide a foundation for future investigations into the mechanism and reversibility of skeletal stem cell aging in humans.

  View details for DOI 10.1111/acel.13164

  View details for PubMedID 32537886

• Complication Rates after Lateral Plate Fixation of Periprosthetic Distal Femur Fractures: A Multicenter Study. Injury Campbell, S. T., Lim, P. K., Kantor, A. H., Gausden, E. B., Goodnough, L. H., Park, A. Y., Bishop, J. A., Achor, T. S., Scolaro, J. A., Gardner, M. J. 2020

  Abstract

  OBJECTIVE: Periprosthetic fractures of the distal femur can be challenging injuries to treat; nonunion rates of up to 22% have been reported. The purpose of this study was to determine the rate of complications and nonunion in a multicenter series, and to identify patient or surgical factors that were associated with nonunion.DESIGN: Retrospective comparative study SETTING: Three Level 1 trauma centers PATIENTS: Fifty-five patients with a periprosthetic distal femur fracture proximal to a total knee arthroplasty. Minimum follow up for inclusion was six months or until union or failure.INTERVENTION: Surgical fixation using a precontoured lateral locking plate MAIN OUTCOME MEASUREMENT: Fracture union was the primary outcome. Patient demographic and injury variables (age, comorbidities, fracture classification and characteristics) and surgical technique factors (mode of plate fixation, plate material, working length, screw density, and proximal screw type) were identified and compared between patients who developed a nonunion and those who did not. Regression analysis was performed to identify independent risk factors for nonunion.RESULTS: The overall rate of nonunion was 18% and the total complication rate was 24%. After additional surgery, 49 of 55 patients went on to heal (89%). There were no statistical differences in patient demographic or injury variables between the union and nonunion groups, and none of the variables studied were independent risk factors for nonunion in the regression analysis.CONCLUSIONS: In this series of 55 patients with periprosthetic distal femur fractures treated with precontoured lateral locking plates, 18% developed nonunion and the overall complication rate was 24%. No patient or surgical variables were identified as risk factors. Future research should seek to identify patients at high risk for complication and nonunion who could benefit from alternative fixation strategies or distal femoral replacement.

  View details for DOI 10.1016/j.injury.2020.05.009

  View details for PubMedID 32482424

• How do pilon fractures heal? An analysis of dual plating and bridging callus formation. Injury Campbell, S. T., Goodnough, L. H., Salazar, B., Lucas, J. F., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  OBJECTIVES: 1) To determine the effect of single versus dual plate metaphyseal fixation for pilon fractures on callus formation and reoperation rates, 2) to determine the effect of biomechanically matched versus unmatched fixation, and 3) to determine whether patient or surgical factors were independent predictors of bridging callus formation or need for reoperation.DESIGN: Retrospective comparative study.SETTING: Single level one trauma center.PATIENTS: Fifty patients with AO/OTA type C2 or C3 pilon fractures treated with plate fixation.INTERVENTION: Internal fixation with a plate and screw construct, with comparisons made between patients with single versus dual plate fixation, and patients treated with biomechanically matched or unmatched fixation.MAIN OUTCOME MEASUREMENTS: Modified RUST (mRUST) scores at three and six months and reoperation rate.RESULTS: At six months, mean mRUST scores were significantly lower in patients treated with dual metaphyseal plates compared to a single plate (8.7 vs 10.4, p=0.046) There were 15 open fractures; eight were treated with supplemental fixation, while seven were treated with single-column fixation. Open fracture (OR 51.05, p=0.008) was a risk factor for reoperation. Screw density between 0.4 and 0.5 was a protective factor against reoperation (OR 0.03, p=0.026). Biomechanically unmatched fixation did not affect mRUST scores or reoperation rates.CONCLUSIONS: Pilon fractures treated with a single plate had more callus formation six months after surgery compared to those treated with dual plate fixation, and there was no difference in reoperation rates. Screw density between 0.4-0.5 was protective against reoperation. These data may serve as the basis of future work to determine the ideal fixation construct for the frequently comminuted metaphysis in pilon fractures. Further work is necessary to determine whether callus formation in these injuries is desirable.LEVEL OF EVIDENCE: Three.

  View details for DOI 10.1016/j.injury.2020.04.023

  View details for PubMedID 32434713

• Contouring Plates in Fracture Surgery: Indications and Pitfalls. The Journal of the American Academy of Orthopaedic Surgeons Bishop, J. A., Campbell, S. T., Graves, M. L., Gardner, M. J. 2020

  Abstract

  Effective fracture surgery requires contouring orthopaedic implants in multiple planes. The amount of force required for contouring is dependent on the amount and type of material contained within the plane to be altered. The type of contouring used depends on the desired plate function; for example, buttress mode often requires some degree of undercontouring, whereas compression plating may require prebending. Other reasons to contour a plate include matching patient anatomy either to maximize fixation options or to reduce implant prominence. Precontoured plates can be convenient and help to facilitate soft-tissue friendly techniques but have the potential to introduce malreduction if the plate position and fit are not carefully monitored.

  View details for DOI 10.5435/JAAOS-D-19-00462

  View details for PubMedID 32332261

• Hook versus locking plate fixation for Neer type-II and type-V distal clavicle fractures: a retrospective cohort study. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Chen, M. J., DeBaun, M. R., Salazar, B. P., Lai, C., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  PURPOSE: This study examined the outcomes and complications after treatment of unstable distal clavicle fractures with hook or locking plate fixation.METHODS: A retrospective search was performed of all acute distal clavicle fractures treated with open reduction and internal fixation from 2009 to 2019 at a Level I trauma center. Patients were separated into hook and locking plate fixation groups. Rates of union, complications, and reoperation, were extracted. QuickDASH (Disabilities of Arm, Shoulder, and Hand) scores were determined.RESULTS: Thirty-one patients met the inclusion criteria and were included in the study. Of these, 12 patients were treated with hook plates and 19 were treated with locking plates. All fractures healed without loss of reduction, regardless of implant selection. There were no immediate or long-term complications in either group. 83% of hook plate patients underwent planned implant removal, while 37% of locking plate patients requested implant removal secondary to irritation. QuickDASH scores were comparable and excellent in both groups.CONCLUSIONS: Hook and locking plate fixation for Neer type-II and type-V distal clavicle fractures have comparably high rates of union. Hook plates were removed routinely per protocol, while locking plates were removed only if symptomatic and occurred significantly less often.

  View details for DOI 10.1007/s00590-020-02658-7

  View details for PubMedID 32221679

• Variability in opioid prescribing following fracture fixation: A retrospective cohort analysis CURRENT ORTHOPAEDIC PRACTICE Fithian, A., Nathan, K., Campbell, S. T., Finlay, A., Bishop, J., Gardner, M. J. 2020; 31 (2): 101–4

  View details for DOI 10.1097/BCO.0000000000000847

  View details for Web of Science ID 000517283300001

• Early Postoperative Radiographs Have No Effect on Orthopaedic Trauma Patient's Satisfaction With Their Clinic Visit. The Journal of the American Academy of Orthopaedic Surgeons Schultz, B. J., Bishop, J. A., Hall, K., Finlay, A., Gardner, M. J. 2020; 28 (3): e125-e130

  Abstract

  Patient satisfaction plays a prominent role in modern orthopaedic care, reimbursement, and quality assessment, even if it runs contrary to the "standard of care." The literature shows that routine early radiographs after acute fracture care have no impact on clinical decision-making or patient outcomes, but little is known about their effect on patient satisfaction and understanding of their injuries. We hypothesized that eliminating these radiographs would negatively influence patient satisfaction scores with their clinic visit.One hundred patients were prospectively enrolled after acute fracture fixation. Half the patients obtained radiographs at the 2-week follow-up visit, whereas the other half did not. All patients completed a satisfaction survey about their clinic visit.No difference was observed between the groups in overall satisfaction with the clinic visit (P = 0.62) or complications. However, patients with radiographs were more satisfied with the surgeon's explanations of their injury and progression (P = 0.03).Eliminating routine early postoperative radiographs had no effect on overall patient satisfaction with the clinic visit, but it did affect satisfaction with the surgeon's explanation of their injury. This could save time, money, and radiation exposure without adversely affecting patient outcome or satisfaction, but an equivalent educational tool should be identified for clinic visits.

  View details for DOI 10.5435/JAAOS-D-18-00697

  View details for PubMedID 31977614

• Safety and efficacy of using 2.4/2.4mm and 2.0/2.4mm dual mini-fragment plate combinations for fixation of displaced diaphyseal clavicle fractures. Injury Chen, M. J., DeBaun, M. R., Salazar, B. P., Lai, C., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  PURPOSE: The purpose of this study was to evaluate the safety and efficacy of using lower profile 2.4/2.4mm and 2.0/2.4mm dual mini-fragment plate constructs for fixation of diaphyseal clavicle fractures.METHODS: This was a retrospective case series of all displaced diaphyseal clavicle fractures treated with 2.4/2.4 and 2.0/2.4 dual mini-fragment plate constructs at a single level-one trauma center. Postoperative complications and fracture healing rates were recorded. A subset of patients with long-term follow up was used to determine the rate of reoperation for symptomatic implant removal.RESULTS: All 36 identified fractures healed without loss of reduction or implant failure. There was one superficial infection and no deep infections or cases of wound dehiscence. Twenty patients from the entire cohort had longer-term follow up available to assess the reoperation rate for symptomatic implant removal. Two patients (10%) underwent symptomatic implant removal, and one patient with retained implants was planning on future removal due to soft-tissue irritation; this combined to a projected reoperation rate of 15% for symptomatic implant removal.CONCLUSION: Dual mini-fragment plating of diaphyseal clavicle fractures, using 2.4/2.4mm and 2.0/2.4mm plate combinations, creates a lower profile construct that reliably maintains fracture reduction to healing, and has a low rate of reoperation for symptomatic implant removal.

  View details for DOI 10.1016/j.injury.2020.01.014

  View details for PubMedID 31948781

• Metaphyseal callus formation in pilon fractures is associated with loss of alignment: Is stiffer better? Injury Van Rysselberghe, N. L., Campbell, S. T., Goodnough, L. H., Salazar, B. P., Bishop, J. A., Bellino, M. J., Lucas, J. F., Gardner, M. J. 2020

  Abstract

  To assess the relationship between metaphyseal callus formation and preservation of distal tibial alignment in pilon fractures treated with internal plate fixation.Retrospective Review SETTING: Academic Level I Trauma Center PATIENTS: Forty-two patients with AO/OTA type C2 or C3 pilon fractures treated with plate fixation.Internal fixation with anterolateral plating, medial plating, or both. Modified Radiographic Union Score in Tibial fracture (mRUST) scores were determined from six-month radiographs.Change in lateral and anterior distal tibial angles (LDTA and ADTA) at six months post-operatively.High callus formation (mRUST ≥ 11 at six months) was associated with a greater loss of coronal reduction as measured by LDTA compared to low callus formation (mRUST < 11): 3.8 vs 2.1° (p = .019), with no difference in ADTA change between groups. In a multivariable logistic regression controlling for age, smoking, obesity, and open fracture, higher mRUST scores were a predictor of coronal reduction loss of five or more degrees (OR 1.71, p=.039). Dual column plating did not independently predict maintenance of alignment.Recent literature has popularized dual column fixation for pilon fractures, but it remains unknown whether increased metaphyseal stiffness enhances or impairs healing. In this series, decreased metaphyseal callus formation was associated with maintained coronal alignment, suggesting that a stiffer mechanical environment may be preferable to prevent short term reduction loss in these complex injuries.III.

  View details for DOI 10.1016/j.injury.2020.10.080

  View details for PubMedID 33097204

• Trochanteric fixation nail advanced with helical blade and cement augmentation: early experience with a retrospective cohort. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Goodnough, L. H., Wadhwa, H. n., Tigchelaar, S. S., DeBaun, M. R., Chen, M. J., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  Intra-articular screw cut-out is a potential complication of intertrochanteric femur fracture fixation with a cephalomedullary nail. Cement augmentation of fixation in the proximal segment offers the prospect of increased stability and fewer complications, but clinical experience with non-resorbable cement is limited. To determine the handling properties and efficacy of this new technique, we performed a retrospective propensity-matched cohort of forty-four geriatric intertrochanteric femur fractures treated with a cephalomedullary nail with (n = 11) or without (n = 33) augmentation with non-resorbable cement injected into the proximal segment. In the patients treated with cement augmentation, at minimum 3-month follow-up, there were no instances of intra-articular cut-out, and no increase in re-operation compared to conventional fixation. Cement augmentation appears to be safe and effective in geriatric intertrochanteric femur fractures to mitigate risk of cut-out.

  View details for DOI 10.1007/s00590-020-02762-8

  View details for PubMedID 32804288

• Reamed Intramedullary Nailing of a Femur Fracture in a Polytraumatized Patient on Extracorporeal Membrane Oxygenation: A Case Report. JBJS case connector Bosch, L., Ruoss, S., Bishop, J. 2020; 10 (1): e0349

  Abstract

  CASE: We present the case of a young adult with blunt lung trauma and acute respiratory distress syndrome requiring extracorporeal membrane oxygenation (ECMO) after a motor vehicle crash with a concomitant diaphyseal femur fracture who underwent reamed intramedullary nailing (IMN) while on ECMO support.CONCLUSION: This case is important because it demonstrates that reamed IMN of the femur has been performed safely in a critically ill patient on ECMO.

  View details for DOI 10.2106/JBJS.CC.19.00349

  View details for PubMedID 32044786

• Outcomes after locking plate fixation of distal clavicle fractures with and without coracoclavicular ligament augmentation. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Salazar, B. P., Chen, M. J., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  The need for coracoclavicular (CC) ligament augmentation when performing locking plate fixation of unstable distal clavicle fractures is controversial. The purpose of this study was to compare the results after locking plate fixation for treatment of Neer type-II and type-V distal clavicle fractures with and without suture suspensory augmentation of the CC ligaments.This was a retrospective case series of all Neer type-II and type-V distal clavicle fractures treated with locking plates at a single Level I trauma center. Patients were separated into locking plate-only and locking plate with CC ligament augmentation groups. Postoperative complications and fracture healing rates were recorded. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were recorded as functional outcomes during follow-up phone interviews. Standard descriptive statistics were performed.Sixteen patients were treated with locking plate fixation-only, and seven patients were treated with additional CC ligament augmentation. There was a similar distribution of Neer fracture types with each group. All fractures in both groups went onto union without loss of reduction or implant failure. There were no cases of infection or wound complications in either group. QuickDASH scores were comparable between locking plate-only fixation (mean 4.1 ± 3.9) and additional suspensory suture fixation (mean 4.5 ± 3.6).This comparative study of Neer type-II and type-V distal clavicle fractures demonstrated comparable outcomes after locking plate fixation with and without CC ligament augmentation. CC ligament augmentation may not be necessary when treating unstable distal clavicle fractures if locking plate fixation is used.

  View details for DOI 10.1007/s00590-020-02797-x

  View details for PubMedID 32949271

• CORR Insights®: Can an Integrative Care Approach Improve Physical Function Trajectories after Orthopaedic Trauma? A Randomized Controlled Trial. Clinical orthopaedics and related research Bishop, J. A. 2020

  View details for DOI 10.1097/CORR.0000000000001195

  View details for PubMedID 32118608

• Is percutaneous screw fixation really superior to non-operative management after valgus-impacted femoral neck fracture: a retrospective cohort study. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Goodnough, L. H., Wadhwa, H. n., Fithian, A. T., DeBaun, M. R., Campbell, S. T., Gardner, M. J., Bishop, J. A. 2020

  Abstract

  The optimal management of valgus-impacted femoral neck fractures remains controversial. Internal fixation is associated with significant rates of re-operation, while historical non-operative management strategies consisting of prolonged bed rest also resulted in patient morbidity. Our hypothesis was that screw fixation would have comparable failure rates to non-operative treatment and immediate mobilization for valgus-impacted femoral neck fractures.Retrospective cohort at a single academic Level I trauma center of patients with valgus-impacted femoral neck fractures (AO/OTA 31-B1) treated with percutaneous screw fixation (n = 97) or non-operatively (n = 28). Operative treatment consisted of percutaneous screw fixation. Non-operative treatment consisted of early mobilization. The primary outcome was a salvage operation. Patient demographics were assessed between groups.More non-operatively treated patients were permitted unrestricted weight-bearing (WBAT; p = 0.002). There was no increase in complication rates or mortality, and return to previous ambulatory status was comparable between operatively and non-operatively treated patients. 35.7% (10/28) of non-operatively treated patients underwent a subsequent operation, compared to 15.5% (15/97) of patients with screw fixation (p = 0.03). Only WBAT was independently associated with treatment failure (OR 3.1, 95%CI 1.2-8.3, p =0.02). WBAT was predictive of treatment failure only in the non-operatively treated group (64.3%, 9/14 WBAT vs 8.3%, 1/12 partial, p =0.005).After controlling for weight-bearing restrictions, we found no difference in failure rates between non-operative treatment and screw fixation. Non-operative treatment with partial weight-bearing had low failure rates, comparable complication and mortality rates, and equivalent functional outcomes to operative treatment and is reasonable if a patient would like to avoid surgery and accepts the risk of subsequent arthroplasty. Overall, there were relatively high failure rates in all groups.

  View details for DOI 10.1007/s00590-020-02742-y

  View details for PubMedID 32710126

• The Impact of Subspecialty Fellows on Orthopaedic Resident Surgical Experience: A Multicenter Study of 51,111 Cases. The Journal of the American Academy of Orthopaedic Surgeons Jiang, S. Y., Carlock, K. D., Campbell, S. T., Vorhies, J. S., Gardner, M. J., Leucht, P. n., Bishop, J. A. 2020

  Abstract

  Meaningful participation in surgery is important for orthopaedic resident education. This study aimed to quantify the effect of fellows on resident surgical experience. We hypothesized that as fellowship programs expanded, resident caseload would decrease, whereas "double-scrubbed" cases would increase.This multicenter retrospective study included 9 years of surgical caselog data from two orthopaedic residency programs. Six subspecialty services on which fellow number varied over time were included (trauma, spine, foot and ankle, adult reconstruction, and hand). Case volume and personnel composition per case were extracted. Statistical analysis was performed with two-sample equal variance Student t-tests.A total of 51,111 cases were assessed. Surgical volume increased across all sites/services over time. Fellow numbers did not affect average resident caseload. However, in years with more fellows, an 11% decrease in one-on-one resident-attending cases (P = 0.002) and a 17% increase in resident-fellow-attending "double-scrubbed" cases was observed (P < 0.001).Increasing orthopaedic fellows did not affect resident case volume but resulted in fewer one-on-one cases with the attending and more "double-scrubbed" cases with a fellow. The implications of these findings to resident education require further study, but orthopaedic educators should be aware of these findings to try to maximize educational opportunities.Level III.

  View details for DOI 10.5435/JAAOS-D-20-00233

  View details for PubMedID 32649442

• Patient-Reported Outcome Measures (PROMs): Influence of Motor Tasks and Psychosocial Factors on FAAM Scores in Foot and Ankle Trauma Patients. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons Schultz, B. J., Tanner, N. n., Shapiro, L. M., Segovia, N. A., Kamal, R. N., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  Patient-reported outcome measures (PROMS) are being increasingly used as a quality of care metric. However, the validity and consistency of PROMS remain undefined. The study sought to determine whether Foot and Ankle Ability Measure (FAAM) scores improve after patients complete motor tasks evaluated on the survey and to examine the relationship between depression and self-efficacy and FAAM scores or change in scores. We conducted a prospective comparison study of adults with isolated foot, ankle, or distal tibia fractures treated operatively at level I trauma center. Twenty-seven patients completed the FAAM survey at the first clinic visit after being made weightbearing as tolerated (mean 3 months). Patients then completed 6 motor tasks queried on FAAM (standing, walking without shoes, squatting, stairs, up to toes), followed by a repeat FAAM and General Self-Efficacy scale (GSE) and Patient Health Questionnaire-2 (PHQ-2) instruments. FAAM scores before and after intervention; GSE and PHQ-2 scores compared with baseline FAAM and change in FAAM scores. Performing motor tasks significantly improved postintervention scores for squatting (P = .044) and coming up to toes (P = .012), the 2 most strenuous tasks. No difference was found for the remaining tasks. Higher depression ratings correlated with worse FAAM scores overall (P < .05). Higher self-efficacy ratings correlated with increase in FAAM Sports subscale postintervention (P = .020). FAAM scores are influenced by performing motor tasks. Self-reported depression influences baseline FAAM scores and self-efficacy may influence change in FAAM scores. Context and patient factors (modifiable and nonmodifiable) affect PROM implementation, with implications for clinical care, reimbursement models, and use of quality measure.

