Adam Driesman

Functional and Clinical Outcomes of Nonsurgically Managed Tibial Plateau Fractures

Introduction: This study sought to assess and compare long-term functional and clinical outcomes in patients with tibial plateau fractures that are treated nonsurgically. Methods: Over a period of 8 years, 305 consecutive tibial plateau fractures were treated by three surgeons at a single institution and followed prospectively in an Institutional Review Board–approved study. Overall, 41 patients (13%) were treated nonsurgically and 37 were available for follow-up. Indications for nonsurgical management were minimal fracture displacement or preclusion of surgery because of comorbidities. A series of univariate retrospective analyses were used to identify individual risk factors potentially predictive of Short Musculoskeletal Functional Assessment scores. Results: Thirty-seven patients were included with a mean follow-up of 21 ± 14.9 months. Overall, 59% of patients (n = 22) attained good to excellent functional outcomes. In patients for whom surgery was precluded because of comorbidities, outcome scores were significantly poorer (38.8 ± 23.0 versus 12.7 ± 14.2; P = 0.001). Surgery precluded by a factor other than minimal fracture displacement predicted poor outcome (P = 0.002). Discussion: Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically. Level of Evidence: Level III, retrospective comparative study

Race and Ethnicity Have a Mixed Effect on the Treatment of Tibial Plateau Fractures

Objectives: To determine whether racial or economic disparities are associated with short-term complications and outcomes in tibial plateau fracture care. Design: Retrospective cohort study. Setting: All New York State hospital admissions from 2000 to 2014, as recorded by the New York Statewide Planning and Research Cooperative System database. Patients/Participants: Thirteen thousand five hundred eighteen inpatients with isolated tibial plateau fractures (OTA/AO 44), stratified in 4 groups: white, African American, Hispanic, and other. Intervention: Closed treatment and operative fixation of the tibial plateau. Main Outcome Measurements: Hospital length of stay (LOS, days), in-hospital complications/mortality, estimated total costs, and 30-day readmission. Results: There were no significant differences regarding in-hospital mortality, infection, deep vein thrombosis/pulmonary embolism, or wound complications between races, even when controlling for income. There was a higher rate of nonoperatively treated fractures in the racial minority populations. Minority patients had on average 2 days longer LOS compared with whites (P < 0.001), costing on average

The Use of Liposomal Bupivacaine administered with standard Bupivacaine in Ankle Fractures Requiring Open Reduction Internal Fixation: A Single-blinded Randomized Controlled Trial.

4000 more per hospitalization (P < 0.001). Multivariate logistic regression found that neither race nor estimated median family income were independent risk factors for readmission. Conclusions: Although nature of initial injury, use of external fixator, comorbidity burden, age, insurance type, and LOS were independent risk factors for readmission, race and estimated median family income were not. In patients who sustained a tibial plateau fracture, race and ethnicity seemed to affect treatment choice, but once treated racial minority groups did not demonstrate worse short-term complications, including increased mortality and postoperative readmission rates. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fracture Severity Based on Classification Does Not Predict Outcome Following Proximal Humerus Fracture

