Christian A. Pean

Functional Outcomes of Isolated Medial Tibial Plateau Fractures

Isolated medial tibial plateau injuries are uncommon and underdescribed in the literature. As such, the range of fracture severity and outcomes in comparison to more frequently described tibial plateau fractures are lacking. To assess outcomes of this rare injury, we compared two cohorts of patients. Overall, 27 patients who sustained 27 isolated medial plateau (Schatzker type IV) fractures and 81 patients with 81 split depression lateral plateau (Schatzker type II) fractures were compared. The outcomes were stratified by injury mechanism energy and assessed with radiographs, clinical and arthroscopic examinations, and functional status with the short musculoskeletal function assessment questionnaire (SMFA). Overall, 52% of Schatzker type IV fractures versus 71% of Schatzker type II were associated with high-energy injuries. Schatzker type IV fractures were more often nondisplaced and amenable to being managed, nonoperatively, 22 versus 6%, with excellent results. Schatzker type II fractures had a corresponding higher proportion of postoperative articular step off greater than 12 mm and poorer 12-month SMFA scores. Schatzker type IV fractures were more often treated with an external fixator than Schatzker type II fractures (22 vs. 1%). Within Schatzker type IV fractures, high- versus low-energy injuries did not differ significantly with regards to initial articular step off (4.2 vs. 5.1 mm), ligamentous and meniscal injury, or SMFA outcomes. Isolated medial plateau fractures had low- and high-energy patterns with differing management and outcomes. Schatzker type IV fractures overall were associated with lower energy mechanisms, less initial articular step off, and better functional outcomes than Schatzker II comparisons in this cohort. The level of evidence is 4.

Comparison of Short-Term Outcomes of Geriatric Distal Femur and Femoral Neck Fractures: Results From the NSQIP Database.

Purpose: To compare and contrast postoperative complications in the geriatric population following open reduction and internal fixation (ORIF) for (DF) fractures relative to femoral neck (FN) fractures. Methods: Patients aged 65 years and older in the American College of Surgeons National Surgical Quality Improvement Program database who underwent ORIF for FN fractures or DF fractures from 2005 to 2012 were identified. Differences in rates of any adverse events (AAEs), serious adverse events (SAEs), infectious complications, and mortality between groups were explored using univariate and multivariate analyses. Results: The DF cohort had a higher proportion of females (81.95% vs 71.35%, P < .001), were younger (79.41 ± 7.93 vs 82.11 ± 7.26 years old, P < .001), and had a lower age adjusted modified Charlson comorbidity index score (4.22 ± 1.32 vs 4.49 ± 1.35, P = .02). Cases with DF and FN did not differ in AAE (20.05% vs 20.20%, P = .94), SAE (12.03% vs 13.19%, P = .51), infectious complication (4.26% vs 4.22%, P = .97), hospital length of stay (7.32 ± 6.73 days vs 7.02 ± 10.67 days, P = .59), or mortality rates (4.51% vs 5.99%, P = .23). Multivariate analyses revealed that fracture type did not impact AAE (P = .28), SAE (P = .58), infectious complications (P = .83), or mortality (P = .85) rates. Conclusion: Postoperative morbidity and mortality of geriatric patients who sustain DF and FN fractures treated operatively were comparable. This information can be used when risk stratifying and prognosticating for elderly patients undergoing these procedures.

Current Practices Regarding Perioperative Management of Patients With Fracture on Antiplatelet Therapy: A Survey of Orthopedic Surgeons.

Objective: There continues to be controversy over whether operative delay is necessary for patients on antiplatelet therapy, particularly for elderly patients with hip fractures. This study sought to assess current clinical practices of orthopedic surgeons regarding perioperative management of these patients. Methods: A 12-question, Web-based survey was distributed to orthopedic surgeons via e-mail. Questions regarding timing of surgery assumed patients were on antiplatelet therapy and assessed attitudes toward emergent and nonemergent orthopedic cases as well as operative delay for specific closed fracture types. Responses were compared using unpaired, 2-tailed Student t tests for continuous variables and Pearson chi-square tests with odds ratios (ORs) and 95% confidence intervals (CIs) for categorical variables. Statistical significance was defined as a P value <.05. Results: Overall 67 orthopedic surgeons responded. Fifty-two percent (n = 35) of the respondents described their practice as academic. Thirty-nine percent (n = 25) of the surgeons indicated that no delay was acceptable for urgent but nonemergent surgery, and 78% (n = 50) reported no delay for emergent surgery was acceptable. Sixty-eight percent (n = 46) of respondents felt patients on antiplatelet therapy with closed hip fractures did not require operative delay. Surgeons who opted for surgical delay in hip fractures were more likely to delay surgery in other lower extremity fracture types (OR = 16.4, 95% CI 4.48-60.61, P < .001). Sixty-four percent (n = 41) of the surgeons indicated there was no protocol in place at their institution. Conclusions: There continues to be wide variability among orthopedic surgeons with regard to management of patients with fracture on antiplatelet therapy. Over a quarter of surgeons continue to opt for surgical delay in patients with hip fracture. This survey highlights the need to formulate and better disseminate practice management guidelines for patients with fracture on antiplatelet therapy, particularly given the aging population in the United States.