  View details for DOI 10.1053/j.jfas.2020.01.008

  View details for PubMedID 32173179

• How are peri-implant fractures below short versus long cephalomedullary nails different? European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Goodnough, L. H., Salazar, B. P., Furness, J. n., Feng, J. E., DeBaun, M. R., Campbell, S. T., Lucas, J. F., Cross, W. W., Leucht, P. n., Grant, K. D., Gardner, M. J., Bishop, J. A. 2020

  Abstract

  Cephalomedullary nails are a commonly used implant for the treatment of many pertrochanteric femur fractures and are available in short and long configurations. There is no consensus on ideal nail length. Relative advantages can be ascribed to short and long intramedullary nails, yet both implant styles share the potentially devastating complication of peri-implant fracture. Determining the clinical sequelae after fractures below nails of different lengths would provide valuable information for surgeons choosing between short or long nails. Thus, the purpose of the study was to compare injury patterns and treatment outcomes following peri-implant fractures below short or long cephalomedullary nails.This was a multicenter retrospective cohort study that identified 33 patients referred for treatment of peri-implant fractures below short and long cephalomedullary nails (n = 19 short, n = 14 long). We compared fracture pattern, treatment strategy, complications, and outcomes between these two groups.Short nails were associated with more diaphyseal fractures (odds ratio [OR] 13.75, CI 2.2-57.9, p 0.002), which were treated more commonly with revision intramedullary nailing (OR, infinity; p 0.01), while long nails were associated with distal metaphyseal fractures (OR 13.75, CI 2.2-57.9, p 0.002), which were treated with plate and screw fixation (p 0.002). After peri-implant fracture, there were no differences in blood loss, operative time, weight bearing status, or complication rates based on the length of the initial nail. In patients treated with revision nailing, there was greater estimated blood loss (EBL, median 300 cc, interquartile range [IQR] 250-1200 vs median 200 cc, IQR 100-300, p 0.03), blood product utilization and complication rates (OR 11.1, CI 1.1-135.7, p 0.03), but a trend toward unrestricted post-operative weight-bearing compared to patients treated with plate and screw constructs.Understanding fracture patterns and patient outcomes after fractures below nails of different lengths will help surgeons make more informed implant choices when treating intertrochanteric hip fractures. Revision to a long nail for the treatment of fractures at the tip of a short nail may be associated with increased patient morbidity.

  View details for DOI 10.1007/s00590-020-02785-1

  View details for PubMedID 32909108

• Dual Mini-Fragment Plating is Comparable to Precontoured Small Fragment Plating for Operative Diaphyseal Clavicle Fractures: A Retrospective Cohort Study. Journal of orthopaedic trauma DeBaun, M. R., Chen, M. J., Campbell, S. T., Goodnough, L. H., Lai, C., Salazar, B. P., Bishop, J. A., Gardner, M. J. 2019

  Abstract

  OBJECTIVES: To compare precontoured (Pc) small fragment plating to dual mini-fragment plating (DmF) for open reduction and internal fixation (ORIF) of diaphyseal clavicle fractures.DESIGN: Retrospective Cohort SETTING:: Level 1 Trauma CenterPatients/Participants: A total of 133 patients with displaced fractures of the diaphyseal clavicle (OTA/AO 15-B1, -2, and -3) treated with ORIF with a minimum of 1 year follow up or until radiographic and clinical union.INTERVENTION: Two patient cohorts were identified: 1) patients treated with orthogonal DmF plate constructs and 2) patients treated with Pc clavicle-specific plates.OUTCOME MEASUREMENTS: Union rate and implant removal were assessed using standard descriptive statistics. Odds ratios (OR), 95% confidence intervals (CI), and p-values (p) were calculated.RESULTS: There were 60 DmF and 74 Pc patients. There were no significant differences between groups with respect to age, gender, surgeon, body mass index, or mode of fixation. There was no significant difference in union (98.3% DmF; 100% Pc, p=0.45) or maintenance of reduction (98.3% DmF; 100% Pc, p=0.45). A total of 8% of DmF patients had symptomatic implant removal compared to 20% of Pc patients (OR 0.36, CI 0.12-1.05, p=0.061).CONCLUSIONS: This retrospective comparative study found no difference in union or maintenance of reduction for diaphyseal clavicle fractures fixed with DmF compared to Pc plating. Patients treated with DmF plates may have lower rates of symptomatic implant removal.LEVEL OF EVIDENCE: Therapeutic Level III.

  View details for DOI 10.1097/BOT.0000000000001727

  View details for PubMedID 31868765

• Intramedullary Cage Fixation for Proximal Humerus Fractures Has Low Reoperation Rates at One Year: Results of a Multi-Center Study. Journal of orthopaedic trauma Goodnough, L. H., Campbell, S. T., Githens, T. C., DeBaun, M. R., Bishop, J. A., Gardner, M. J. 2019

  Abstract

  OBJECTIVES: To determine reoperation rates following treatment of a proximal humerus fracture with Cage fixation.DESIGN: Retrospective case series SETTING:: Eleven U.S. hospitals PATIENTS:: Fifty- two patients undergoing surgical treatment of proximal humerus fractures INTERVENTION:: Open reduction and internal fixation of a proximal humerus fracture with a proximal humerus Cage MAIN OUTCOME MEASUREMENTS:: Re-operation rate at one year RESULTS:: At a minimum follow-up of one year, reoperations occurred in 4/52 patients (7.7%). Avascular necrosis (2/41) occurred in 4.9% of patients.CONCLUSION: Standard locked plating remains an imperfect solution for proximal humerus fractures. Proximal humerus Cage fixation had low rates of revision surgery at one year. Proximal humerus Cage fixation may offer reduced rates of complication and reoperation when compared to conventional locked plating for the management of proximal humerus fractures.LEVEL OF EVIDENCE: IV-Therapeutic.

  View details for DOI 10.1097/BOT.0000000000001712

  View details for PubMedID 31809419

• Posterior Sternoclavicular Dislocation: Do We Need "Cardiothoracic Backup"? Insights from a National Sample. Journal of orthopaedic trauma Leonard, D. A., Segovia, N., Kaur, J., Lucas, J., Bishop, J., Vorhies, J. S. 2019

  Abstract

  OBJECTIVES: To describe the incidence of and risk factors for vascular injury associated with P-SCD.METHODS: We used data from the HCUP-NIS from 2015-2016 and defined a cohort of patients with sternoclavicular dislocation (SCD) using ICD-10-CM diagnosis codes. We further isolated a subset with P-SCD. We describe the incidence of thoracic vascular injury, demographics and injury severity score (ISS) in this cohort.RESULTS: Of an estimated 550 patients who had SCD, 140 (25%) were identified as having a P-SCD. No vascular injuries occurred in the P-SCD cohort. Among all patients with SCD, < 2% of patients had a vascular injury, all of whom had an ISS ≥ 15, independent of the vascular injury itself (Figure 1). Among patients with an isolated P-SCD injury (55), overall length of stay was 1.8 days and total charges averaged $29,724.45. There was no mortality among patients with isolated P-SCD.CONCLUSION: Here we report no vascular injuries in the largest known series of P-SCD. Among all patients with SCD, vascular injury was rare, occurring only in severely polytraumatized patients. The recommendation for routine involvement of cardiothoracic surgeons in all cases of P-SCD should be re-examined.LEVEL OF EVIDENCE: Level III.

  View details for DOI 10.1097/BOT.0000000000001685

  View details for PubMedID 31764407

• Biomechanical comparison of bone-screw-fasteners versus traditional locked screws in plating female geriatric bone. Injury DeBaun, M. R., Swinford, S. T., Chen, M. J., Thio, T., Behn, A. A., Lucas, J. F., Bishop, J. A., Gardner, M. J. 2019

  Abstract

  OBJECTIVES: To biomechanically compare plated constructs using nonlocking bone-screw-fasteners with interlocking threads versus locking screws with traditional buttress threads in geriatric female bone.METHODS: Eleven matched pairs of proximal and distal segments of geriatric female cadaveric tibias were used to create a diaphyseal fracture model. Nonlocking bone-screw-fasteners or locking buttress threaded screws were applied to a locking compression plate on the anterolateral aspect of the tibia placed in bridge mode. Specimens were subjected to incrementally increasing cyclic axial load combined with constant cyclic torsion. Total cycles to failure served as a primary outcome measure, with failure defined as 2mm of displacement or 10 degrees of rotation. Secondary outcome measures included initial stiffness in compression and torsion determined from preconditioning testing and overall rigidity as determined by maximum peak-to-peak axial and rotational motion at 500 cycle intervals during cyclic testing. Group comparisons were made using paired Student's t-tests. Significance was set at p<0.05.RESULTS: Bone-screw-fastener constructs failed at an average of 40,636±22,151 cycles and locking screw constructs failed at an average of 37,773±8433 cycles, without difference between groups (p==0.610). Total cycles to failure was higher in the bone-screw-fasteners group for 7 tibiae out of the eleven matched pairs tested. During static and cyclic testing, bone-screw-fastener constructs demonstrated increased initial torsional stiffness (7.6%) and less peak-to-peak displacement and rotation throughout the testing cycle(p<0.05).CONCLUSIONS: In female geriatric bone, constructs fixed with bone-screw-fasteners incorporate multiplanar interlocking thread geometry and performed similarly to traditional locked plating. These novel devices may combine the benefits of both nonlocking and locking screws when plating geriatric bone.

  View details for DOI 10.1016/j.injury.2019.10.032

  View details for PubMedID 31703961

• Orthopedic Surgeons Have Inadequate Knowledge of the Cost of Trauma-Related Imaging Studies ORTHOPEDICS Schultz, B., Fogel, N., Finlay, A., Collinge, C., Githens, M. F., Higgins, T., Mehta, S., O'Toole, R., Summers, H., Bishop, J. A., Gardner, M. J. 2019; 42 (5): E454–E459

  Abstract

  Radiographic imaging is integral to the diagnosis and treatment of orthopedic injuries. Previous studies have shown that orthopedists consistently underestimate the price of implants, but their knowledge of imaging charges is unknown. This study evaluated whether orthopedic residents and faculty could accurately estimate charges of imaging modalities at their respective institutions. A survey with 10 common imaging studies was sent to 8 academic level I trauma centers. Participants estimated the total charge of each imaging modality. This was compared with the actual charge at their institution. Seven centers produced 162 responders: 74 faculty and 88 residents. The differences between the estimated cost and the billing charge were calculated and broken down by training level and imaging modality. Overall, imaging charges were underestimated by 31% (P<.001), with 19.4% of estimates being within 20% of actual charges (95% confidence interval, 19.1-19.9). There was no difference between training levels (P=.69). There was greater than 1000% variation in charges between institutions. Orthopedists across training levels underestimate hospital charges associated with common imaging studies, and there is a large variation in charges between centers. Awareness of charges is important because charges affect clinical decision making and are relevant to practicing both cost-conscious and clinically sound medicine. [Orthopedics. 2019; 42(5):e454-e459.].

  View details for DOI 10.3928/01477447-20190627-04

  View details for Web of Science ID 000487320700008

  View details for PubMedID 31269218

• Opioid use after ankle fracture surgery: current trends in the United States CURRENT ORTHOPAEDIC PRACTICE Chen, M. J., Zhang, S., DeBaun, M., Fogel, N., Bishop, J. A., Gardner, M. J. 2019; 30 (4): 332–35

  View details for DOI 10.1097/BCO.0000000000000764

  View details for Web of Science ID 000474108600009

• Rates of Perioperative Complications Among Patients Undergoing Orthopedic Trauma Surgery Despite Having Positive Results for Methamphetamine ORTHOPEDICS Githens, T., DeBaun, M. R., Campbell, S. T., Wu, E. J., Goodnough, L., Lichstein, P., Painter, C., Krygier, J. E., Bishop, J., Gardner, M. J. 2019; 42 (4): 192–96

  Abstract

  The burden of psychosocial problems, including substance abuse, is high among trauma patients. Use of illicit substances is often noted during urine toxicology screening on admission and can delay surgery because of concerns for an interaction with anesthesia. Methamphetamine theoretically has potential to increase perioperative anesthetic risks. However, the authors are unaware of any studies documenting increased rates of cardiovascular complications in the perioperative period among orthopedic trauma patients. This study sought to determine the rate of cardiovascular complications in these patients. The authors reviewed the medical records of all patients between 2013 and 2018 who underwent orthopedic trauma surgery at two level I trauma centers in the setting of a methamphetamine-positive urine toxicology screening prior to surgery. Information on demographics, injury, type of surgical intervention, and incidence of perioperative cardiovascular and overall medical complications prior to discharge was recorded. Ninety-four patients were included in the study (mean age, 44 years; range, 16-78 years). Twenty-six (28%) patients had multiple injuries. Thirteen (14%) patients had debridement and/or provisional stabilization of an open or unstable fracture, 18 (19%) had treatment for an infection, and 63 (67%) had definitive fracture surgery. The overall rates of perioperative cardiovascular complications and perioperative medical complications were 2.1% and 3.2%, respectively. This study provides both a baseline understanding of the complication rate for methamphetamine-positive orthopedic trauma patients during general anesthesia and justification for larger multicenter studies to further investigate this topic. [Orthopedics. 2019; 42(4):192-196.].

  View details for DOI 10.3928/01477447-20190523-01

  View details for Web of Science ID 000476648200015

  View details for PubMedID 31136677

• Changing practice patterns: flexed versus semi-extended positioning for tibial nailing CURRENT ORTHOPAEDIC PRACTICE Goodnough, L., Campbell, S. T., Githens, M. F., Gardner, M. J., Bishop, J. A. 2019; 30 (4): 356–60

  View details for DOI 10.1097/BCO.0000000000000763

  View details for Web of Science ID 000474108600014

• Geriatric olecranon fractures treated with plate fixation have low complication rates CURRENT ORTHOPAEDIC PRACTICE Campbell, S. T., DeBaun, M. R., Goodnough, L., Bishop, J. A., Gardner, M. J. 2019; 30 (4): 353–55

  View details for DOI 10.1097/BCO.0000000000000765

  View details for Web of Science ID 000474108600013

• Optimizing the Orthopaedic Medical Student Rotation: Keys to Success for Students, Faculty, and Residency Programs. The Journal of the American Academy of Orthopaedic Surgeons Campbell, S. T., Chan, J. Y., Gardner, M. J., Bishop, J. A. 2019

  Abstract

  Senior medical students interested in pursuing careers in orthopaedic surgery participate in orthopaedic rotations around the country. These rotations are an important part of the application process because they allow students to demonstrate their work ethic and knowledge and learn more about the fit and culture of the residency program. Although knowledge and technical ability are important, several less tangible factors also contribute to success. These include maintaining situational awareness and a positive attitude, putting forth an appropriate effort, preparing effectively, and critically evaluating one's own performance. Attention to these details can help maximize the student's chance for a successful rotation. The hosting program and faculty can further facilitate a successful rotation by setting appropriate expectations, orienting the student to the program, carefully selecting appropriate services and faculty, and providing dedicated education to the student.

  View details for DOI 10.5435/JAAOS-D-19-00096

  View details for PubMedID 31136321

• Distal Femur Locking Plates Fit Poorly Before and After Total Knee Arthroplasty JOURNAL OF ORTHOPAEDIC TRAUMA Campbell, S. T., Bosch, L. C., Swinford, S., Amanatullah, D. F., Bishop, J. A., Gardner, M. J. 2019; 33 (5): 239–43

  View details for DOI 10.1097/BOT.0000000000001431

  View details for Web of Science ID 000467807900015

• Prophylactic Fixation Can Be Cost-effective in Preventing a Contralateral Bisphosphonate-associated Femur Fracture CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Jiang, S. Y., Kaufman, D. J., Chien, B. Y., Longoria, M., Shachter, R., Bishop, J. A. 2019; 477 (3): 480–90

  View details for DOI 10.1097/CORR.0000000000000545

  View details for Web of Science ID 000472558500003

• Orthopaedic Trauma Quality Measures for Value-Based Health Care Delivery: A Systematic Review JOURNAL OF ORTHOPAEDIC TRAUMA DeBaun, M. R., Chen, M. J., Bishop, J. A., Gardner, M. J., Kamal, R. N. 2019; 33 (2): 104–10

  View details for DOI 10.1097/BOT.0000000000001372

  View details for Web of Science ID 000467804300017

• Orthopaedic Trauma Quality Measures for Value Based Healthcare Delivery: A Systematic Review. Journal of orthopaedic trauma DeBaun, M. R., Chen, M. J., Bishop, J. A., Gardner, M. J., Kamal, R. N. 2019

  Abstract

  OBJECTIVES: To assess the current portfolio of quality measures and candidate quality measures that address orthopaedic trauma surgery.DATA SOURCES: We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Quality Payment Program for quality measures relevant to fracture surgery. We also searched MEDLINE/PubMed, Embase/Scopus, and Cochrane libraries.DATA EXTRACTION: Clinical practice guidelines were included as candidate quality measures if their development was in accordance with the Institute of Medicine criteria for development of clinical practice guidelines, were based on consistent clinical evidence including at least one Level I study, and carried the strongest possible recommendation by the developing body. We categorized the measures as structure, process, or outcome domains according to the framework described by Donabedian.DATA SYNTHESIS: From the 3809 articles initially identified and screened, a total of 189 combined quality or candidate quality measures were extracted from our review. With regard to the Donabedian framework, there were a total of 7% (13/189) structure, 52% process (99/189), and 41% (77/189) outcome measures identified.CONCLUSIONS: As quality measures progressively inform reimbursement in value based healthcare models, quality measures evaluating the care of patients sustaining a fracture will become increasingly relevant to orthopaedic trauma surgeons.

  View details for PubMedID 30624346

• Distal Femur Locking Plates Fit Poorly Before and After Total Knee Arthroplasty. Journal of orthopaedic trauma Campbell, S. T., Bosch, L. C., Swinford, S., Amanatullah, D. F., Bishop, J. A., Gardner, M. J. 2019

  Abstract

  OBJECTIVE: To evaluate the fit of distal femur locking plates. Secondarily, we sought to compare plate fit among patients with and without a total knee arthroplasty (TKA).DESIGN: We retrospectively reviewed full-length femur radiographs of patients who underwent primary TKA.SETTING: All patients underwent TKA at a large university hospital.INTERVENTION: Standard length pre-contoured distal femur locking plates from four manufacturers were digitally templated onto each patient's pre- and post-TKA radiographs.MAIN OUTCOME MEASUREMENTS: The maximum distance from the plate to the lateral femoral cortex (plate-bone distance) was measured in the metaphyseal region. Mean plate-bone distances were compared between manufacturers and between pre and post-TKA radiographs.RESULTS: All implants tested were undercontoured in all patients. Plate-bone distances ranged from 6.6 ± 0.4 mm to 8.0 ± 0.4 mm (mean ± standard error) pre-TKA and 8.2 ± 0.3 mm to 8.6 ± 0.3 mm after TKA, indicating worse fit after arthroplasty (p < 0.001). There were also inter-manufacturer differences, with Synthes and Smith & Nephew implants demonstrating the lowest plate-bone distances in the pre- and post-TKA groups, respectively. Proportionally, plate-bone increase was greater in the female cohort (16%) compared to the male cohort (8%).CONCLUSIONS: There was a plate-bone mismatch for the distal femur locking plates tested in this study, due to undercontouring of the implants. After patients underwent TKA, poor implant fit was exacerbated. Surgeons must be aware of the potential for deformity if the proximal segment is brought into contact with the implant. These finding may help optimize implant design for the treatment of periprosthetic distal femur fractures.LEVEL OF EVIDENCE: V.

  View details for PubMedID 30614915

• A Structured Review Instrument Improves the Quality of Orthopaedic Journal Club JOURNAL OF SURGICAL EDUCATION Campbell, S. T., Kleimeyer, J. P., Young, J. L., Gardner, M. J., Wood, K. B., Bishop, J. A. 2019; 76 (1): 294–300

  View details for DOI 10.1016/j.jsurg.2018.06.017

  View details for Web of Science ID 000456356300036

• Understanding the Radiographic Anatomy of the Proximal Ulna and Avoiding Inadvertent Intraarticular Screw Placement. Journal of orthopaedic trauma Githens, T. C., Campbell, S. T., Salazar, B. n., Goodnough, L. H., DeBaun, M. R., Bishop, J. A., Gardner, M. J. 2019

  Abstract

  To map the proximal ulnar articular margins and ensure safe extraarticular placement of implants.Ten fresh frozen adult elbow cadaver specimens were obtained. Radio opaque wire was applied to the articular margin of the articular facets and the central trochlear ridge of the proximal ulna. Fluoroscopic images were obtained demonstrating the articular facet margins. Radiographic measurements were performed and used to identify relative safe screw zones.All specimens demonstrated marked extension of the ulnar and radial facets dorsal to the central trochlear ridge. The dorsal extent of the ulnar facets from the central trochlear ridge averaged 9.7 mm (range, 7.9-13 mm; SD, 1.5 mm) and 6.2 mm (range, 3.4-9.4 mm; SD, 1.9 mm) respectively. The average footprint of the posterior ulnar facet occupied 44% (+/-4.9%) of the total ulnar height from the dorsal cortex to the trochlear ridge.The articular margins of the anterior and posterior facets of the proximal ulna are challenging to identify radiographically. A surgical "at risk zone" exists within 9.7 mm from the radiographic margin of the central trochlear ridge. Implants placed within this zone have the potential to violate the articular surface.