Objectives: To determine the efficacy of liposomal bupivacaine compared to placebo for postoperative pain control in patients undergoing operative fixation of ankle fractures. Design: Prospective single-blinded randomized control trial. Setting: Academic Medical Center. Patients/Participants: After Institutional Review Board (IRB) approval, 76 patients who sustained an acute ankle fracture (OTA/AO 44A-C) requiring operative fixation met inclusion criteria. Intervention: Patients were randomly assigned to 1 of 2 groups, control (local intraoperative sterile saline injection under general anesthesia) or interventional (local intraoperative liposomal bupivacaine and bupivacaine injection under general anesthesia). Injections were administered in a standardized fashion and included injection of a 1:1 mixture of a 40 mL solution consisting of 1.3% Exparel and sterile saline (interventional) or a 40 mL injection of normal saline (control) into the surrounding periosteal, peritendinous, surrounding muscles and subcutaneous tissue of the surgical incision(s). Main Outcome Measurements: Pain medications administered and pain according to the Visual Analogue Scale was recorded at scheduled postoperative time points: 4, 24, 48, 72, and 336 hours (14 days). Results: Thirty-nine patients were randomized to the control group and 37 to the interventional group (mean age = 42 ± 15 years), with no statistically significant differences between groups with regards to severity of injury and patient demographics. Pain scores were significantly lower in the interventional group versus control up to 2 weeks after surgery. Percocet ingestion at 4 hours was significantly lower in the interventional group (0.7 vs. 1.3, P = 0.004), while it approached significance at 48 hours postoperatively (2.8 vs. 3.69, P = 0.07). No other significant differences were noted for Percocet ingestion postoperatively at other time points assessed. The overall satisfaction with pain control was not statistically different between the 2 groups (P = 0.93). Conclusion: Local intraoperative infiltration of liposomal bupivacaine administered with standard bupivacaine for ankle fractures requiring Open Reduction Internal Fixation (ORIF) affords improved pain relief in the immediate postoperative period resulting in a reduction in Percocet ingestion, with resultant effects seen up to 2 days postoperatively. Continued investigation of this drug for use with extremity fractures is warranted. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Social to Moderate Alcohol Consumption Provides a Protective Effect for Functional Outcomes After Fixation of Orthopaedic Fractures

This study was conducted to determine whether proximal humerus fracture patterns as defined by the Orthopaedic Trauma Association (AO/OTA) classification and the Neer 4-part system predicted functional outcomes for patients treated with open reduction and internal fixation with locked plates and, if so, which system correlated better with outcomes. During a 12-year period, 213 patients with a displaced proximal humerus fracture who underwent surgical treatment with a locking plate at 1 academic institution were prospectively followed. All patients were treated in a similar way and were followed by the operating surgeon at routine intervals. Functional outcomes were measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Of these patients, 164 were available for analysis. Functional outcomes based on DASH scores did not differ significantly by Neer system, AO/OTA classification, or varus/valgus humeral head alignment at more than 12 months postoperatively. However, patients with Neer 4-part fracture and AO/OTA type 11-C fracture had worse shoulder range of motion in terms of forward elevation and external rotation. Time to healing and complication rates also were not significantly different based on either classification system. Fracture classification can predict shoulder range of motion 12 months after surgical fixation, but its use is limited in predicting functional outcome scores, time to healing, and complication rates. Patients who undergo surgical repair of a proximal humerus fracture can expect good functional results independent of the initial injury pattern, but more severe fracture patterns may lead to decreased shoulder range of motion. [Orthopedics. 2017; 40(6):368-374.].

Racial disparities in outcomes of operatively treated lower extremity fractures

Objectives: To identify the association between social and moderate alcohol consumption and functional outcomes after surgical management of orthopaedic fractures. Design: Prospective cohort study. Setting: Level 1 trauma center. Patients/Participants: Seven hundred eighty-four patients who were operatively treated for an isolated orthopaedic fracture were prospectively followed. Patients were categorized into groups according to self-reported drinking frequencies based on NIAAA guidelines. Main Outcome Measurements: SMFA scores at baseline, 3, 6, and 12 months postoperatively; postoperative complications; and subsequent operations. Results: There were 367 (46.8%) abstinent, 327 (41.7%) social, 52 (6.6%) moderate, and 38 (4.8%) heavy drinkers. Mean SMFA scores of social and moderate drinkers were significantly lower than those of abstinent patients at 3-, 6-, and 12-month follow-ups, denoting better functional outcomes (social: 24.3 vs. 30.5, P = 0.001; 14.8 vs. 21.5, P < 0.005; and 10.1 vs. 18.8, P < 0.005); (moderate: 18.3 vs. 30.5, P = 0.001; 9.7 vs. 21.5, P = 0.001; and 5.4 vs. 18.8, P < 0.005). Multiple linear regression revealed that social drinking and baseline SMFA scores were the only statistically significant independent predictors of lower SMFA scores at 12 months after surgery. Conclusions: Social to moderate drinking may have a protective effect on functional outcomes at 3, 6, and 12 months after surgery. Social drinking may also have a protective effect on postoperative complications and reoperation rates. Further studies should be performed to fully appreciate the clinical effect of social and moderate drinking after operative treatment of orthopaedic fractures. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.