  View details for DOI 10.1097/BOT.0000000000001638

  View details for PubMedID 31809415

• An Excellent Addition to Recent Studies in the US From Various Disciplines and Locations That Show Similar Results Response JOURNAL OF ORTHOPAEDIC TRAUMA Bishop, J., Vorhies, J., Paci, G. 2019; 33 (1): E38

  View details for Web of Science ID 000467798900013

• Preclinical induced membrane model to evaluate synthetic implants for healing critical bone defects without autograft JOURNAL OF ORTHOPAEDIC RESEARCH DeBaun, M. R., Stahl, A. M., Daoud, A. I., Pan, C., Bishop, J. A., Gardner, M. J., Yang, Y. P. 2019; 37 (1): 60–68

  View details for DOI 10.1002/jor.24153

  View details for Web of Science ID 000461585200007

• In response. Journal of orthopaedic trauma Bishop, J., Vorhies, J., Paci, G. 2019; 33 (1): e38

  View details for PubMedID 30562264

• Assessment of Open Syndesmosis Reduction Techniques in an Unbroken Fibula Model: Visualization Versus Palpation JOURNAL OF ORTHOPAEDIC TRAUMA Pang, E., Coughlan, M., Bonaretti, S., Finlay, A., Bellino, M., Bishop, J. A., Gardner, M. J. 2019; 33 (1): E14–E18

  View details for DOI 10.1097/BOT.0000000000001322

  View details for Web of Science ID 000467798900003

• Early Postoperative Radiographs Have No Effect on Orthopaedic Trauma Patient's Satisfaction With Their Clinic Visit. The Journal of the American Academy of Orthopaedic Surgeons J Schultz, B. n., Bishop, J. A., Hall, K. n., Finlay, A. n., Gardner, M. J. 2019

  Abstract

  Patient satisfaction plays a prominent role in modern orthopaedic care, reimbursement, and quality assessment, even if it runs contrary to the "standard of care." The literature shows that routine early radiographs after acute fracture care have no impact on clinical decision-making or patient outcomes, but little is known about their effect on patient satisfaction and understanding of their injuries. We hypothesized that eliminating these radiographs would negatively influence patient satisfaction scores with their clinic visit.One hundred patients were prospectively enrolled after acute fracture fixation. Half the patients obtained radiographs at the 2-week follow-up visit, whereas the other half did not. All patients completed a satisfaction survey about their clinic visit.No difference was observed between the groups in overall satisfaction with the clinic visit (P = 0.62) or complications. However, patients with radiographs were more satisfied with the surgeon's explanations of their injury and progression (P = 0.03).Eliminating routine early postoperative radiographs had no effect on overall patient satisfaction with the clinic visit, but it did affect satisfaction with the surgeon's explanation of their injury. This could save time, money, and radiation exposure without adversely affecting patient outcome or satisfaction, but an equivalent educational tool should be identified for clinic visits.

  View details for DOI 10.5435/JAAOS-D-18-00697

  View details for PubMedID 31268869

• Lower Complication Rate Following Ankle Fracture Fixation by Orthopaedic Surgeons Versus Podiatrists. The Journal of the American Academy of Orthopaedic Surgeons Chan, J. Y., Truntzer, J. N., Gardner, M. J., Bishop, J. A. 2018

  Abstract

  INTRODUCTION: Increased overlap in the scope of practice between orthopaedic surgeons and podiatrists has led to increased podiatric treatment of foot and ankle injuries. However, a paucity of studies exists in the literature comparing orthopaedic and podiatric outcomes following ankle fracture fixation.METHODS: Using an insurance claims database, 11,745 patients who underwent ankle fracture fixation between 2007 and 2015 were retrospectively evaluated. Patient data were analyzed based on the provider type. Complications were identified by the International Classification of Diseases, Ninth Revision, codes, and revision surgeries were identified by the Current Procedural Terminology codes. Complications analyzed included malunion/nonunion, infection, deep vein thrombosis, and rates of irrigation and debridement. Risk factors for complications were compared using the Charlson Comorbidity Index.RESULTS: Overall, 11,115 patients were treated by orthopaedic surgeons and 630 patients were treated by podiatrists. From 2007 to 2015, the percentage of ankle fractures surgically treated by podiatrists had increased, whereas that treated by orthopaedic surgeons had decreased. Surgical treatment by podiatrists was associated with higher malunion/nonunion rates among all types of ankle fractures. No differences in complications were observed in patients with unimalleolar fractures. In patients with bimalleolar or trimalleolar fractures, treatment by a podiatrist was associated with higher malunion/nonunion rates. Patients treated by orthopaedic surgeons versus podiatrists had similar comorbidity profiles.DISCUSSION: Surgical treatment of ankle fractures by orthopaedic surgeons was associated with lower rates of malunion/nonunion when compared with that by podiatrists. The reasons for these differences are likely multifactorial but warrants further investigation. Our findings have important implications in patients who must choose a surgeon to surgically manage their ankle fracture, as well as policymakers who determine the scope of practice.LEVEL OF EVIDENCE: Level III-retrospective cohort study.

  View details for DOI 10.5435/JAAOS-D-18-00630

  View details for PubMedID 30601371

• Incidence and Risk Factors for Postoperative Hypothermia After Orthopaedic Surgery JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Kleimeyer, J. P., Harris, A. S., Sanford, J., Maloney, W. J., Kadry, B., Bishop, J. A. 2018; 26 (24): E497–E503

  View details for DOI 10.5435/JAAOS-D-16-00742

  View details for Web of Science ID 000462410600001

• Prophylactic Fixation Can Be Cost-effective in Preventing a Contralateral Bisphosphonate-associated Femur Fracture. Clinical orthopaedics and related research Jiang, S. Y., Kaufman, D. J., Chien, B. Y., Longoria, M., Shachter, R., Bishop, J. A. 2018

  Abstract

  BACKGROUND: Bisphosphonates reduce the risk of fractures associated with osteoporosis but increase the risk of atypical subtrochanteric femur fractures. After unilateral atypical femur fracture, there is risk of contralateral fracture, but the indications for prophylactic fixation are controversial.QUESTIONS/PURPOSES: The purpose of this study is to use Markov modeling to determine whether contralateral prophylactic femur fracture fixation is cost-effective after a bisphosphonate-associated atypical femur fracture and, if so, what patient-related factors may influence that determination.METHODS: Markov modeling was used to determine the cost-effectiveness of contralateral prophylactic fixation after an initial atypical femur fracture. Simulated patients aged 60 to 90 years were included and separated into standard and high fracture risk cohorts. Patients with standard fracture risk were defined as those presenting with one atypical femur fracture but without symptoms or findings in the contralateral femur, whereas patients with high fracture risk were typified as those with more than one risk factor, including Asian ethnicity, prodromal pain, femoral geometry changes, or radiographic findings in the contralateral femur. Outcome probabilities and utilities were derived from studies matching to patient characteristics, and fragility fracture literature was used when atypical femur fracture data were not available. Associated costs were largely derived from Medicare 2015 reimbursement rates. Sensitivity analysis was performed on all model parameters within defined ranges.RESULTS: Prophylactic fixation for a 70-year-old patient with standard risk for fracture costs USD 131,300/quality-adjusted life-year (QALY) and for high-risk patients costs USD 22,400/QALY. Sensitivity analysis revealed that prophylaxis for high-risk patients is cost-effective at USD 100,000/QALY when the cost of prophylaxis was less than USD 29,400, the probability of prophylaxis complications was less than 21%, or if the patient was younger than 89 years old. The parameters to which the model was most sensitive were the cost of prophylaxis, patient age, and probability of prophylaxis-related complications.CONCLUSIONS: Prophylactic fixation of the contralateral side after unilateral atypical femur fracture is not cost-effective for standard-risk patients but is cost-effective among high-risk patients between 60 and 89 years of age with a high risk for an atypical femur fracture defined by patients with more than one risk factor such as Asian ethnicity, prodromal pain, varus proximal femur geometry, femoral bowing, or radiographic changes such as periosteal beaking and a transverse radiolucent line. However, our findings are based on several key assumptions for modeling such as the probability of fractures and complications, the costs associated for each health state, and the risks of surgical treatment. Future research should prospectively evaluate the degree of risk contributed by known radiographic and demographic parameters to guide management of the contralateral femur after a patient presents with an atypical femur fracture.LEVEL OF EVIDENCE: Level III, economic and decision analyses.

  View details for PubMedID 30394950

• A Preclinical Induced Membrane Model to Evaluate Synthetic Implants for Healing Critical Bone Defects Without Autograft. Journal of orthopaedic research : official publication of the Orthopaedic Research Society DeBaun, M. R., Stahl, A. M., Daoud, A. I., Pan, C., Bishop, J. A., Gardner, M. J., Yang, Y. P. 2018

  Abstract

  Critical bone defects pose a formidable orthopaedic problem in patients with bone loss. We developed a preclinical model based on the induced membrane technique using a synthetic graft to replace autograft for healing critical bone defects. Additionally, we used a novel osteoconductive scaffold coupled with a synthetic membrane to evaluate the potential for single-stage bone regeneration. Three experimental conditions were investigated in critical femoral defects in rats. Group A underwent a two-stage procedure with insertion of a polymethylmethacrylate (PMMA) spacer followed by replacement with a 3D printed polycaprolactone(PCL)/beta-tricalcium phosphate (beta-TCP) osteoconductive scaffold after 4 weeks. Group B received a single-stage PCL/beta-TCP scaffold wrapped in a PCL-based microporous polymer film creating a synthetic membrane. Group C received a single-stage bare PCL/beta-TCP scaffold. All groups were examined by serial radiographs for callus formation. After 12 weeks, the femurs were explanted and analyzed with micro-CT and histology. Mean callus scores tended to be higher in Group A. Group A showed statistically significant greater bone formation on micro-CT compared with other groups, although bone volume fraction was similar between groups. Histology results suggested extensive bone ingrowth and new bone formation within the macroporous scaffolds in all groups and cell infiltration into the microporous synthetic membrane. This study supports the use of a critical size femoral defect in rats as a suitable model for investigating modifications to the induced membrane technique without autograft harvest. Future investigations should focus on bioactive synthetic membranes coupled with growth factors for single-stage bone healing. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30273977

• Identification of the Human Skeletal Stem Cell. Cell Chan, C. K., Gulati, G. S., Sinha, R., Tompkins, J. V., Lopez, M., Carter, A. C., Ransom, R. C., Reinisch, A., Wearda, T., Murphy, M., Brewer, R. E., Koepke, L. S., Marecic, O., Manjunath, A., Seo, E. Y., Leavitt, T., Lu, W., Nguyen, A., Conley, S. D., Salhotra, A., Ambrosi, T. H., Borrelli, M. R., Siebel, T., Chan, K., Schallmoser, K., Seita, J., Sahoo, D., Goodnough, H., Bishop, J., Gardner, M., Majeti, R., Wan, D. C., Goodman, S., Weissman, I. L., Chang, H. Y., Longaker, M. T. 2018; 175 (1): 43

  Abstract

  Stem cell regulation and hierarchical organization ofhuman skeletal progenitors remain largely unexplored. Here, we report the isolation of a self-renewing and multipotent human skeletal stem cell (hSSC) that generates progenitors of bone, cartilage, and stroma, but not fat. Self-renewing and multipotent hSSCs are present in fetal and adult bones and can also be derived from BMP2-treated human adipose stroma (B-HAS) and induced pluripotent stem cells (iPSCs). Gene expression analysis of individual hSSCs reveals overall similarity between hSSCs obtained from different sources and partially explains skewed differentiation toward cartilage in fetal and iPSC-derived hSSCs. hSSCs undergo local expansion in response to acute skeletal injury. In addition, hSSC-derived stroma can maintain human hematopoietic stem cells (hHSCs) in serum-free culture conditions. Finally, we combine gene expression and epigenetic data of mouse skeletal stem cells (mSSCs) and hSSCs to identify evolutionarily conserved and divergent pathways driving SSC-mediated skeletogenesis. VIDEO ABSTRACT.

  View details for PubMedID 30241615

• Identification of the Human Skeletal Stem Cell CELL Chan, C. F., Gulati, G. S., Sinha, R., Tompkins, J., Lopez, M., Carter, A. C., Ransom, R. C., Reinisch, A., Wearda, T., Murphy, M., Brewer, R. E., Koepke, L. S., Marecic, O., Manjunath, A., Seo, E., Leavitt, T., Lu, W., Allison Nguyen, Conley, S. D., Salhotra, A., Ambrosi, T. H., Borrelli, M. R., Siebel, T., Chan, K., Schallmoser, K., Seita, J., Sahoo, D., Goodnough, H., Bishop, J., Gardner, M., Majeti, R., Wan, D. C., Goodman, S., Weissman, I. L., Chang, H. Y., Longaker, M. T. 2018; 175 (1): 43-+

  View details for DOI 10.1016/j.cell.2018.07.029

  View details for Web of Science ID 000445120000013

• Knee Pain After Intramedullary Nailing of Tibia Fractures: Prevalence, Etiology, and Treatment JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Bishop, J. A., Campbell, S. T., Eno, J. T., Gardner, M. J. 2018; 26 (18): E381–E387

  View details for DOI 10.5435/JAAOS-D-18-00076

  View details for Web of Science ID 000462409200001

• Percutaneous Versus Open Treatment of Posterior Pelvic Ring Injuries: Changes in Practice Patterns Over Time JOURNAL OF ORTHOPAEDIC TRAUMA Gire, J. D., Jiang, S. Y., Gardner, M. J., Bishop, J. A. 2018; 32 (9): 457–60

  View details for DOI 10.1097/BOT.0000000000001236

  View details for Web of Science ID 000451356800017

• Avoiding Neurovascular Risk During Percutaneous Clamp Reduction of Spiral Tibial Shaft Fractures: An Anatomic Correlation With Computed Tomography JOURNAL OF ORTHOPAEDIC TRAUMA Horrigan, P. B., Coughlan, M. J., DeBaun, M. R., Schultz, B., Bishop, J. A., Gardner, M. J. 2018; 32 (9): E376–E380

  View details for DOI 10.1097/BOT.0000000000001239

  View details for Web of Science ID 000451356800007

• Assessment of Open Syndesmosis Reduction Techniques in an Unbroken Fibula Model: Visualization vs. Palpation. Journal of orthopaedic trauma Pang, E. Q., Coughlan, M., Bonaretti, S., Finlay, A., Bellino, M., Bishop, J., Gardner, M. J. 2018

  Abstract

  OBJECTIVES: This cadaveric study sought to evaluate the accuracy of syndesmotic reduction using direct visualization via an anterolateral approach compared to palpation of the syndesmosis through a laterally based incision.METHODS: Ten cadaveric specimens were obtained and underwent baseline CT scans. Subsequently, a complete syndesmotic injury was simulated by transecting the anterior inferior tibiofibular ligament (AITFL), posterior tibiofibular ligament (PITFL), transverse ligament, interosseous membrane, and deltoid ligament. Three orthopaedic trauma surgeons were then asked to reduce each syndesmosis using direct visualization via an anterolateral approach. Specimens were then stabilized and underwent post-reduction CT scans. Fixation was then removed, the anterolateral exposure closed, and the surgeons were then asked to reduce the syndesmosis using palpation only via a direct lateral approach. Specimens were again instrumented and underwent post-reduction CT scans. Two tailed paired t-tests were used to compare reductions with baseline scans with significance set at p<0.05.RESULTS: There was no statistically significant difference between reduction via direct visualization or palpation via lateral approach when compared with baseline scans. Although measurements did not reach significance, there was a tendency towards external rotation, and anteromedial translation with direct visualization and a trend towards fibular external rotation and posterolateral translation with palpation.CONCLUSIONS: There is no difference in reduction quality using direct visualization or palpation to assess the syndesmosis. Surgeons may therefore choose either technique when reducing syndesmotic injures based on personal preference and other injury factors.

  View details for PubMedID 30169400

• Incidence and Risk Factors for Postoperative Hypothermia After Orthopaedic Surgery. The Journal of the American Academy of Orthopaedic Surgeons Kleimeyer, J. P., Harris, A. H., Sanford, J., Maloney, W. J., Kadry, B., Bishop, J. A. 2018

  Abstract

  INTRODUCTION: Postoperative hypothermia is a common complication of orthopaedic surgery associated with increased morbidity. We identified the incidence and risk factors for postoperative hypothermia across orthopaedic surgical procedures.METHODS: A total of 3,822 procedures were reviewed. Hypothermia was defined as temperature <36.0°C. Incidences were calculated and associated risk factors were evaluated by mixed-effects regression analyses.RESULTS: Hypothermia was observed in 72.5% of patients intraoperatively and 8.3% postoperatively. Risk factors for postoperative hypothermia included intraoperative hypothermia (odds ratio [OR], 2.72), lower preoperative temperature (OR, 1.46), female sex (OR, 1.42), lower body mass index (OR, 1.06 per kg/m), older age (OR, 1.02 per year), adult reconstruction by specialty (OR, 4.06), and hip and pelvis procedures by anatomic region (OR, 8.76).DISCUSSION: Intraoperative and postoperative hypothermia are common in patients who have undergone orthopaedic surgery. The high-risk groups identified in this study warrant increased attention and should be targets for interventions to prevent hypothermia and limit morbidity.LEVEL OF EVIDENCE: Level IV, prognostic study.

  View details for PubMedID 30169443

• Knee Pain After Intramedullary Nailing of Tibia Fractures: Prevalence, Etiology, and Treatment. The Journal of the American Academy of Orthopaedic Surgeons Bishop, J. A., Campbell, S. T., Eno, J. T., Gardner, M. J. 2018

  Abstract

  Intramedullary nailing is often the treatment of choice for fractures of the tibia, but postoperative knee pain is common after this procedure. Potential etiologies include implant prominence, injury to intra-articular structures, patellar tendon or fat pad injury, damage to the infrapatellar branch of the saphenous nerve, and altered biomechanics. Depending on the etiology, described treatment options include observation, implant removal, assessment and treatment of injured intra-articular structures, and selective denervation. Careful attention to appropriate starting point and implant selection combined with more recently described semiextended nailing techniques may aid in prevention of knee pain.

  View details for PubMedID 30095516

• A Structured Review Instrument Improves the Quality of Orthopaedic Journal Club. Journal of surgical education Campbell, S. T., Kleimeyer, J. P., Young, J. L., Gardner, M. J., Wood, K. B., Bishop, J. A. 2018

  Abstract

  OBJECTIVE: We asked the following questions: 1. Does the use of an structured review instrument (SRI) at journal club increase presentation quality, as measured objectively by a standardized evaluation rubric? 2. Does SRI use increase the time required to prepare for journal club? 3. Does SRI use positively impact presenter perceptions about confidence while presenting, satisfaction, and journal club effectiveness, as measured by postparticipation surveys?DESIGN: A prospective study was designed in which a grading rubric was developed to evaluate journal club presentations. The rubric was applied to 24 presentations at journal clubs prior to introduction of the SRI. An SRI was developed and distributed to journal club participants, who were instructed to use it to prepare for journal club. The grading rubric was then used to assess 25 post-SRI presentations and scores were compared between the pre- and post-SRI groups. Presentations occurred at either trauma, pediatrics, or spine subspecialty journal clubs. Participants were also surveyed regarding time requirements for preparation, perceptions of confidence while presenting, satisfaction, and perceptions of overall club effectiveness.SETTING: A single academic center with an orthopaedic surgery residency program.PARTICIPANTS: Resident physicians in the department of orthopaedic surgery.RESULTS: Mean presentation scores increased from 14.0 ± 5.9 (mean ± standard deviation) to 24.4 ± 5.2 after introduction of the SRI (p < 0.001). Preparation time decreased from a mean of 47 minutes to 40 minutes after SRI introduction (p = 0.22). Perceptions of confidence, satisfaction, and club effectiveness among trainees trended toward more positive responses after SRI introduction (confidence: 63% positive responses pre-SRI vs 72% post-SRI, p = 0.73; satisfaction: 64% vs 91%, p = 0.18; effectiveness: 64% vs 91%, p = 0.19).CONCLUSIONS: The use of a structured review instrument to guide presentations at orthopaedic journal club increased presentation quality, and there was no difference in preparation time. There were trends toward improved presenter confidence, satisfaction, and perception of journal club effectiveness. SRI utilization at orthopaedic journal club may be an effective method for increasing the quality of journal club presentations. Future work should examine the relationship between presentation quality and overall club effectiveness.

  View details for PubMedID 30093334

• Defining the width of the normal tibial plateau relative to the distal femur: Critical normative data for identifying pathologic widening in tibial plateau fractures CLINICAL ANATOMY Johannsen, A., Cook, A. M., Gardner, M. J., Bishop, J. A. 2018; 31 (5): 688–92

  View details for DOI 10.1002/ca.23196

  View details for Web of Science ID 000435936000013

• Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Lichstein, P. M., Kleimeyer, J. P., Githens, M., Vorhies, J. S., Gardner, M. J., Bellino, M., Bishop, J. 2018; 476 (7): 1468–76

  View details for DOI 10.1097/01.blo.0000533627.07650.bb

  View details for Web of Science ID 000438532900019

• Pediatric Supracondylar Humerus Fractures: Does After-Hours Treatment Influence Outcomes? JOURNAL OF ORTHOPAEDIC TRAUMA Paci, G. M., Tileston, K. R., Vorhies, J. S., Bishop, J. A. 2018; 32 (6): E215–E220

  View details for DOI 10.1097/BOT.0000000000001134

  View details for Web of Science ID 000451353900004

• Percutaneous versus Open Treatment of Posterior Pelvic Ring Injuries: Changes in Practice Patterns Over Time. Journal of orthopaedic trauma Gire, J. D., Jiang, S. Y., Gardner, M. J., Bishop, J. A. 2018

  Abstract

  OBJECTIVE: To determine how the utilization of open versus percutaneous treatment of posterior pelvic ring injuries in early career orthopaedic surgeons has changed over time.METHODS: Case log data from surgeons testing in the trauma subspecialty for Part II of the ABOS examination from 2003 to 2015 were evaluated. CPT codes for percutaneous fixation (27216) and open fixation (27218) of the posterior pelvic ring were evaluated using a regression analysis.RESULTS: A total of 377 candidates performed 2,095 posterior ring stabilization procedures (1,626 percutaneous, 469 open). Total case volume was stable over time (beta=-1.7 (1.1), p=.14). There was no significant change in the number of posterior pelvic ring fracture surgery cases performed per candidate per test year (beta= 0.1 (0.1), p=.50). The proportion of posterior pelvic ring cases performed percutaneously increased significantly from 49% in 2003 to 79% in 2015 (beta= 1.0 (0.4), p=.03). There was a significant decrease in the number of open cases reported per candidate (beta= -0.07 (0.03), p=.008).DISCUSSION AND CONCLUSION: Early career orthopaedic surgeons are performing more percutaneous fixation of the posterior pelvic ring and less open surgery. The impact of this change in volume on surgeon proficiency is unknown and warrants additional research.

  View details for PubMedID 29912737

• Which orthopaedic trauma patients need psychiatry consultation? A single institution pilot survey study CURRENT ORTHOPAEDIC PRACTICE Campbell, S. T., Schultz, B. J., Franciscus, A. M., Ravindranath, D., Bishop, J. A. 2018; 29 (3): 270–74

  View details for DOI 10.1097/BCO.0000000000000619

  View details for Web of Science ID 000435074900018

• What Makes Journal Club Effective? - A Survey of Orthopaedic Residents and Faculty JOURNAL OF SURGICAL EDUCATION Campbell, S. T., Kang, J. R., Bishop, J. A. 2018; 75 (3): 722–29

  View details for DOI 10.1016/j.jsurg.2017.07.026

  View details for Web of Science ID 000434907100025

• What Makes Journal Club Effective?-A Survey of Orthopaedic Residents and Faculty. Journal of surgical education Campbell, S. T., Kang, J. R., Bishop, J. A. 2018; 75 (3): 722–29

  Abstract

  BACKGROUND: Journal clubs play an important role in the education of orthopaedic surgery residents; however, there are sparse data available on the characteristics that make journal clubs effective.OBJECTIVE: The primary goal of this study was to determine the characteristics of effective journal clubs as identified by orthopaedic residents and faculty. We sought to compare the opinions of residents and faculty in order to identify areas that may benefit from future research and discussion.DESIGN: Orthopaedic surgery residents and faculty at residency programs around the country were surveyed anonymously. The survey was designed to determine the contribution of various journal club characteristics on the effectiveness of journal club. Nonparametric statistics were used to test for goodness-of-fit, and to compare responses between faculty and residents.RESULTS: A total of 204 individuals participated. The most important goals of journal clubs were teaching the skillset of evaluating scientific papers (2.0 ± 1.2 [mean rank ± standard deviation, on a scale of 6, with 1 being most important]), encouraging participants to read current orthopaedic literature, (2.4 ± 1.1), and instilling career-long habits of reading the orthopaedic literature among residents (3.1 ± 1.3). Mandatory attendance (71.8%), monthly journal clubs (80.9%), resident presentation of articles (86.7%), and discussion of 3 to 5 papers (78.7%) were thought to lead to more effective clubs. The most clinically relevant articles published within the last year (63.8%), and classic articles that have influenced practice (68.1%) were preferred. Participation and attendance (2.4 ± 1.5) and paper selection (2.6 ± 1.5) were the most important characteristics overall.CONCLUSIONS: In orthopaedics, journal clubs fulfill the role of encouraging reading of the literature, as well as educating residents and faculty. There are many possible club formats, but some are clearly felt to be more effective. Particular attention should be paid to attendance, participation, and paper selection.

  View details for PubMedID 28822821

• Defining the width of the normal tibial plateau relative to the distal femur: Critical normative data for identifying pathologic widening in tibial plateau fractures. Clinical anatomy (New York, N.Y.) Johannsen, A. M., Cook, A. M., Gardner, M., Bishop, J. A. 2018

  Abstract

  INTRODUCTION: Tibial plateau widening in the setting of fracture is an indication for surgical treatment, and restoring width is an important goal of surgery. In order to identify and correct pathological widening, the width of the normal tibial plateau must first be defined. The aim of this study was to establish normative data for the width of the tibial plateau relative to the distal femur to enable surgeons to identify and correct pathological widening in the setting of tibial plateau fracture.MATERIALS AND METHODS: Fifty-one uninjured anteroposterior (AP) knee radiographs and 11 XR and CT scans of lateral tibial plateau fractures were retrospectively reviewed. The distances measured included maximal distal femoral width, femoral articular width, tibial articular width, and lateral plateau widening.RESULTS: On average, lateral plateau widening was +0.02±2.03 mm, indicating that the most lateral aspect of the tibial plateau is collinear with the most lateral aspect of the lateral epicondyle of the femur. In the fracture population, average widening was 7.13±3.59 mm on XR and 6.57±3.34 mm on CT, with an absolute difference between XR and CT of 1.19±0.66 mm.CONCLUSIONS: This study is the first to define the radiographic anatomy of the proximal tibia quantitatively. In the setting of tibial plateau fracture, residual widening of 2.1 mm could be within normal variation. However, the authors consider widening>2.1 mm pathological. These values can be used for assessing pathological widening of tibial plateau fractures. This article is protected by copyright. All rights reserved.

  View details for PubMedID 29700856

• Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation? Clinical orthopaedics and related research Lichstein, P. M., Kleimeyer, J. P., Githens, M. n., Vorhies, J. S., Gardner, M. J., Bellino, M. n., Bishop, J. n. 2018

  Abstract

  A well-reduced femoral neck fracture is more likely to heal than a poorly reduced one, and increasing the quality of the surgical exposure makes it easier to achieve anatomic fracture reduction. Two open approaches are in common use for femoral neck fractures, the modified Smith-Petersen and Watson-Jones; however, to our knowledge, the quality of exposure of the femoral neck exposure provided by each approach has not been investigated.(1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches?Ten fresh-frozen human pelvi underwent both modified Smith-Petersen (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approaches. Dissections were performed by three fellowship-trained orthopaedic traumatologists with extensive experience in both approaches. Exposure (in cm) was quantified with calibrated digital photographs and specialized software. Modified Smith-Petersen approaches were analyzed before and after rectus femoris tenotomy. The ability to visualize and palpate seven clinically relevant anatomic structures (the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater trochanter, lesser trochanter, and medial femoral neck) was also recorded. The quantified area of the exposed proximal femur was utilized to compare which approach afforded the largest field of view of the femoral neck and articular surface for assessment of femoral neck fracture and associated femoral head injury. The ability to visualize and palpate surrounding structures was assessed so that we could better understand which approach afforded the ability to assess structures that are relevant to femoral neck fracture reduction and fixation.After controlling for age, body mass index, height, and sex, we found the modified Smith-Petersen approach provided a mean of 2.36 cm (95% confidence interval [CI], 0.45-4.28 cm; p = 0.015) additional exposure without rectus femoris tenotomy (p = 0.015) and 3.33 cm (95% CI, 1.42-5.24 cm; p = 0.001) additional exposure with a tenotomy compared with the Watson-Jones approach. The labrum, femoral head, subcapital femoral neck, basicervical femoral neck, and greater trochanter were reliably visible and palpable in both approaches. The lesser trochanter was palpable in all of the modified Smith-Petersen and none of the Watson-Jones approaches (p < 0.001). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 Watson-Jones versus all 10 modified Smith-Petersen approaches (p = 0.470).In the hands of surgeons experienced with both surgical approaches to the femoral neck, the modified Smith-Petersen approach, with or without rectus femoris tenotomy, provides superior exposure of the femoral neck and articular surface as well as visualization and palpation of clinically relevant proximal femoral anatomic landmarks compared with the Watson-Jones approach.Open reduction and internal fixation of a femoral neck fracture is typically performed in a young patient (< 60 years old) with the objective of obtaining anatomic reduction that would not be possible by closed manipulation, thus enhancing healing potential. In the hands of surgeons experienced in both approaches, the modified Smith-Petersen approach offers improved direct access for reduction and fixation. Higher quality reductions and fixation are expected to translate to improved healing potential and outcomes. Although our experimental results are promising, further clinical studies are needed to verify if this larger exposure area imparts increased quality of reduction, healing, and improved outcomes compared with other approaches. The learning curve for the exposure is unclear, but the approach has broad applications and is frequently used in other subspecialties such as for direct anterior THA and pediatric septic hip drainage. Surgeons treating femoral neck fractures with open reduction and fixation should familiarize themselves with the modified Smith-Petersen approach.

  View details for PubMedID 29698292

• Avoiding Neurovascular Risk During Percutaneous Clamp Reduction of Spiral Tibial Shaft Fractures: An Anatomic Correlation with Computed Tomography. Journal of orthopaedic trauma Horrigan, P. B., Coughlan, M. J., DeBaun, M. n., Schultz, B. n., Bishop, J. A., Gardner, M. J. 2018

  Abstract

  Use of percutaneous clamps are often helpful tools to aid reduction and intramedullary nailing of distal tibial spiral diaphyseal fractures. However, the anterior and posterior neurovascular bundles are at risk without careful clamp placement. We describe our preferred technique of percutaneous clamp reduction for distal spiral tibial fractures with a distal posterolateral fracture spike, with care to protect the adjacent neurovascular structures. We also investigated the relationship between these neurovascular structures and the site of common percutaneous clamp placement. Preoperative CT images of surgically managed patients who sustained this specific common fracture pattern (distal third spiral diaphyseal tibia fracture with a posterolateral fragment) were retrospectively reviewed. On CT, we extrapolated the ideal virtual clamp site on the posterolateral fracture fragment to facilitate reduction. The average distance of this clamp position from the anterior neurovascular bundle was 14 mm (SD= 7.6), with a range of 6 mm to 32 mm. The average distance of the clamp site from the posterior neurovascular bundle was 19 mm (SD= 6.1), with a range of 11 mm to 30 mm. In 31% of patients, the distal fragment's apex extended anterior to the interosseous membrane, and in 69% the apex was posterior to the interosseous membrane. We also describe our preferred surgical technique with percutaneous clamping and tibial nailing, which involves sliding the posterolateral tine of the percutaneous clamp along the lateral tibial cortex to prevent neurovascular bundle injury.

  View details for PubMedID 29905623

• Pediatric Supracondylar Humerus Fractures: Does After-Hours Treatment Influence Outcomes? Journal of orthopaedic trauma Paci, G. M., Tileston, K. R., Vorhies, J. S., Bishop, J. A. 2018; 32 (6): e215–e220

  Abstract

  To compare the outcomes of pediatric supracondylar humerus fractures treated during daytime hours to those treated after-hours.Retrospective.Academic Level I trauma center.Two hundred ninety-eight pediatric patients treated with surgical reduction and fixation of closed supracondylar fractures were included.Seventy-seven patients underwent surgery during daytime hours (06:00-15:59 on weekdays). One hundred eighty-six patients underwent surgery after-hours (16:00-05:59 on weekdays and any surgery on weekends or holidays).Surgeon subspecialty, operative duration, and radiographic and clinical outcomes, including range of motion and carrying angle, were extracted from the patient medical records.There were no patient-related demographic differences between the daytime hours and after-hours groups. Daytime surgery was more likely to be performed by a pediatric orthopaedic surgeon than after-hours surgery. Fractures treated after-hours had more severe injury patterns. After-hours surgery was not independently associated with rate of open reduction, operative times, complications, achievement of functional range of motion, or radiographic alignment. A late-night surgery subgroup analysis demonstrated an increased rate of malunion in patients undergoing surgery between the hours of 23:00 and 05:59.There is no difference in the operative duration or outcomes after surgical treatment of pediatric supracondylar humerus fractures performed after-hours when compared with daytime surgery. However, late-night surgery performed between 23:00 and 05:59 may be associated with a higher rate of malunion. Surgeons can use these data to make better-informed decisions about the timing of surgery in this patient population.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for PubMedID 29432316

• Bilateral Sacral Ala Fractures Are Strongly Associated With Lumbopelvic Instability JOURNAL OF ORTHOPAEDIC TRAUMA Bishop, J. A., Dangelmajer, S., Corcoran-Schwartz, I., Gardner, M. J., Routt, M., Castillo, T. N. 2017; 31 (12): 636–39

  View details for DOI 10.1097/BOT.0000000000000972

  View details for Web of Science ID 000416625900013

• Bilateral Sacral Ala Fractures Are Strongly Associated With Lumbopelvic Instability. Journal of orthopaedic trauma Bishop, J. A., Dangelmajer, S., Corcoran-Schwartz, I., Gardner, M. J., Routt, M. L., Castillo, T. N. 2017; 31 (12): 636-639

  Abstract

  To quantify the incidence of lumbopelvic instability in the setting of unilateral and bilateral sacral fractures and assess whether the presence of bilateral sacral fractures on axial imaging is a useful screening test for lumbopelvic instability.Retrospective case series.Level I trauma center at an academic medical center.A hospital database was used to identify patients diagnosed with a sacral fracture by The International Classification of Diseases, Ninth Revision (ICD-9) code from 2000 to 2014.Axial cross-sectional imaging was reviewed to confirm the presence of unilateral or bilateral sacral ala fractures. Sagittal reconstructions were scrutinized for a transverse fracture line separating the lumbar spine from the pelvis, which was used to define lumbopelvic instability.The Roy-Camille classification system was applied to all identified cases of lumbopelvic instability.One thousand five hundred twenty-six patients were diagnosed with sacral fractures by the ICD-9 code. Four hundred ninety had adequate axial and sagittal cross-sectional imaging. Four hundred forty-three of these patients had unilateral sacral ala fractures, and none of these were associated with lumbopelvic instability. Forty-seven patients had bilateral sacral ala fractures, and 41 of these (87%) had a transverse component indicating some degree of lumbopelvic instability. The presence of bilateral sacral fractures was 100% sensitive and 99% specific for lumbopelvic instability. Among fractures with lumbopelvic instability, 27 (66%) were Roy-Camille type 1, 11 (27%) were type 2, and 3 (7%) were type 3.Bilateral sacral ala fractures are strongly associated with lumbopelvic instability and can be used as a very sensitive and specific screening tool. All patients with bilateral sacral fractures on axial computed tomography or magnetic resonance imaging should have close assessment of the sagittal plane images to evaluate for this pathology.Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000000972

  View details for PubMedID 29189523

• Are factor Xa inhibitors effective thromboprophylaxis following hip fracture surgery?: A large national database study INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED Campbell, S. T., Bala, A., Jiang, S. Y., Gardner, M. J., Bishop, J. A. 2017; 48 (12): 2768–72

  View details for DOI 10.1016/j.injury.2017.10.044

  View details for Web of Science ID 000418074900023

• Are factor Xa inhibitors effective thromboprophylaxis following hip fracture surgery?: A large national database study. Injury Campbell, S. T., Bala, A., Jiang, S. Y., Gardner, M. J., Bishop, J. A. 2017

  Abstract

  INTRODUCTION: The purpose of this study was to evaluate the effectiveness of Factor Xa inhibitors (XaI) for thromboprophylaxis following hip fracture surgery in a large cohort of patients, and compare XaI against warfarin and enoxaparin.METHODS: Patients undergoing hip fracture surgery from 2007 to 2015 were identified in a large claims database. Patients prescribed warfarin, XaI, or enoxaparin within 2 weeks of surgery were identified and grouped into cohorts. Medical comorbidities and complication incidences, including deep venous thrombosis (DVT), pulmonary embolism (PE), and bleeding complications were calculated. Chi-square analysis was performed and adjusted residuals calculated to determine significant differences.RESULTS: DVT rates were significantly different between groups at thirty days only (5.03% warfarin, 2.91% XaI, 3.48% enoxaparin, p=0.047). PE rates were significantly different at all time points; enoxaparin had the lowest rates. There were no differences in the rates of other complications.DISCUSSION: XaI are an option for thromboprophylaxis in hip fracture patients, although their possible decreased effectiveness against PE compared to enoxaparin should be considered.CONCLUSIONS: This study compares the effectiveness of Factor Xa inhibitors to warfarin and enoxaparin for hip fracture patients, using a large national database. In this study, Factor Xa inhibitors had similar effectiveness for DVT prophylaxis compared to these agents.

  View details for PubMedID 29102371

• Disparities in Total Hip Arthroplasty Versus Hemiarthroplasty in the Management of Geriatric Femoral Neck Fractures GERIATRIC ORTHOPAEDIC SURGERY & REHABILITATION Dangelmajer, S., Yang, A., Githens, M., Harris, A. S., Bishop, J. A. 2017; 8 (3): 155–60

  Abstract

  Recent clinical evidence suggests that total hip arthroplasty (THA) provides improved clinical outcomes as compared to hemiarthroplasty (HA) for displaced femoral neck fractures in elderly individuals. However, THA is still utilized relatively infrequently. Few studies have evaluated the factors affecting utilization and the role socioeconomics plays in THA versus HA.In the United States, the National Inpatient Sample (NIS) database was used to identify patients treated surgically for femoral neck fracture, between 2009 and 2010. Patients were identified using International Classification of Diseases, Ninth Revision, codes for closed, transcervical femoral neck fractures and closed fractures at unspecified parts of the femoral neck. All candidate predictors of THA versus HA were entered into a multilevel mixed-effect regression model.Older patient age, being Asian or Pacific Islander, and having Medicaid payer status were all associated with lower odds of receiving THA. Patients with private insurance including Health Maintenance organization (HMO) had higher odds of THA as did patients with other insurance. Odds of THA were significantly lower among patients in teaching hospitals and higher at hospitals with greater THA volume.Ethnicity, payer status, hospital size, and institutional THA volume were all associated with the utilization of THA versus HA in the treatment of geriatric femoral neck fractures.Level III Retrospective Cohort study.

  View details for PubMedID 28835872

  View details for PubMedCentralID PMC5557198

• Continuous Femoral Nerve Catheters Decrease Opioid-Related Side Effects and Increase Home Disposition Rates Among Geriatric Hip Fracture Patients. Journal of orthopaedic trauma Arsoy, D., Gardner, M. J., Amanatullah, D. F., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Bishop, J. A. 2017; 31 (6): e186-e189

  Abstract

  To evaluate the effect of continuous femoral nerve catheter (CFNC) for postoperative pain control in geriatric proximal femur fractures compared with standard analgesia (SA) treatment.Retrospective comparative study.Academic Level 1 trauma center.We retrospectively identified 265 consecutive geriatric hip fracture patients who underwent surgical treatment.One hundred forty-nine patients were treated with standard analgesia without nerve catheter whereas 116 patients received an indwelling CFNC.Daily average preoperative and postoperative pain scores, daily morphine equivalent consumption, opioid-related side effects and discharge disposition.Patients with CFNC patients reported lower average pain scores preoperatively (1.9 ± 1.7 for CFNC vs. 4.7 ± 2 for SA; P < 0.0001), on postoperative day 1 (1.5 ± 1.6 for CFNC vs. 3 ± 1.7 for SA; P < 0.0001) and postoperative day 2 (1.2 ± 1.5 for CFNC vs. 2.6 ± 2.1 for SA; P < 0.0001). CFNC group consumed 39% less morphine equivalents on postoperative day 1 (4.4 ± 5.8 mg for CFNC vs. 7.2 ± 10.8 mg for SA; P = 0.005) and 50% less morphine equivalent on postoperative day 2 (3.4 ± 4.4 mg for CFNC vs. 6.8 ± 13 mg for SA; P = 0.105). Patients with CFNC had a lower rate of opioid-related side effects compared with patients with SA (27.5% for CFNC vs. 47% for SA; P = 0.001). More patients with CFNC were discharged to home with or without health services than patients with SA (15% for CFNC vs. 6% for SA; P = 0.023).Continuous femoral nerve catheter decreased daily average patient-reported pain scores, narcotic consumption while decreasing the rate of opioid-related side effects. Patients with CFNC were discharged to home more frequently.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000000854

  View details for PubMedID 28538458

• Buttress Plating versus Anterior-to-Posterior Lag Screws for Fixation of the Posterior Malleolus: A Biomechanical Study. Journal of orthopaedic trauma Bennett, C., Behn, A., Daoud, A., Nork, S., Sangeorzan, B., Dikos, G., Bishop, J. 2016: -?

  Abstract

  The preferred method of fixation for posterior malleolus fractures remains controversial, and practices vary widely among surgeons. The purpose of this study was to compare anterior-to-posterior (AP) lag screws with posterior buttress plating for fixation of posterior malleolus fractures in a human cadaveric model.Posterior malleolus fractures involving 30% of the distal tibial articular surface were created in 7 pairs of fresh frozen cadaveric ankles. One specimen in each pair was randomly assigned to fixation with either 2 AP lag screws or a one-third tubular buttress plate without supplemental lag screws. Each specimen was then subjected to cyclic loading from 0% to 50% of body weight for 5000 cycles followed by loading to failure. Outcome measures included permanent axial displacement during each test cycle (axial displacement at no load), peak axial displacement during each test cycle (axial displacement at 50% body weight), load at 1-mm axial displacement, ultimate load, and axial displacement at ultimate load.The buttress plate group showed significantly less peak axial displacement at all time points during cyclic loading. Permanent axial displacement was significantly less in the buttress plate group beginning at cycle 200. There were no significant differences between the 2 groups during load-to-failure testing.Posterior malleolus fractures treated with posterior buttress plating showed significantly less displacement during cyclical loading compared with fractures fixed with AP lag screws. Surgeons should consider these findings when selecting a fixation strategy for these common fractures. Further research is warranted to investigate the clinical implications of these biomechanical findings.

  View details for PubMedID 27755282

• Are Early Career Orthopaedic Trauma Surgeons Performing Less Complex Trauma Surgery? JOURNAL OF ORTHOPAEDIC TRAUMA Gire, J. D., Gardner, M. J., Harris, A. H., Bishop, J. A. 2016; 30 (10): 525-529

  Abstract

  There has recently been an increase in the number of fellowship trained orthopaedic trauma surgeons, raising concerns that the surgical experience of early career surgeons may be diluted. We sought to evaluate the change in complex trauma case volume of orthopaedic trauma surgeons sitting for Part II of the American Board of Orthopaedic Surgeons certification examination.The case log data from all surgeons taking Part II of the American Board of Orthopaedic Surgeons examination over a 13-year period (2003-2015) was evaluated. Any surgeon who examined in the trauma subspecialty was included. We defined pelvis, acetabulum, and periarticular fracture surgeries as complex trauma procedures and evaluated changes in case volume over time.We included 468 candidates who examined as trauma subspecialists and performed 90,261 procedures. The number of candidates testing in trauma per year ranged from 15 to 65 and increased significantly over time [β = 4.05 (0.37), P < 0.0001]. Their case volume was stable over time [β = -1.7 (1.1), P = 0.16]. The number of acetabulum fracture surgeries performed decreased significantly over time from a mean of 10.1 cases in 2003 to 5.2 cases in 2015 [β = -0.34 (0.08), P = 0.0015]. There was no significant change in the number of pelvic fracture surgeries [β = -0.1 (0.1), P = 0.285]. There was a trend toward less periarticular fracture surgeries [β = -0.3 (0.1), P = 0.072].Although pelvic ring and periarticular fracture case volume have remained stable, early career surgeons have experienced a significant decrease in acetabular fracture case volume. The implications of this decreased surgical experience warrant careful consideration as the orthopaedic trauma workforce evolves.

  View details for DOI 10.1097/BOT.0000000000000653

  View details for Web of Science ID 000384467000009

• Are Early Career Orthopaedic Trauma Surgeons Performing Less Complex Trauma Surgery? Journal of orthopaedic trauma Gire, J. D., Gardner, M. J., Harris, A. H., Bishop, J. A. 2016; 30 (10): 525-529

  Abstract

  There has recently been an increase in the number of fellowship trained orthopaedic trauma surgeons, raising concerns that the surgical experience of early career surgeons may be diluted. We sought to evaluate the change in complex trauma case volume of orthopaedic trauma surgeons sitting for Part II of the American Board of Orthopaedic Surgeons certification examination.The case log data from all surgeons taking Part II of the American Board of Orthopaedic Surgeons examination over a 13-year period (2003-2015) was evaluated. Any surgeon who examined in the trauma subspecialty was included. We defined pelvis, acetabulum, and periarticular fracture surgeries as complex trauma procedures and evaluated changes in case volume over time.We included 468 candidates who examined as trauma subspecialists and performed 90,261 procedures. The number of candidates testing in trauma per year ranged from 15 to 65 and increased significantly over time [β = 4.05 (0.37), P < 0.0001]. Their case volume was stable over time [β = -1.7 (1.1), P = 0.16]. The number of acetabulum fracture surgeries performed decreased significantly over time from a mean of 10.1 cases in 2003 to 5.2 cases in 2015 [β = -0.34 (0.08), P = 0.0015]. There was no significant change in the number of pelvic fracture surgeries [β = -0.1 (0.1), P = 0.285]. There was a trend toward less periarticular fracture surgeries [β = -0.3 (0.1), P = 0.072].Although pelvic ring and periarticular fracture case volume have remained stable, early career surgeons have experienced a significant decrease in acetabular fracture case volume. The implications of this decreased surgical experience warrant careful consideration as the orthopaedic trauma workforce evolves.

  View details for DOI 10.1097/BOT.0000000000000653

  View details for PubMedID 27668503

• Admission Through the Emergency Department Is an Independent Risk Factor for Lower Satisfaction With Physician Performance Among Orthopaedic Surgery Patients: A Multicenter Study JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Vorhies, J. S., Weaver, M. J., Bishop, J. A. 2016; 24 (10): 735-742

  Abstract

  Patient experience data are increasingly used to guide performance improvement and to determine physician and hospital reimbursement. We studied the relationship between emergency department (ED) admission and patient satisfaction with physicians' performance, and identified other associated predictors.We evaluated 6,524 inpatient Press Ganey patient experience surveys from two academic level I trauma centers over 5 years. We stratified patients by ED admission or other admission and compared the proportions of patients in each group who were satisfied with physician performance. We used logistic regression to control for demographic differences and characteristics of hospitalizations.Among patients admitted through the ED, 85.18% were satisfied, compared with 89.44% of patients admitted through other pathways (P < 0.001). Admission through the ED predicted decreased satisfaction, with an odds ratio of 0.67 (P = 0.032) after controls were applied through logistic regression.Admission through the ED is an independent risk factor for lower satisfaction with physician performance. Understanding the determinants of patient satisfaction will help improve physician-patient interactions and guide quality improvement and value-based reimbursement initiatives.This retrospective survey-based analysis of satisfaction does not fall clearly under any of the Journal's established categories of level of evidence. The most closely aligned choice would be Level III Prognostic.

  View details for DOI 10.5435/JAAOS-D-16-00084

  View details for Web of Science ID 000385408400010

  View details for PubMedID 27579815

• The Effect of Transiliac-Transsacral Screw Fixation for Pelvic Ring Injuries on the Uninjured Sacroiliac Joint JOURNAL OF ORTHOPAEDIC TRAUMA Mardam-Bey, S. W., Beebe, M. J., Black, J. C., Chang, E. Y., Kubiak, E. N., Bishop, J. A., McAndrew, C. M., Ricci, W. M., Gardner, M. J. 2016; 30 (9): 463-468

  Abstract

  To evaluate the functional outcomes and pain in patients with unilateral posterior pelvic ring injuries treated with transiliac-transsacral screw fixation compared with unilateral iliosacral screw fixation.Retrospective comparative study.Three academic level 1 trauma centers.From a group of 866 patients with pelvic ring injuries treated surgically, 86 patients with unilateral pelvic ring injuries treated with transiliac-transsacral screws and 97 patients treated with unilateral iliosacral screws were identified. Thirty-six patients treated with transiliac-transsacral fixation and 26 patients treated with unilateral iliosacral screws met the inclusion criteria and participated.Patients were treated surgically for unstable pelvic ring injuries with either unilateral iliosacral screws or transiliac-transsacral screws at the discretion of the treating surgeon.Majeed Pelvic Score.There was no significant difference in Majeed Pelvic Scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws (72.8 ± 23.7 vs. 70.4 ± 19.0, P = 0.66). There was no difference in side-specific Numeric Rating Scale pain scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws on the injured side (2.5 ± 3.1 vs. 2.0 ± 2.4, P = 0.46) or the uninjured side (1.7 ± 2.8 vs. 0.8 ± 1.7, P = 0.12). Mean follow-up was greater than 3 years with no difference between the groups (mean 1270 vs. 1242 days, P = 0.84).Treatment of unilateral pelvic ring injuries with transiliac-transsacral screws does not adversely affect or improve patient outcomes or subjective pain scores when compared with those treated with unilateral iliosacral screws.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000000622

  View details for PubMedID 27144820

• Cancellous Screws Are Biomechanically Superior to Cortical Screws in Metaphyseal Bone ORTHOPEDICS Wang, T., Boone, C., Behn, A. W., Ledesma, J. B., Bishop, J. A. 2016; 39 (5): E828-E832

  Abstract

  Cancellous screws are designed to optimize fixation in metaphyseal bone environments; however, certain clinical situations may require the substitution of cortical screws for use in cancellous bone, such as anatomic constraints, fragment size, or available instrumentation. This study compares the biomechanical properties of commercially available cortical and cancellous screw designs in a synthetic model representing various bone densities. Commercially available, fully threaded, 4.0-mm outer-diameter cortical and cancellous screws were tested in terms of pullout strength and maximum insertion torque in standard-density and osteoporotic cancellous bone models. Pullout strength and maximum insertion torque were both found to be greater for cancellous screws than cortical screws in all synthetic densities tested. The magnitude of difference in pullout strength between cortical and cancellous screws increased with decreasing synthetic bone density. Screw displacement prior to failure and total energy absorbed during pullout strength testing were also significantly greater for cancellous screws in osteoporotic models. Stiffness was greater for cancellous screws in standard and osteoporotic models. Cancellous screws have biomechanical advantages over cortical screws when used in metaphyseal bone, implying the ability to both achieve greater compression and resist displacement at the screw-plate interface. Surgeons should preferentially use cancellous over cortical screws in metaphyseal environments where cortical bone is insufficient for fixation. [Orthopedics.2016; 39(5):e828-e832.].

  View details for DOI 10.3928/01477447-20160509-01

  View details for Web of Science ID 000393107500003

  View details for PubMedID 27172369

• Evaluation of Contemporary Trends in Femoral Neck Fracture Management Reveals Discrepancies in Treatment. Geriatric orthopaedic surgery & rehabilitation Bishop, J., Yang, A., Githens, M., Sox, A. H. 2016; 7 (3): 135-141

  Abstract

  Recent evidence supports total hip arthroplasty (THA) as compared to hemiarthroplasty (HA) for the management of displaced femoral neck fractures in a significant subset of elderly patients. The purpose of this study was to examine trends in femoral neck fracture management over the last 12 years.Using the National Inpatient Sample database, we identified patients treated for femoral neck fractures between 1998 and 2010 with THA, HA, or internal fixation (IF). We examined treatment trends and demographic variables including patient age, gender, socioeconomic status, and payer and hospital characteristics.We identified 362 127 femoral neck fracture patients treated between 1998 and 2010. Overall, there were statistically significant increases in rates of THA and HA, whereas rates of IF decreased. Total hip arthroplasty varied based on patient age, with significant increases occurring in age-groups 0 to 49 years, 50 to 59 years, 60 to 69 years, and 70 to 79 years. Utilization of THA varied significantly based on socioeconomic status and race. Patient sex, urban versus rural hospital location, and teaching versus nonteaching hospital status were not related to rates of THA.Rates of THA for femoral neck fractures increased between 1998 and 2010 in patients younger than 80 years, suggesting that surgeons are responding to clinical evidence supporting THA for the treatment of elderly femoral neck fractures. This is the first study to demonstrate this change and expose disparities in practice patterns over time in response to this evidence in the United States. Further research is indicated to explore the effect of socioeconomic status and race on femoral neck fracture management.

  View details for DOI 10.1177/2151458516658328

  View details for PubMedID 27551571

  View details for PubMedCentralID PMC4976740

• The Effects of Limb Elevation on Muscle Oxygen Saturation: A Near-Infrared Spectroscopy Study in Humans PM&R Palanca, A. A., Yang, A., Bishop, J. A. 2016; 8 (3): 221-224

  Abstract

  Orthopaedic and rehabilitation physicians often instruct patients to elevate a traumatized or postoperative lower extremity. Elevation is thought to improve patient comfort, as well as decrease swelling, wound complications, and the risk of compartment syndrome. Elevating a limb with increased compartment pressures, however, has been shown to reduce perfusion pressure and contribute to tissue ischemia. This investigation aims to advance our understanding of the tissue effects of limb elevation using a healthy patient model.To quantify the effects of elevation, experimentally induced ischemia, and immobilization on muscle oxygen saturation in the human leg using near-infrared spectroscopy (NIRS).Experimental crossover study.Orthopaedic Surgery research laboratory, Stanford Hospitals & Clinics.Twenty-six healthy volunteers.Using transcutaneous sensors, we measured muscle oxygen saturation of the anterior compartment of the left (control) leg at 0, 15, and 30 cm of elevation relative to the heart using NIRS. A standardized short leg splint and a thigh tourniquet inflated to 50 mmHg were then applied to the right (experimental) leg to simulate a traumatized state. NIRS measurements were then repeated, again at 0, 15, and 30 cm of elevation. Muscle oxygen saturation values at various degrees of elevation of the control and experimental limb were then compared and analyzed by the use of a crossover study design and mixed-effects regression.Muscle oxygen saturation at varying levels of elevation in both the (1) control leg and (2) experimental leg in a simulated traumatic state.Male (18) males and female (8) patients between 22 and 62 years of age (mean 29.8 years) were enrolled. Mean regional muscle oxygen saturation (rSO2) of the control limbs at 0, 15 and, 30 cm of elevation were 74.2%, 72.5%, and 70.6%, respectively, whereas mean rSO2 of the experimental limbs were 66.3%, 65.0%, and 63.3%. A statistically significant decrease of rSO2 was observed (mean 7.65%) in the experimental limbs compared with the control limbs. As elevation increased, there was a statistically significant decrease in rSO2 of 0.12% per centimeter of elevation. Elevation did not decrease the rSO2 in the experimental limb to a greater degree than in the control limb.Increasing levels of elevation in a human limb results in progressively compromised muscle oxygen saturation as measured by NIR.

  View details for DOI 10.1016/j.pmrj.2015.07.015

  View details for Web of Science ID 000372434900004

• Intraoperative Distal Femoral Fine Wire Traction to Facilitate Intramedullary Nailing of the Femur ORTHOPEDICS Githens, M., Alton, T. B., Firoozabadi, R., Bishop, J. A. 2016; 39 (2): E380–E385

  Abstract

  Many techniques have been employed to facilitate intramedullary nailing of femur fractures. Maintaining limb length during the operation can be difficult. The authors describe the use of distal femoral fine wire skeletal traction as a technique to maintain reduction while allowing intramedullary nailing of femur fractures. This technique is safe, is effective, and negates the need for a fracture table or an assistant.

  View details for DOI 10.3928/01477447-20160201-07

  View details for Web of Science ID 000377511000034

  View details for PubMedID 26881460

• The Effects of Limb Elevation on Muscle Oxygen Saturation: A Near-Infrared Spectroscopy Study in Humans. PM & R : the journal of injury, function, and rehabilitation Palanca, A. A., Yang, A., Bishop, J. A. 2016; 8 (3): 221-224

  Abstract

  Orthopaedic and rehabilitation physicians often instruct patients to elevate a traumatized or postoperative lower extremity. Elevation is thought to improve patient comfort, as well as decrease swelling, wound complications, and the risk of compartment syndrome. Elevating a limb with increased compartment pressures, however, has been shown to reduce perfusion pressure and contribute to tissue ischemia. This investigation aims to advance our understanding of the tissue effects of limb elevation using a healthy patient model.To quantify the effects of elevation, experimentally induced ischemia, and immobilization on muscle oxygen saturation in the human leg using near-infrared spectroscopy (NIRS).Experimental crossover study.Orthopaedic Surgery research laboratory, Stanford Hospitals & Clinics.Twenty-six healthy volunteers.Using transcutaneous sensors, we measured muscle oxygen saturation of the anterior compartment of the left (control) leg at 0, 15, and 30 cm of elevation relative to the heart using NIRS. A standardized short leg splint and a thigh tourniquet inflated to 50 mmHg were then applied to the right (experimental) leg to simulate a traumatized state. NIRS measurements were then repeated, again at 0, 15, and 30 cm of elevation. Muscle oxygen saturation values at various degrees of elevation of the control and experimental limb were then compared and analyzed by the use of a crossover study design and mixed-effects regression.Muscle oxygen saturation at varying levels of elevation in both the (1) control leg and (2) experimental leg in a simulated traumatic state.Male (18) males and female (8) patients between 22 and 62 years of age (mean 29.8 years) were enrolled. Mean regional muscle oxygen saturation (rSO2) of the control limbs at 0, 15 and, 30 cm of elevation were 74.2%, 72.5%, and 70.6%, respectively, whereas mean rSO2 of the experimental limbs were 66.3%, 65.0%, and 63.3%. A statistically significant decrease of rSO2 was observed (mean 7.65%) in the experimental limbs compared with the control limbs. As elevation increased, there was a statistically significant decrease in rSO2 of 0.12% per centimeter of elevation. Elevation did not decrease the rSO2 in the experimental limb to a greater degree than in the control limb.Increasing levels of elevation in a human limb results in progressively compromised muscle oxygen saturation as measured by NIR.

  View details for DOI 10.1016/j.pmrj.2015.07.015

  View details for PubMedID 26261022

• Operative Versus Nonoperative Treatment of Jones Fractures: A Decision Analysis Model. American journal of orthopedics (Belle Mead, N.J.) Bishop, J. A., Braun, H. J., Hunt, K. J. 2016; 45 (3): E69-76

  Abstract

  Optimal management of metadiaphyseal fifth metatarsal fractures (Jones fractures) remains controversial. Decision analysis can optimize clinical decision-making based on available evidence and patient preferences. We conducted a study to establish the determinants of decision-making and to determine the optimal treatment strategy for Jones fractures using a decision analysis model. Probabilities for potential outcomes of operative and nonoperative treatment of Jones fractures were determined from a review of the literature. Patient preferences for outcomes were obtained by questionnaire completed by 32 healthy adults with no history of foot fracture. Derived values were used in the model as a measure of utility. A decision tree was constructed, and fold-back and sensitivity analyses were performed to determine optimal treatment. Nonoperative treatment was associated with a value of 7.74, and operative treatment with an intramedullary screw was associated with a value of 7.88 given the outcome probabilities and utilities studied, making operative treatment the optimal strategy. When parameters were varied, nonoperative treatment was favored when the likelihood of healing with nonoperative treatment rose above 82% and when the probability of healing after surgery fell below 92%. In this decision analysis model, operative fixation is the preferred management strategy for Jones fractures.

  View details for PubMedID 26991586

• Arthroscopic Reduction and Internal Fixation of an Inferior Glenoid Fracture With Scapular Extension (Ideberg V). Arthroscopy techniques Tuman, J. M., Bishop, J. A., Abrams, G. D. 2015; 4 (6): e869-72

  Abstract

  Arthroscopic reduction and internal fixation of glenoid fractures have been well described, especially for glenoid rim (Bankart) fractures, as well as for scapular body fractures with extensions into the articular surface. This approach has the advantage of decreasing comorbidities associated with a standard open approach, but it can be technically challenging and may not be amenable to all fracture patterns. Arthroscopic fixation of scapular fractures incorporating a transverse pattern along the inferior aspect of the glenoid is particularly challenging because of difficulty in accessing this space. We detail the use of a posteroinferior arthroscopic portal for fracture reduction and hardware placement in a scapular fracture with inferior glenoid involvement.

  View details for DOI 10.1016/j.eats.2015.08.012

  View details for PubMedID 27284526

  View details for PubMedCentralID PMC4886700

• Surgical Treatment of Posterior Tibial Plateau Fractures OPERATIVE TECHNIQUES IN ORTHOPAEDICS Bishop, J., Githens, M. 2015; 25 (4): 242–47

  View details for DOI 10.1053/j.oto.2015.08.004

  View details for Web of Science ID 000437584700004

• Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States? A Survey of Orthopaedic Surgeons. Clinical orthopaedics and related research Niu, E., Yang, A., Harris, A. H., Bishop, J. 2015; 473 (11): 3647-3655

  Abstract

  The best treatment for intertrochanteric hip fractures is controversial. The use of cephalomedullary nails has increased, whereas use of sliding hip screws has decreased despite the lack of evidence that cephalomedullary nails are more effective. As current orthopaedic trainees receive less exposure to sliding hip screws, this may continue to perpetuate the preferential use of cephalomedullary nails, with important implications for resident education, evidence-based best practices, and healthcare cost.We asked: (1) What are the current practice patterns in surgical treatment of intertrochanteric fractures among orthopaedic surgeons? (2) Do surgical practice patterns differ based on surgeon characteristics, practice setting, and other factors? (3) What is the rationale behind these surgical practice patterns? (4) What postoperative approaches do surgeons use for intertrochanteric fractures?A web-based survey containing 20 questions was distributed to active members of the American Academy of Orthopaedic Surgeons. Three thousand seven-hundred eighty-six of 10,321 invited surgeons participated in the survey (37%), with a 97% completion rate (3687 of 3784 responded to all questions in the survey). The survey elicited information regarding surgeon demographics, preferred management strategies, and decision-making rationale for intertrochanteric fractures.Surgeons use cephalomedullary nails most frequently for treatment of intertrochanteric hip fractures. Sixty-eight percent primarily use cephalomedullary nails, whereas only 19% primarily use sliding hip screws, and the remaining 13% use cephalomedullary nails and sliding hip screws with equal frequency. The cephalomedullary nail was the dominant approach regardless of experience level or practice setting. Surgeons who practiced in a nonacademic setting (71% versus 58%; p < 0.001), did not supervise residents (71% versus 61%; p < 0.001), or treated more than five intertrochanteric fractures a month (78% versus 67%; p < 0.001) were more likely to use primarily cephalomedullary nails. Of the surgeons who used only cephalomedullary nails, ease of surgical technique (58%) was cited as the primary reason, whereas surgeons who used only sliding hip screws cite familiarity (44%) and improved outcomes (37%) as their primary reasons. Of those who use only short cephalomedullary nails, ease of technique (59%) was most frequently cited. Postoperatively, 67% allow the patient to bear weight as tolerated. Nearly all respondents (99.5%) use postoperative chemical thromboprophylaxis.Despite that either sliding hip screw or cephalomedullary nail fixation are associated with equivalent outcomes for most intertrochanteric femur fractures, the cephalomedullary nail has emerged as the preferred construct, with the majority of surgeons believing that a cephalomedullary nail is easier to use, associated with improved outcomes, or is biomechanically superior to a sliding hip screw. The difference between what is evidence-based and what is done in clinical practice may be attributed to several factors, including financial considerations, educational experience, or inability of our current outcomes measures to reflect the experiences of surgeons. The educators, researchers, and policymakers among us must work harder to better define the roles of sliding hip screws and cephalomedullary nails and ensure that the increasing population with hip fractures receives high-quality and economically responsible care.Level V, therapeutic study.

  View details for DOI 10.1007/s11999-015-4469-5

  View details for PubMedID 26208608

  View details for PubMedCentralID PMC4586189

• Conventional versus virtual radiographs of the injured pelvis and acetabulum SKELETAL RADIOLOGY Bishop, J. A., Rao, A. J., Pouliot, M. A., Beaulieu, C., Bellino, M. 2015; 44 (9): 1303-1308

  Abstract

  Evaluation of the fractured pelvis or acetabulum requires both standard radiographic evaluation as well as computed tomography (CT) imaging. The standard anterior-posterior (AP), Judet, and inlet and outlet views can now be simulated using data acquired during CT, decreasing patient discomfort, radiation exposure, and cost to the healthcare system. The purpose of this study is to compare the image quality of conventional radiographic views of the traumatized pelvis to virtual radiographs created from pelvic CT scans.Five patients with acetabular fractures and ten patients with pelvic ring injuries were identified using the orthopedic trauma database at our institution. These fractures were evaluated with both conventional radiographs as well as virtual radiographs generated from a CT scan. A web-based survey was created to query overall image quality and visibility of relevant anatomic structures. This survey was then administered to members of the Orthopaedic Trauma Association (OTA).Ninety-seven surgeons completed the acetabular fracture survey and 87 completed the pelvic fracture survey. Overall image quality was judged to be statistically superior for the virtual as compared to conventional images for acetabular fractures (3.15 vs. 2.98, p = 0.02), as well as pelvic ring injuries (2.21 vs. 1.45, p = 0.0001). Visibility ratings for each anatomic landmark were statistically superior with virtual images as well.Virtual radiographs of pelvic and acetabular fractures offer superior image quality, improved comfort, decreased radiation exposure, and a more cost-effective alternative to conventional radiographs.

  View details for DOI 10.1007/s00256-015-2171-z

  View details for Web of Science ID 000358329600008

• The Inadequacy of Pediatric Fracture Care Information in Emergency Medicine and Pediatric Literature and Online Resources. Journal of pediatric orthopedics Tileston, K., Bishop, J. A. 2015; 35 (7): 769-773

  Abstract

  Emergency medicine and pediatric physicians often provide initial pediatric fracture care. Therefore, basic knowledge of the various treatment options is essential. The purpose of this study was to determine the accuracy of information commonly available to these physicians in textbooks and online regarding the management of pediatric supracondylar humerus and femoral shaft fractures.The American Academy of Orthopaedic Surgeons Clinical Practice Guidelines for pediatric supracondylar humerus and femoral shaft fractures were used to assess the content of top selling emergency medicine and pediatric textbooks as well as the top returned Web sites after a Google search. Only guidelines that addressed initial patient management were included. Information provided in the texts was graded as consistent, inconsistent, or omitted.Five emergency medicine textbooks, 4 pediatric textbooks, and 5 Web sites were assessed. Overall, these resources contained a mean 31.6% (SD=32.5) complete and correct information, whereas 3.6 % of the information was incorrect or inconsistent, and 64.8% was omitted. Emergency medicine textbooks had a mean of 34.3% (SD=28.3) correct and complete recommendations, 5.7% incorrect or incomplete recommendations, and 60% omissions. Pediatric textbooks were poor in addressing any of the American Academy of Orthopaedic Surgeons guidelines with an overall mean of 7.14% (SD=18.9) complete and correct recommendations, a single incorrect/incomplete recommendation, and 91.1% omissions. Online resources had a mean of 48.6% (SD=33.1) complete and correct recommendations, 5.72% incomplete or incorrect recommendations, and 45.7% omissions.This study highlights important deficiencies in resources available to pediatric and emergency medicine physicians seeking information on pediatric fracture management. Information in emergency medicine and pediatric textbooks as well as online is variable, with both inaccuracies and omissions being common. This lack of high-quality information could compromise patient care. Resources should be committed to ensuring accurate and complete information is readily available to all physicians providing pediatric fracture care. In addition, orthopaedic surgeons should take an active role to ensure that nonorthopaedic textbooks and online resources contain complete and accurate information.Level IV.

  View details for DOI 10.1097/BPO.0000000000000357

  View details for PubMedID 25393570

• Anterolateral Versus Medial Plating of Distal Extra-articular Tibia Fractures: A Biomechanical Model ORTHOPEDICS Pirolo, J. M., Behn, A. W., Abrams, G. D., Bishop, J. A. 2015; 38 (9): E760-E765

  Abstract

  Both medial and anterolateral plate applications have been described for the treatment of distal tibia fractures, each with distinct advantages and disadvantages. The objective of this study was to compare the biomechanical properties of medial and anterolateral plating constructs used to stabilize simulated varus and valgus fracture patterns of the distal tibia. In 16 synthetic tibia models, a 45° oblique cut was made to model an Orthopedic Trauma Association type 43-A1.2 distal tibia fracture in either a varus or valgus injury pattern. Each fracture was then reduced and plated with a precontoured medial or anterolateral distal tibia plate. The specimens were biomechanically tested in axial and torsional loading, cyclic axial loading, and load to failure. For the varus fracture pattern, medial plating showed less fracture site displacement and rotation and was stiffer in both axial and torsional loading (P<.05). For the valgus fracture pattern, there was no statistically significant difference between medial and anterolateral plating. There were no significant differences between the 2 constructs for either fracture pattern with respect to ultimate load, displacement, or energy absorption in load to failure testing. When used to stabilize varus fracture patterns, medial plates showed superior biomechanical performance compared with anterolateral plates. In this application, the medial plates functioned in anti-glide mode. For valgus fracture patterns, no biomechanical differences between anterolateral and medial plating were observed. In clinical practice, surgeons should take this biomechanical evidence into account when devising a treatment strategy for fixation of distal tibia fractures.

  View details for DOI 10.3928/01477447-20150902-52

  View details for Web of Science ID 000365393600003

  View details for PubMedID 26375532

• Conventional versus virtual radiographs of the injured pelvis and acetabulum. Skeletal radiology Bishop, J. A., Rao, A. J., Pouliot, M. A., Beaulieu, C., Bellino, M. 2015; 44 (9): 1303-8

  Abstract

  Evaluation of the fractured pelvis or acetabulum requires both standard radiographic evaluation as well as computed tomography (CT) imaging. The standard anterior-posterior (AP), Judet, and inlet and outlet views can now be simulated using data acquired during CT, decreasing patient discomfort, radiation exposure, and cost to the healthcare system. The purpose of this study is to compare the image quality of conventional radiographic views of the traumatized pelvis to virtual radiographs created from pelvic CT scans.Five patients with acetabular fractures and ten patients with pelvic ring injuries were identified using the orthopedic trauma database at our institution. These fractures were evaluated with both conventional radiographs as well as virtual radiographs generated from a CT scan. A web-based survey was created to query overall image quality and visibility of relevant anatomic structures. This survey was then administered to members of the Orthopaedic Trauma Association (OTA).Ninety-seven surgeons completed the acetabular fracture survey and 87 completed the pelvic fracture survey. Overall image quality was judged to be statistically superior for the virtual as compared to conventional images for acetabular fractures (3.15 vs. 2.98, p = 0.02), as well as pelvic ring injuries (2.21 vs. 1.45, p = 0.0001). Visibility ratings for each anatomic landmark were statistically superior with virtual images as well.Virtual radiographs of pelvic and acetabular fractures offer superior image quality, improved comfort, decreased radiation exposure, and a more cost-effective alternative to conventional radiographs.

  View details for DOI 10.1007/s00256-015-2171-z

  View details for PubMedID 26009268

• Surgical wound closure in orthopaedic surgery: operative techniques and adjunctive treatment modalities CURRENT ORTHOPAEDIC PRACTICE Kang, J. R., Friedrich, J. B., Hanel, D. P., Barei, D. P., Bishop, J. A. 2015; 26 (4): 403–10

  View details for DOI 10.1097/BCO.0000000000000257

  View details for Web of Science ID 000217846000015

• The prevalence of sacroiliac joint degeneration in asymptomatic adults. journal of bone and joint surgery. American volume Eno, J. T., Boone, C. R., Bellino, M. J., Bishop, J. A. 2015; 97 (11): 932-936

  Abstract

  Degenerative changes of the sacroiliac joint have been implicated as a cause of lower back pain in adults. The purpose of this study was to determine the prevalence of sacroiliac joint degeneration in asymptomatic patients.Five hundred consecutive pelvic computed tomography (CT) scans, made at a tertiary-care medical center, of patients with no history of pain in the lower back or pelvic girdle were retrospectively reviewed and analyzed for degenerative changes of the sacroiliac joint. After exclusion criteria were applied, 373 CT scans (746 sacroiliac joints) were evaluated for degenerative changes. Regression analysis was used to determine the association between age and the degree of sacroiliac joint degeneration.The prevalence of sacroiliac joint degeneration was 65.1%, with substantial degeneration occurring in 30.5% of asymptomatic subjects. The prevalence steadily increased with age, with 91% of subjects in the ninth decade of life displaying degenerative changes.Radiographic evidence of sacroiliac joint degeneration is highly prevalent in the asymptomatic population and is associated with age. Caution must be exercised when attributing lower back or pelvic girdle pain to sacroiliac joint degeneration seen on imaging.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.N.01101

  View details for PubMedID 26041855

• The Prevalence of Sacroiliac Joint Degeneration in Asymptomatic Adults JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Eno, J. T., Boone, C. R., Bellino, M. J., Bishop, J. A. 2015; 97A (11): 932-936

  Abstract

  Degenerative changes of the sacroiliac joint have been implicated as a cause of lower back pain in adults. The purpose of this study was to determine the prevalence of sacroiliac joint degeneration in asymptomatic patients.Five hundred consecutive pelvic computed tomography (CT) scans, made at a tertiary-care medical center, of patients with no history of pain in the lower back or pelvic girdle were retrospectively reviewed and analyzed for degenerative changes of the sacroiliac joint. After exclusion criteria were applied, 373 CT scans (746 sacroiliac joints) were evaluated for degenerative changes. Regression analysis was used to determine the association between age and the degree of sacroiliac joint degeneration.The prevalence of sacroiliac joint degeneration was 65.1%, with substantial degeneration occurring in 30.5% of asymptomatic subjects. The prevalence steadily increased with age, with 91% of subjects in the ninth decade of life displaying degenerative changes.Radiographic evidence of sacroiliac joint degeneration is highly prevalent in the asymptomatic population and is associated with age. Caution must be exercised when attributing lower back or pelvic girdle pain to sacroiliac joint degeneration seen on imaging.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.N.01101

  View details for Web of Science ID 000363418100010

• CORR Insights ®: A dedicated research program increases the quantity and quality of orthopaedic resident publications. Clinical orthopaedics and related research Bishop, J. A. 2015; 473 (4): 1522-1523

  View details for DOI 10.1007/s11999-014-4111-y

  View details for PubMedID 25516003

  View details for PubMedCentralID PMC4353522

• Terrible Triad Elbow Fracture-Dislocation With Triceps and Flexor-Pronator Mass Avulsion ORTHOPEDICS Gajendran, V. K., Bishop, J. A. 2015; 38 (2): E143-E146

  Abstract

  Terrible triad elbow injuries, consisting of fractures of the radial head and coronoid with ulnohumeral dislocation, are challenging to treat. They require a comprehensive understanding of the complex anatomy of the elbow to effectively treat all of the pathology and create a stable, congruent joint. The authors present a case of a terrible triad injury with avulsion of the triceps and flexor-pronator mass after a low-energy fall in a young patient. Although most terrible triad fracture-dislocations can be successfully treated with coronoid fixation, radial head fixation or replacement, and repair of the lateral collateral ligament complex, this case involved a completely circumferential injury to the elbow. The coronoid and anterior capsule were disrupted anteriorly, the radial head and lateral collateral ligament complex were disrupted laterally, the triceps was disrupted posteriorly, and the flexor-pronator mass was disrupted medially. Although the authors prefer to address most terrible triad injuries through a lateral approach, they suspected a circumferential injury preoperatively and elected to use a single posterior incision to address all of the pathology conveniently. This injury required treatment of all disrupted structures, because the elbow remained unstable until the triceps and flexor-pronator mass avulsions were ultimately repaired. With any elbow fracture-dislocation, surgeons should look for evidence of additional injuries that do not fit the commonly described patterns, because they may necessitate modifications to the treatment plan. Given the relatively common complications of stiffness and instability despite modern surgical techniques, additional injuries may further compromise functional outcomes unless they are addressed properly.

  View details for DOI 10.3928/01477447-20150204-91

  View details for Web of Science ID 000352076100012

  View details for PubMedID 25665121

• Optimizing stabilization in osteoporotic ankle fractures CURRENT ORTHOPAEDIC PRACTICE Chan, J. Y., Bishop, J. A. 2015; 26 (6): 605-609

  View details for DOI 10.1097/BCO.0000000000000303

• Open Reduction and Internal Fixation Versus Total Elbow Arthroplasty for the Treatment of Geriatric Distal Humerus Fractures: A Systematic Review and Meta-Analysis JOURNAL OF ORTHOPAEDIC TRAUMA Githens, M., Yao, J., Sox, A. H., Bishop, J. 2014; 28 (8): 481-488

  Abstract

  The purpose of this systematic review and meta-analysis was to pool and analyze outcomes and complication rates in elderly patients with intraarticular distal humerus fractures being treated with either total elbow arthroplasty (TEA) or open reduction and internal fixation (ORIF) with locking plates.PubMed, Embase, and the Cochrane databases were used. The search included publications up to June 2013. Article selection was independently performed by 2 authors and disagreements were resolved by consensus.Studies meeting criteria for inclusion were observational cohort studies or randomized controlled trials evaluating functional and radiographic outcomes and complications in elderly patients treated for distal humerus fractures with either primary TEA or ORIF with locking plates. Studies with mean age <60 years, indications for TEA other than acute fracture, and those including nonlocked plates were excluded.Standardized data extraction was performed. A quality assessment tool was used to evaluate individual study methodology.Descriptive statistics for functional outcomes were reported. Meta-analysis and regression analysis were performed for complication rates.A systematic review and meta-analysis revealed that TEA and ORIF for the treatment of geriatric distal humerus fractures produced similar functional outcome scores and range of motion. Although there was a trend toward a higher rate of major complications and reoperation after ORIF, this was not statistically significant. The quality of study methodology was generally weak. Ongoing research including prospective trials and cost analysis is indicated to better define the roles of ORIF versus TEA in the management of these injuries.

  View details for Web of Science ID 000340149400019

• Open Reduction and Internal Fixation Versus Total Elbow Arthroplasty for the Treatment of Geriatric Distal Humerus Fractures: A Systematic Review and Meta-Analysis. Journal of orthopaedic trauma Githens, M., Yao, J., Sox, A. H., Bishop, J. 2014; 28 (8): 481-488

  Abstract

  The purpose of this systematic review and meta-analysis was to pool and analyze outcomes and complication rates in elderly patients with intraarticular distal humerus fractures being treated with either total elbow arthroplasty (TEA) or open reduction and internal fixation (ORIF) with locking plates.PubMed, Embase, and the Cochrane databases were used. The search included publications up to June 2013. Article selection was independently performed by 2 authors and disagreements were resolved by consensus.Studies meeting criteria for inclusion were observational cohort studies or randomized controlled trials evaluating functional and radiographic outcomes and complications in elderly patients treated for distal humerus fractures with either primary TEA or ORIF with locking plates. Studies with mean age <60 years, indications for TEA other than acute fracture, and those including nonlocked plates were excluded.Standardized data extraction was performed. A quality assessment tool was used to evaluate individual study methodology.Descriptive statistics for functional outcomes were reported. Meta-analysis and regression analysis were performed for complication rates.A systematic review and meta-analysis revealed that TEA and ORIF for the treatment of geriatric distal humerus fractures produced similar functional outcome scores and range of motion. Although there was a trend toward a higher rate of major complications and reoperation after ORIF, this was not statistically significant. The quality of study methodology was generally weak. Ongoing research including prospective trials and cost analysis is indicated to better define the roles of ORIF versus TEA in the management of these injuries.

  View details for DOI 10.1097/BOT.0000000000000050

  View details for PubMedID 24375273

• Fabrication, vascularization and osteogenic properties of a novel synthetic biomimetic induced membrane for the treatment of large bone defects. Bone Ren, L., Kang, Y., Browne, C., Bishop, J., Yang, Y. 2014; 64: 173-182

  Abstract

  The induced membrane has been widely used in the treatment of large bone defects but continues to be limited by a relatively lengthy healing process and a requisite two stage surgical procedure. Here we report the development and characterization of a synthetic biomimetic induced membrane (BIM) consisting of an inner highly pre-vascularized cell sheet and an outer osteogenic layer using cell sheet engineering. The pre-vascularized inner layer was formed by seeding human umbilical vein endothelial cells (HUVECs) on a cell sheet comprised of a layer of undifferentiated human bone marrow-derived mesenchymal stem cells (hMSCs). The outer osteogenic layer was formed by inducing osteogenic differentiation of hMSCs. In vitro results indicated that the undifferentiated hMSC cell sheet facilitated the alignment of HUVECs and significantly promoted the formation of vascular-like networks. Furthermore, seeded HUVECs rearranged the extracellular matrix produced by hMSC sheet. After subcutaneous implantation, the composite constructs showed rapid vascularization and anastomosis with the host vascular system, forming functional blood vessels in vivo. Osteogenic potential of the BIM was evidenced by immunohistochemistry staining of osteocalcin, tartrate-resistant acid phosphatase (TRAP) staining, and alizarin red staining. In summary, the synthetic BIM showed rapid vascularization, significant anastomoses, and osteogenic potential in vivo. This synthetic BIM has the potential for treatment of large bone defects in the absence of infection.

  View details for DOI 10.1016/j.bone.2014.04.011

  View details for PubMedID 24747351

• Fabrication, vascularization and osteogenic properties of a novel synthetic biomimetic induced membrane for the treatment of large bone defects. Bone Ren, L., Kang, Y., Browne, C., Bishop, J., Yang, Y. 2014; 64: 173-182

  View details for DOI 10.1016/j.bone.2014.04.011

  View details for PubMedID 24747351

• Delayed union and nonunions: Epidemiology, clinical issues, and financial aspects INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED Hak, D. J., Fitzpatrick, D., Bishop, J. A., Marsh, J. L., Tilp, S., Schnettler, R., Simpson, H., Alt, V. 2014; 45: S3-S7

  Abstract

  Fracture healing is a critically important clinical event for fracture patients and for clinicians who take care of them. The clinical evaluation of fracture healing is based on both radiographic findings and clinical findings. Risk factors for delayed union and nonunion include patient dependent factors such as advanced age, medical comorbidities, smoking, non-steroidal anti-inflammatory use, various genetic disorders, metabolic disease and nutritional deficiency. Patient independent factors include fracture pattern, location, and displacement, severity of soft tissue injury, degree of bone loss, quality of surgical treatment and presence of infection. Established nonunions can be characterised in terms of biologic capacity, deformity, presence or absence of infection, and host status. Hypertrophic, oligotrophic and atrophic radiographic appearances allow the clinician to make inferences about the degree of fracture stability and the biologic viability of the fracture fragments while developing a treatment plan. Non-unions are difficult to treat and have a high financial impact. Indirect costs, such as productivity losses, are the key driver for the overall costs in fracture and non-union patients. Therefore, all strategies that help to reduce healing time with faster resumption of work and activities not only improve medical outcome for the patient, they also help reduce the financial burden in fracture and non-union patients.

  View details for DOI 10.1016/j.injury.2014.04.002

  View details for Web of Science ID 000343236400002

  View details for PubMedID 24857025

• Lack of Proficiency in Musculoskeletal Medicine Among Emergency Medicine Physicians JOURNAL OF ORTHOPAEDIC TRAUMA Comer, G. C., Liang, E., Bishop, J. A. 2014; 28 (4): E85-E87

  Abstract

  Emergency medicine (EM) physicians are frequently responsible for evaluating and treating patients with urgent or emergent musculoskeletal conditions, so it is critical that they achieve a basic level of proficiency in musculoskeletal medicine. However, inadequacies in musculoskeletal education have previously been documented among medical students, residents, and attending physicians in a number of specialties. The goal of this study was to assess the proficiency with musculoskeletal medicine among EM physicians in particular.A validated musculoskeletal medicine competency examination was administered to the EM residents and faculty at a university-affiliated level 1 trauma center. Demographic data and satisfaction with musculoskeletal education were also surveyed.Twenty-three EM residents and 21 attending physicians completed the survey. Thirty-five percent of residents and 43% of attending physicians failed to demonstrate proficiency on the examination. Pass rates were not significantly different among junior residents, senior residents, or attending physicians. Twenty-three percent of respondents indicated that they were dissatisfied with their musculoskeletal education.Significant deficiencies in musculoskeletal education exist among EM physicians in training and attending staff. Given the frequency with which these physicians evaluate and treat acute musculoskeletal conditions, additional resources should be committed to their training.

  View details for DOI 10.1097/BOT.0b013e3182a66829

  View details for Web of Science ID 000333153200004

  View details for PubMedID 23899765

• The Biomechanical Significance of Washer Use With Screw Fixation JOURNAL OF ORTHOPAEDIC TRAUMA Bishop, J. A., Behn, A. W., Castillo, T. N. 2014; 28 (2): 114-117

  Abstract

  OBJECTIVES:: Washers can be used with lag screws during fracture fixation to optimize compression and minimize the risk of unintentional intrusion of the screw head through cortical bone during screw insertion. The concept of using washers to optimize screw fixation is particularly applicable to iliosacral screw fixation as well as screw fixation of the femoral neck, distal femur, proximal and distal tibia. However, there is a paucity of literature on this topic. The purpose of this study was to detail the biomechanical consequences of washer use and screw intrusion. METHODS:: Partially threaded 7.0 mm cannulated screws with and without washers were placed through synthetic bone blocks fabricated to simulate cortical and cancellous bone. A load cell was used to measure the compressive force before and after screw intrusion. Screws were tested with a washer (N=8), without a washer (N=8), and with a washer after initially being intruded (N=8). RESULTS:: Screws inserted with washers generated significantly more compressive force than screws inserted without washers before screw intrusion. After intrusion, compressive force decreased significantly under all conditions, but screws inserted with washers maintained greater compressive force than screws inserted without washers. Screws with washers reinserted after intrusion without a washer, produced almost as much compressive force as screws inserted with washers primarily. CONCLUSIONS:: Screw intrusion during fracture fixation results in a loss of compressive force that may compromise fixation quality. Washers are advantageous in that they allow for more compression to be generated before intrusion occurs and can be used to salvage compressive force of intruded screws.

  View details for Web of Science ID 000331197000014

  View details for PubMedID 23782961

• Survey Finds Few Orthopedic Surgeons Know The Costs Of The Devices They Implant HEALTH AFFAIRS Okike, K., O'Toole, R. V., Pollak, A. N., Bishop, J. A., McAndrew, C. M., Mehta, S., Cross, W. W., Garrigues, G. E., Harris, M. B., Lebrun, C. T. 2014; 33 (1): 103-109

  Abstract

  Orthopedic procedures represent a large expense to the Medicare program, and costs of implantable medical devices account for a large proportion of those procedures' costs. Physicians have been encouraged to consider cost in the selection of devices, but several factors make acquiring cost information difficult. To assess physicians' levels of knowledge about costs, we asked orthopedic attending physicians and residents at seven academic medical centers to estimate the costs of thirteen commonly used orthopedic devices between December 2012 and March 2013. The actual cost of each device was determined at each institution; estimates within 20 percent of the actual cost were considered correct. Among the 503 physicians who completed our survey, attending physicians correctly estimated the cost of the device 21 percent of the time, and residents did so 17 percent of the time. Thirty-six percent of physicians and 75 percent of residents rated their knowledge of device costs "below average" or "poor." However, more than 80 percent of all respondents indicated that cost should be "moderately," "very," or "extremely" important in the device selection process. Surgeons need increased access to information on the relative prices of devices and should be incentivized to participate in cost containment efforts.

  View details for DOI 10.1377/hlthaff.2013.0453

  View details for Web of Science ID 000330289300014

  View details for PubMedID 24395941

• The posterior approach to pelvic ring injuries: A technique for minimizing soft tissue complications INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED Fowler, T. T., Bishop, J. A., Bellino, M. J. 2013; 44 (12): 1780-1786

  Abstract

  Surgical techniques and fixation strategies for the treatment of unstable posterior pelvic ring injuries continue to evolve. The safety of the posterior surgical approach in particular has been questioned due to historically high rates of wound related complications. More contemporary studies have shown lower infection rates, however concern still persists. These concerns for infection and wound necrosis have led, in part, to increased interest in closed reduction and percutaneous fixation for treatment of these injuries but an open posterior approach remains the optimal strategy in some injury patterns. We describe herein a modified posterior approach to the pelvis designed to minimize wound related complications and present our clinical results demonstrating wound complication rates consistent with contemporary publications.

  View details for DOI 10.1016/j.injury.2013.08.005

  View details for Web of Science ID 000326376500016

  View details for PubMedID 24011422

• Surgical versus nonsurgical treatment of femur fractures in people with spinal cord injury: an administrative analysis of risks. Archives of physical medicine and rehabilitation Bishop, J. A., Suarez, P., DiPonio, L., Ota, D., Curtin, C. M. 2013; 94 (12): 2357-2364

  Abstract

  To assess the risks associated with surgical and nonsurgical care of femur fractures in people with spinal cord injury (SCI).Retrospective cohort study; an analysis of Veterans Affairs (VA) data from the National Patient Care Database.Administrative data from database.The cohort was identified by searching the administrative data from fiscal years 2001 to 2006 for veterans with a femur fracture diagnosis using the International Classification of Diseases, 9th Revision, Clinical Modification codes. This group was subdivided into those with (n=396) and without (n=13,350) SCI and those treated with and without surgical intervention.Not applicable.Rates of mortality and adverse events.The SCI group was younger with more distal fractures than the non-SCI group. In the non-SCI population, 78% of patients had associated surgical codes compared with 37% in the SCI population. There was higher mortality in the non-SCI group treated nonoperatively. In the SCI population, there was no difference in mortality between patients treated nonoperatively and operatively. Overall adverse events were similar between groups except for pressure sores in the SCI population, of which the nonoperative group had 20% and the operative had 7%. Rates of surgical interventions for those with SCI varied greatly among VA institutions.We found lower rates of surgical intervention in the SCI population. Those with SCI who had surgery did not have increased mortality or adverse events. Surgical treatment minimizes the risks of immobilization and should be considered in appropriate SCI patients.

  View details for DOI 10.1016/j.apmr.2013.07.024

  View details for PubMedID 23948614

• Synthesis and characterization of novel elastomeric poly(D,L-lactide urethane) maleate composites for bone tissue engineering EUROPEAN POLYMER JOURNAL Mercado-Pagan, A. E., Kang, Y., Ker, D. F., Park, S., Yao, J., Bishop, J., Yang, Y. P. 2013; 49 (10): 3337-3349

  Abstract

  Here, we report the synthesis and characterization of a novel 4-arm poly(lactic acid urethane)-maleate (4PLAUMA) elastomer and its composites with nano-hydroxyapatite (nHA) as potential weight-bearing composite. The 4PLAUMA/nHA ratios of the composites were 1:3, 2:5, 1:2 and 1:1. FTIR and NMR characterization showed urethane and maleate units integrated into the PLA matrix. Energy dispersion and Auger electron spectroscopy confirmed homogeneous distribution of nHA in the polymer matrix. Maximum moduli and strength of the composites of 4PLAUMA/nHA, respectively, are 1973.31 ± 298.53 MPa and 78.10 ± 3.82 MPa for compression, 3630.46 ± 528.32 MPa and 6.23 ± 1.44 MPa for tension, 1810.42 ± 86.10 MPa and 13.00 ± 0.72 for bending, and 282.46 ± 24.91 MPa and 5.20 ± 0.85 MPa for torsion. The maximum tensile strains of the polymer and composites are in the range of 5% to 93%, and their maximum torsional strains vary from 0.26 to 0.90. The composites exhibited very slow degradation rates in aqueous solution, from approximately 50% mass remaining for the pure polymer to 75% mass remaining for composites with high nHA contents, after a period of 8 weeks. Increase in ceramic content increased mechanical properties, but decreased maximum strain, degradation rate, and swelling of the composites. Human bone marrow stem cells and human endothelial cells adhered and proliferated on 4PLAUMA films and degradation products of the composites showed little-to-no toxicity. These results demonstrate that novel 4-arm poly(lactic acid urethane)-maleate (4PLAUMA) elastomer and its nHA composites may have potential applications in regenerative medicine.

  View details for DOI 10.1016/j.eurpolymj.2013.07.004

  View details for Web of Science ID 000325233800049

  View details for PubMedCentralID PMC4012890

• Synthesis and characterization of novel elastomeric poly(D,L-lactide urethane) maleate composites for bone tissue engineering. European polymer journal Mercado-Pagán, A. E., Kang, Y., Ker, D. F., Park, S., Yao, J., Bishop, J., Yang, Y. 2013; 49 (10): 3337-3349

  Abstract

  Here, we report the synthesis and characterization of a novel 4-arm poly(lactic acid urethane)-maleate (4PLAUMA) elastomer and its composites with nano-hydroxyapatite (nHA) as potential weight-bearing composite. The 4PLAUMA/nHA ratios of the composites were 1:3, 2:5, 1:2 and 1:1. FTIR and NMR characterization showed urethane and maleate units integrated into the PLA matrix. Energy dispersion and Auger electron spectroscopy confirmed homogeneous distribution of nHA in the polymer matrix. Maximum moduli and strength of the composites of 4PLAUMA/nHA, respectively, are 1973.31 ± 298.53 MPa and 78.10 ± 3.82 MPa for compression, 3630.46 ± 528.32 MPa and 6.23 ± 1.44 MPa for tension, 1810.42 ± 86.10 MPa and 13.00 ± 0.72 for bending, and 282.46 ± 24.91 MPa and 5.20 ± 0.85 MPa for torsion. The maximum tensile strains of the polymer and composites are in the range of 5% to 93%, and their maximum torsional strains vary from 0.26 to 0.90. The composites exhibited very slow degradation rates in aqueous solution, from approximately 50% mass remaining for the pure polymer to 75% mass remaining for composites with high nHA contents, after a period of 8 weeks. Increase in ceramic content increased mechanical properties, but decreased maximum strain, degradation rate, and swelling of the composites. Human bone marrow stem cells and human endothelial cells adhered and proliferated on 4PLAUMA films and degradation products of the composites showed little-to-no toxicity. These results demonstrate that novel 4-arm poly(lactic acid urethane)-maleate (4PLAUMA) elastomer and its nHA composites may have potential applications in regenerative medicine.

  View details for DOI 10.1016/j.eurpolymj.2013.07.004

  View details for PubMedID 24817764

  View details for PubMedCentralID PMC4012890

• Provisional mini-fragment plate fixation in clavicle shaft fractures. American journal of orthopedics (Belle Mead, N.J.) Bishop, J. A., Castillo, T. N. 2013; 42 (10): 470-472

  Abstract

  Plate fixation has an increasingly prominent role in the management of select clavicle fractures. However, many fracture patterns are not easily reduced and provisionally stabilized with conventional clamp application and lag-screw placement, and maintaining an appropriate reduction can be a challenge. In this article, we present a technique in which a mini-fragment plate is used to provisionally maintain fracture reduction while the definitive plate is applied.

  View details for PubMedID 24278907

• Antegrade Femoral Nailing in Acetabular Fractures Requiring a Kocher-Langenbeck Approach ORTHOPEDICS Bishop, J. A., Cross, W. W., Krieg, J. C., Routt, M. L. 2013; 36 (9): E1159-E1164

  Abstract

  Ipsilateral displaced acetabular and femoral shaft fractures represent a dilemma for orthopedic surgeons because antegrade femoral nailing may complicate a Kocher-Langenbeck acetabular exposure. The goals of this study were to review the results of ipsilateral femoral and acetabular fractures treated with antegrade femoral nailing and a Kocher-Langenbeck approach and to evaluate the assertion that this treatment strategy is associated with increased morbidity. This was a retrospective cohort study at a regional Level I trauma center. Sixteen patients with a femoral fracture treated with antegrade nailing and an ipsilateral acetabular fracture treated with a Kocher-Langenbeck approach were identified. One patient died as a result of his injuries, and 2 were not available for long-term follow-up. One had a deep infection requiring irrigation, debridement, and intraveonous antibiotics. One patient developed a hematoma requiring irrigation and debridement. At final follow-up, 2 patients had no heterotopic ossification about the hip, 4 had Brooker class I heterotopic ossification, 3 had Brooker class II heterotopic ossification, 2 had Brooker class III heterotopic ossification, and 2 patients had Brooker class IV heterotopic ossification requiring excision. Ipsilateral femoral and acetabular fractures represent a rare and severe injury constellation. Antegrade nailing of the femur with ipsilateral Kocher-Langenbeck exposure for fixation of the acetabulum was not associated with excessive rates of wound-healing complications, but the incidence of heterotopic ossification was increased.

  View details for DOI 10.3928/01477447-20130821-18

  View details for Web of Science ID 000325553500009

• The effect of rhBMP-2 and PRP delivery by biodegradable beta-tricalcium phosphate scaffolds on new bone formation in a non-through rabbit cranial defect model JOURNAL OF MATERIALS SCIENCE-MATERIALS IN MEDICINE Lim, H., Mercado-Pagan, A. E., Yun, K., Kang, S., Choi, T., Bishop, J., Koh, J., Maloney, W., Lee, K., Yang, Y. P., Park, S. 2013; 24 (8): 1895-1903

  Abstract

  This study evaluated whether the combination of biodegradable β-tricalcium phosphate (β-TCP) scaffolds with recombinant human bone morphogenetic protein-2 (rhBMP-2) or platelet-rich plasma (PRP) could accelerate bone formation and increase bone height using a rabbit non-through cranial bone defect model. Four non-through cylindrical bone defects with a diameter of 8-mm were surgically created on the cranium of rabbits. β-TCP scaffolds in the presence and absence of impregnated rhBMP-2 or PRP were placed into the defects. At 8 and 16 weeks after implantation, samples were dissected and fixed for analysis by microcomputed tomography and histology. Only defects with rhBMP-2 impregnated β-TCP scaffolds showed significantly enhanced bone formation compared to non-impregnated β-TCP scaffolds (P < 0.05). Although new bone was higher than adjacent bone at 8 weeks after implantation, vertical bone augmentation was not observed at 16 weeks after implantation, probably due to scaffold resorption occurring concurrently with new bone formation.

  View details for DOI 10.1007/s10856-013-4939-9

  View details for Web of Science ID 000321915300008

  View details for PubMedID 23779152

• Acute Thoracic Aortic Dissection After Chiropractic Intervention: A Case Report. JBJS case connector Briseño, M. R., Dunnington, G. n., Bishop, J. A. 2013; 3 (4 Suppl 2): e1041–3

  View details for PubMedID 29252259

• Cost-Effectiveness Analysis of Primary Arthroscopic Stabilization Versus Nonoperative Treatment for First-Time Anterior Glenohumeral Dislocations ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Crall, T. S., Bishop, J. A., Guttman, D., Kocher, M., Bozic, K., Lubowitz, J. H. 2012; 28 (12): 1755-1765

  Abstract

  The purpose of this study was to compare the cost-effectiveness of initial observation versus surgery for first-time anterior shoulder dislocation.The clinical scenario of first-time anterior glenohumeral dislocation was simulated using a Markov model (where variables change over time depending on previous states). Nonoperative outcomes include success (no recurrence) and recurrence; surgical outcomes include success, recurrence, and complications of infection or stiffness. Probabilities for outcomes were determined from published literature. Costs were tabulated from Medicare Current Procedural Terminology data, as well as hospital and office billing records. We performed microsimulation and probabilistic sensitivity analysis running 6 models for 1,000 patients over a period of 15 years. The 6 models tested were male versus female patients aged 15 years versus 25 years versus 35 years.Primary surgery was less costly and more effective for 15-year-old boys, 15-year-old girls, and 25-year-old men. For the remaining scenarios (25-year-old women and 35-year-old men and women), primary surgery was also more effective but was more costly. However, for these scenarios, primary surgery was still very cost-effective (cost per quality-adjusted life-year, <$25,000). After 1 recurrence, surgery was less costly and more effective for all scenarios.Primary arthroscopic stabilization is a clinically effective and cost-effective treatment for first-time anterior shoulder dislocations in the cohorts studied. By use of a willingness-to-pay threshold of $25,000 per quality-adjusted life-year, surgery was more cost-effective than nonoperative treatment for the majority of patients studied in the model.Level II, economic and decision analysis.

  View details for DOI 10.1016/j.arthro.2012.05.885

  View details for Web of Science ID 000311751500008

  View details for PubMedID 23040837

• Open Reduction and Intramedullary Nail Fixation of Closed Tibial Fractures ORTHOPEDICS Bishop, J. A., Dikos, G. D., Mickelson, D., Barei, D. P. 2012; 35 (11): E1631-E1634

  Abstract

  Some tibial shaft fractures cannot be accurately reduced using closed or percutaneous techniques during an intramedullary nailing procedure. Under these circumstances, a formal open reduction can be performed. Direct exposure of the fracture facilitates accurate reduction but does violate the soft tissue envelope. The purpose of this study was to evaluate the safety and efficacy of open reduction prior to intramedullary nailing. Using the trauma database at a Level I trauma center, 11 uncomplicated closed displaced tibia fractures treated with formal open reduction prior to intramedullary nailing were identified and matched with a cohort of 21 fractures treated with closed reduction and nailing. The authors attempted to match 2 controls to each patient to improve the power of the study. Clinical and radiographic outcomes were compared. All fractures ultimately healed within 5° of anatomic alignment. No infections or non-unions occurred in the open reduction group, and 1 deep infection and 1 nonunion occurred in the closed reduction group. No significant differences existed between the study groups. Although closed reduction and intramedullary nailing remains the treatment of choice for most significantly displaced tibial shaft fractures, open reduction with respectful handling of the soft tissue envelope can be safe and effective and should be considered when less invasive techniques are unsuccessful.

  View details for DOI 10.3928/01477447-20121023-21

  View details for Web of Science ID 000311031900010

  View details for PubMedID 23127455

• Predictive factors for knee stiffness after periarticular fracture: a case-control study. journal of bone and joint surgery. American volume Bishop, J., Agel, J., Dunbar, R. 2012; 94 (20): 1833-1838

  Abstract

  Knee stiffness is an important complication after periarticular fracture, but a systematic evaluation of risk factors for this complication and outcomes of treatment has not been undertaken, to our knowledge. The aims of this study were to evaluate risk factors for knee stiffness requiring manipulation after periarticular fracture and to document the clinical outcomes of the manipulation.This study was designed as a case-control study in which patients requiring manipulation under anesthesia after periarticular fracture were compared with those who did not require manipulation. Using billing data from a regional level-I trauma center, we identified twenty-four knees requiring manipulation for refractory stiffness over a six-year period. These were matched, on the basis of the AO/OTA classification, with forty-three control knees that did not develop stiffness requiring manipulation. Descriptive statistics were used for frequency and mean analysis.Univariate analysis revealed that extensor mechanism disruption (chi square = 0.05), fasciotomy (chi square = 0.020), wounds requiring ongoing management and precluding knee motion (p = 0.001), and the need for more than two surgical procedures to achieve definitive fracture fixation and soft-tissue coverage (p = 0.003) all placed patients at increased risk for knee stiffness requiring manipulation. The mean improvement in knee motion following all procedures targeting knee stiffness was 62°. Mean final flexion was significantly less in the case group (107°) compared with the control group (124°; p=0.01).To our knowledge, this is the first study to systematically evaluate the risk factors for knee stiffness after periarticular fracture and document the outcomes of manipulation under anesthesia. It demonstrates that injury characteristics that delay or prevent postoperative knee motion place patients at increased risk for refractory knee stiffness. Although knee motion remains compromised, late surgery aimed at improving knee motion leads to improvements in flexion

  View details for PubMedID 23243676

• Predictive Factors for Knee Stiffness After Periarticular Fracture A Case-Control Study JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Bishop, J., Agel, J., Dunbar, R. 2012; 94A (20): 1833-1838

  Abstract

  Knee stiffness is an important complication after periarticular fracture, but a systematic evaluation of risk factors for this complication and outcomes of treatment has not been undertaken, to our knowledge. The aims of this study were to evaluate risk factors for knee stiffness requiring manipulation after periarticular fracture and to document the clinical outcomes of the manipulation.This study was designed as a case-control study in which patients requiring manipulation under anesthesia after periarticular fracture were compared with those who did not require manipulation. Using billing data from a regional level-I trauma center, we identified twenty-four knees requiring manipulation for refractory stiffness over a six-year period. These were matched, on the basis of the AO/OTA classification, with forty-three control knees that did not develop stiffness requiring manipulation. Descriptive statistics were used for frequency and mean analysis.Univariate analysis revealed that extensor mechanism disruption (chi square = 0.05), fasciotomy (chi square = 0.020), wounds requiring ongoing management and precluding knee motion (p = 0.001), and the need for more than two surgical procedures to achieve definitive fracture fixation and soft-tissue coverage (p = 0.003) all placed patients at increased risk for knee stiffness requiring manipulation. The mean improvement in knee motion following all procedures targeting knee stiffness was 62°. Mean final flexion was significantly less in the case group (107°) compared with the control group (124°; p=0.01).To our knowledge, this is the first study to systematically evaluate the risk factors for knee stiffness after periarticular fracture and document the outcomes of manipulation under anesthesia. It demonstrates that injury characteristics that delay or prevent postoperative knee motion place patients at increased risk for refractory knee stiffness. Although knee motion remains compromised, late surgery aimed at improving knee motion leads to improvements in flexion

  View details for DOI 10.2106/JBJS.K.00659

  View details for Web of Science ID 000310416700002

• The osteogenic differentiation of human bone marrow MSCs on HUVEC-derived ECM and beta-TCP scaffold BIOMATERIALS Kang, Y., Kim, S., Bishop, J., Khademhosseini, A., Yang, Y. 2012; 33 (29): 6998-7007

  Abstract

  Extracellular matrix (ECM) serves a key role in cell migration, attachment, and cell development. Here we report that ECM derived from human umbilical vein endothelial cells (HUVEC) promoted osteogenic differentiation of human bone marrow mesenchymal stem cells (hMSC). We first produced an HUVEC-derived ECM on a three-dimensional (3D) beta-tricalcium phosphate (β-TCP) scaffold by HUVEC seeding, incubation, and decellularization. The HUVEC-derived ECM was then characterized by SEM, FTIR, XPS, and immunofluorescence staining. The effect of HUVEC-derived ECM-containing β-TCP scaffold on hMSC osteogenic differentiation was subsequently examined. SEM images indicate a dense matrix layer deposited on the surface of struts and pore walls. FTIR and XPS measurements show the presence of new functional groups (amide and hydroxyl groups) and elements (C and N) in the ECM/β-TCP scaffold when compared to the β-TCP scaffold alone. Immunofluorescence images indicate that high levels of fibronectin and collagen IV and low level of laminin were present on the scaffold. ECM-containing β-TCP scaffolds significantly increased alkaline phosphatase (ALP) specific activity and up-regulated expression of osteogenesis-related genes such as runx2, alkaline phosphatase, osteopontin and osteocalcin in hMSC, compared to β-TCP scaffolds alone. This increased effect was due to the activation of MAPK/ERK signaling pathway since disruption of this pathway using an ERK inhibitor PD98059 results in down-regulation of these osteogenic genes. Cell-derived ECM-containing calcium phosphate scaffolds is a promising osteogenic-promoting bone void filler in bone tissue regeneration.

  View details for DOI 10.1016/j.biomaterials.2012.06.061

  View details for Web of Science ID 000308269600010

  View details for PubMedID 22795852

  View details for PubMedCentralID PMC3427692

• Use of an Inflatable Pressure Bag Bump for Medial and Lateral Operative Approaches to the Lower Leg FOOT & ANKLE INTERNATIONAL Abrams, G. D., Bishop, J. A. 2012; 33 (9): 795-797

  View details for DOI 10.3113/FAI.2012.0795

  View details for Web of Science ID 000308273000019

  View details for PubMedID 22995270

• Osseous fixation pathways in pelvic and acetabular fracture surgery: Osteology, radiology, and clinical applications JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Bishop, J. A., Routt, M. L. 2012; 72 (6): 1502-1509

  View details for DOI 10.1097/TA.0b013e318246efe5

  View details for Web of Science ID 000305422900012

  View details for PubMedID 22695413

• Assessment of Compromised Fracture Healing JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Bishop, J. A., Palanca, A. A., Bellino, M. J., Lowenberg, D. W. 2012; 20 (5): 273-282

  Abstract

  No standard criteria exist for diagnosing fracture nonunion, and studies suggest that assessment of fracture healing varies among orthopaedic surgeons. This variability can be problematic in both clinical and orthopaedic trauma research settings. An understanding of risk factors for nonunion and of diagnostic tests used to assess fracture healing can facilitate a systematic approach to evaluation and management. Risk factors for nonunion include medical comorbidities, age, and the characteristics of the injury. The method of fracture management also influences healing. Comprehensive evaluation includes an assessment of the patient's symptoms, signs, and immune and endocrine status as well as the biologic capacity of the fracture, presence of infection, and quality of reduction and fixation. Diagnostic tests include plain radiography, CT, ultrasonography, fluoroscopy, bone scan, MRI, and several laboratory tests, including assays for bone turnover markers in the peripheral circulation. A systematic approach to evaluating fracture union can help surgeons determine the timing and nature of interventions.

  View details for DOI 10.5435/JAAOS-20-05-273

  View details for PubMedID 22553099

• Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis JOURNAL OF SHOULDER AND ELBOW SURGERY Bishop, J. A., Crall, T. S., Kocher, M. S. 2011; 20 (7): 1087-1094

  Abstract

  The optimal management strategy for primary traumatic anterior glenohumeral dislocation remains controversial. Patients have traditionally been managed nonoperatively, but high recurrence rates in certain populations have led to increased interest in early operative stabilization. The purpose of this study was to use expected-value decision analysis to determine the optimal management strategy--nonoperative treatment or arthroscopic stabilization--for a first-time traumatic anterior shoulder dislocation.Probabilities for the occurrences of the potential outcomes after nonoperative and arthroscopic treatment of a first-time traumatic anterior glenohumeral dislocation were determined from a systematic review of the literature. Utilities for these outcomes were obtained from a questionnaire on patient preferences completed by 42 subjects without a history of shoulder injury. A decision tree was constructed, fold-back analysis was performed to determine optimal management, and sensitivity analyses were used to determine the effect on decision making of varying outcome probabilities and utilities.Nonoperative treatment was associated with a utility value of 5.9 and early arthroscopic surgery with a value of 7.6. On sensitivity analysis, it was found that when the rate of recurrence after nonoperative treatment falls below 32% or when the utility value for successful arthroscopic stabilization falls below 6.6, nonoperative treatment is the preferred management strategy.Arthroscopic stabilization was the preferred strategy after a primary anterior glenohumeral dislocation. In clinical settings where the likelihood of recurrent instability is low after nonoperative care or when an informed patient has an aversion to surgery, nonoperative treatment may be the preferred treatment strategy.

  View details for DOI 10.1016/j.jse.2011.01.031

  View details for Web of Science ID 000296386600015

  View details for PubMedID 21530321

• Closed Intramedullary Nailing of the Femur in the Lateral Decubitus Position JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Bishop, J. A., Rodriguez, E. K. 2010; 68 (1): 231-235

  Abstract

  Closed intramedullary nailing is the standard of care for femoral shaft fractures and the technique now has broader applications with the proliferation of cephalomedullary instrumentation for the treatment of intertrochanteric and subtrochanteric femur fractures. Nailing in the lateral decubitus position has several advantages, but we are unaware of a detailed, contemporary description of the surgical technique published in the English language literature.A retrospective review of 158 patients treated with intramedullary nailing in the lateral position by a single surgeon over a 3-year period was performed. Clinical and radiographic outcomes were evaluated. In a group of 58 diaphyseal femur fractures, there were three rotational malreductions and one limb length discrepancy that required operative intervention. All but one were recognized and corrected intraoperatively on placing the patient supine. In a group of 100 primarily geriatric intertrochanteric, subtrochanteric, or peritrochatneric fractures managed with a cephalomedullary device, there were two lag screw cutouts, one nonunion, and one hardware failure. All of these required revision surgery. There were no rotational or length malreductions that required correction. There were no injuries to the perineum or contralateral leg, nerve palsies, or traction-related complications. Lateral positioning obviates the need for a fracture table, makes it easier to establish a starting point for an intramedullary device, and facilitates conversion to an open procedure without repositioning should this become necessary. This study demonstrates that the technique is safe and effective with an incidence of complications comparable with fracture table and supine positioning.

  View details for DOI 10.1097/TA.0b013e3181c488d8

  View details for Web of Science ID 000273585800045

  View details for PubMedID 20065779

• Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model. journal of hand surgery Bishop, J., Ring, D. 2009; 34 (6): 991-6 e1

  Abstract

  When managing radial nerve palsy associated with a humerus fracture, both surgeon and patient must balance the risks and benefits of performing an invasive surgical procedure to address a functional deficit that is likely, but not certain, to recover with nonsurgical management. The purpose of this study was to better understand the determinants of optimal management strategy using expected-value decision analysis.Probabilities for the occurrences of the potential outcomes after initial observation or early surgery were determined from a systematic review of the literature. Scores for these outcomes were obtained from a questionnaire on patient preferences completed by 82 subjects without a history of humerus fracture and radial nerve palsy and used in the model as a measure of utility. A decision tree was constructed, fold-back analysis was performed to determine optimal treatment, and sensitivity analyses were used to determine the effect on decision making of varying outcome probabilities and utilities.Observation was associated with a value of 8.4 and early surgery a value of 6.7 given the outcome probabilities and utilities studied in this model, making observation the optimal management strategy. When parameters were varied in sensitivity analysis, it was noted that when the rate of recovery after initial observation falls below 40% or when the utility value for successful early surgery rises above 9.4, early surgery is the preferred management strategy.Initial observation was the preferred strategy. In clinical settings in which the likelihood of spontaneous recovery of nerve function is low or when an informed patient has a strong preference for surgery, early surgery may optimize outcome.Economic and Decision Analysis II.

  View details for DOI 10.1016/j.jhsa.2008.12.029

  View details for PubMedID 19361935

• Locking plate fixation for pediatric femur fractures JOURNAL OF PEDIATRIC ORTHOPAEDICS Hedequist, D., Bishop, J., Hresko, T. 2008; 28 (1): 6-9

  Abstract

  The use of locking plates for pediatric femur fractures has not been studied. Locking plate applications for fractures associated with comminution, osteopenia, or minimal bone available for purchase have been well studied in the adult trauma population.We conducted a retrospective review of children at our institution treated with a locking plate for a femur fracture. We identified 32 patients treated at an average age of 11 years (6-15 years of age). Locking plates were chosen for comminution in 13 patients, nonmalignant pathologic fracture in 9 patients, fracture location in 7 patients, and osteopenia in 3 patients. All patients were treated with a locking plate and followed up until definitive radiologic union.There were no intraoperative complications related to this technology. All patients were healed with near-anatomic alignment with the exception of 1 patient who had valgus malalignment of 12 degrees, which was of no clinical concern and required no intervention. Seven patients had the plates removed with no noted complications.Locking plates are a safe and effective treatment for children and adolescents with femur fractures that may not be amenable to other current means of stabilization.

  View details for Web of Science ID 000255766600002

  View details for PubMedID 18157038

• Prophylactic pinning of the contralateral hip after unilateral slipped capital femoral epiphysis JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Kocher, M. S., Bishop, J. A., Hresko, M. T., Millis, M. B., Kim, Y. J., Kasser, J. R. 2004; 86A (12): 2658-2665

  Abstract

  The management of the contralateral hip after unilateral slipped capital femoral epiphysis is controversial. The purpose of this study was to determine, with use of expected-value decision analysis, the optimal management strategy-prophylactic in situ pinning versus observation-for the contralateral hip.Outcome probabilities were determined from a systematic review of the literature. Utility values were obtained from a questionnaire on patient preferences completed with use of a visual analog scale by twenty-five adolescent male patients without slipped capital femoral epiphysis. A decision tree was constructed, fold-back analysis was performed to determine the optimal treatment, and one and two-way sensitivity analyses were performed to determine the effect on decision-making of varying outcome probabilities and utilities.Observation was the optimal management strategy for the contralateral hip given the outcome probabilities and utilities that we studied (the expected value was 9.5 for observation and 9.2 for prophylactic in situ pinning, with a marginal value of 0.3). Increased rates of a late second slip favored prophylactic in situ pinning (the threshold probability was 27%). Risk-taking patients with a high utility for uncomplicated prophylactic in situ pinning favored prophylaxis (the threshold utility was 9.8).The iatrogenic risks of treating a healthy patient or an uninvolved body part rarely outweigh the potential benefits unless the probability of the adverse event is likely and the consequences of the adverse event are very severe. In this decision analysis, the optimal decision was observation. In cases where the probability of contralateral slipped capital femoral epiphysis exceeds 27% or in cases where reliable follow-up is not feasible, pinning of the contralateral hip is favored. For a given individual patient, the optimal strategy depends not only on probabilities of the various outcomes but also on personal preference. Thus, we advocate a model of doctor-patient shared decision-making in which both the outcome probabilities and the patient preferences are considered in order to optimize the decision-making process.Economic and decision analysis, Level III-1 (limited alternatives and costs; poor estimates). See Instructions to Authors for a complete description of levels of evidence.

  View details for Web of Science ID 000225719700011

• Delay in diagnosis of slipped capital femoral epiphysis PEDIATRICS Kocher, M. S., Bishop, J. A., Weed, B., Hresko, M. T., Millis, M. B., Kim, Y. J., Kasser, J. R. 2004; 113 (4): E322-E325

  Abstract

  Delay in diagnosis of slipped capital femoral epiphysis (SCFE) has important implications in terms of slip severity and long-term hip outcome. The purpose of this study was to identify predictors of delay in the diagnosis of SCFE.A review of 196 patients with SCFE was performed. The primary outcome measure was delay from onset of symptoms to diagnosis. Covariates included age, gender, side, weight, pain location, insurance status, family income, slip severity, and slip stability. Delay in diagnosis was not normal in distribution; therefore, nonparametric univariate and multivariate analyses were performed.The median delay in diagnosis was 8.0 weeks. There was a significant relationship between delay in diagnosis and slip severity (<30 degrees : 10.0 weeks; 30 degrees to 50 degrees : 14.4 weeks; >50 degrees : 20.6 weeks). There were no significant associations between delay in diagnosis and covariates of age, gender, side, and weight. There were significant associations between longer delay in diagnosis and covariates of knee/distal-thigh pain versus hip/proximal-thigh pain (6.0 vs 15.0 weeks), Medicaid coverage versus private insurance (12.0 vs 7.5 weeks), lower family income, and stable slips versus unstable slips (8.0 vs 6.5 weeks). Controlling for the other covariates, knee/distal-thigh pain, Medicaid insurance, and stable slips remained significant independent multivariate predictors of delay in diagnosis.Patients who present with primarily knee or distal-thigh pain, patients with Medicaid coverage, and patients with stable slips have longer delays in diagnosis of SCFE. Focused intervention programs to reduce the delay in diagnosis of SCFE should emphasize patients with knee/thigh pain and patients with Medicaid coverage.

  View details for Web of Science ID 000220585100048

  View details for PubMedID 15060261

• Images in clinical medicine. Something fishy going on in the heart. New England journal of medicine de la Torre, J., Bishop, J. 2002; 347 (22): 1769-?

  View details for PubMedID 12456853

• Operative versus nonoperative management of acute Achilles tendon rupture - Expected-value decision analysis 68th Annual Meeting of the American-Academy-of-Orthopaedic-Surgeons Kocher, M. S., Bishop, J., Marshall, R., Briggs, K. K., Hawkins, R. J. SAGE PUBLICATIONS INC. 2002: 783–90

  Abstract

  The optimal management strategy for acute Achilles tendon rupture is controversial.To determine the optimal management by using expected-value decision analysis.Cross-sectional study.Outcome probabilities were determined from a systematic literature review, and patient-derived utility values were obtained from a visual analog scale questionnaire. A decision tree was constructed, and fold-back analysis was used to determine optimal treatment. Sensitivity analyses were used to determine the effect of varying outcome probabilities and utilities on decision-making.Outcome probabilities (expressed as operative; nonoperative) were as follows: well (0.762; 0.846), rerupture (0.022; 0.121), major complication (0.030; 0.025), moderate complication (0.075; 0.003), and mild complication (0.111; 0.005). Outcome utility values were well operative (7.9), well nonoperative (7.0), rerupture (2.6), major complication (1.0), moderate complication (3.5), and mild complication (4.7). Fold-back analysis revealed operative treatment as the optimal management strategy (6.89 versus 6.30). Threshold values were determined for the probability of a moderate complication from operative treatment (0.21) and the utility of rerupture (6.8).Operative management was the optimal strategy, given the outcome probabilities and patient utilities we studied. Nonoperative management was favored by increasing rates of operative complications; operative, by decreasing utility of rerupture. We advocate a model of doctor-patient shared decision-making in which both outcome probabilities and patient preferences are considered.

  View details for Web of Science ID 000179364300004

  View details for PubMedID 12435641