Near-Peer Emergency Medicine for Medical Students in Port-au-Prince, Haiti: An Example of Rethinking Global Health Interventions in Developing Countries

BACKGROUND During a 3-year time frame, a partnership between medical trainees in Haiti and the United States was forged with the objective of implementing an emergency response skills curriculum at a medical school in Port-au-Prince. The effort sought to assess the validity of a near-peer, bidirectional, cross-cultural teaching format as both a global health experience for medical students and as an effective component of improving medical education and emergency response infrastructure in developing countries such as Haiti. METHOD Medical students and emergency medicine (EM) residents from a North American medical school designed and taught a module on emergency response skills in PAP and certified medical students in basic cardiac life support (BLS) over 2 consecutive years. Five-point Likert scale self-efficacy (SE) surveys and multiple-choice fund of knowledge (FOK) assessments were distributed pre- and postmodule each year and analyzed with paired t tests and longitudinal follow-up of the first cohort. Narrative evaluations from participants were collected to gather feedback for improving the module. FINDINGS Challenges included bridging language barriers, maintaining continuity between cohorts, and adapting to unexpected schedule changes. Overall, 115 students were certified in BLS with significant postcurriculum improvements in SE scores (2.75 ± 0.93 in 2013 and 2.82 ± 1.06 in 2014; P < 0.001) and FOK scores (22% ± 15% in 2013 and 41% ± 16% in 2014; P < 0.001). Of 24 Haitian students surveyed at 1-year follow-up from the 2013 cohort, 7 (29.3%) reported using taught skills in real-life situations since completing the module. The US group was invited to repeat the project for a third year. CONCLUSIONS Near-peer, cross-cultural academic exchange is an effective method of medical student-centered emergency training in Haiti. Limitations such as successfully implementing sustainability measures, addressing cultural differences, and coordinating between groups persist. This scalable, reproducible, and mutually beneficial collaboration between North American and Haitian medical trainees is a valid conduit for building Haitis emergency response infrastructure and promoting global health.

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

Using Objective Structured Clinical Examinations to Assess Intern Orthopaedic Physical Examination Skills: A Multimodal Didactic Comparison

Patient care is 1 of the 6 core competencies defined by the Accreditation Council for Graduate Medical Education (ACGME). The physical examination (PE) is a fundamental skill to evaluate patients and make an accurate diagnosis. The purpose of this study was to investigate 3 different methods to teach PE skills and to assess the ability to do a complete PE in a simulated patient encounter. DESIGN Prospective, uncontrolled, observational. SETTING Northeastern academic medical center. PARTICIPANTS A total of 32 orthopedic surgery residents participated and were divided into 3 didactic groups: Group 1 (n = 12) live interactive lectures, demonstration on standardized patients, and textbook reading; Group 2 (n = 11) video recordings of the lectures given to Group 1 and textbook reading alone; Group 3 (n = 9): 90-minute modules taught by residents to interns in near-peer format and textbook reading. RESULTS The overall score for objective structured clinical examinations from the combined groups was 66%. There was a trend toward more complete PEs in Group 1 taught via live lectures and demonstrations compared to Group 2 that relied on video recording. Near-peer taught residents from Group 3 significantly outperformed Group 2 residents overall (p = 0.02), and trended toward significantly outperforming Group 1 residents as well, with significantly higher scores in the ankle (p = 0.02) and shoulder (p = 0.02) PE cases. CONCLUSIONS This study found that orthopedic interns taught musculoskeletal PE skills by near-peers outperformed other groups overall. An overall score of 66% for the combined didactic groups suggests a baseline deficit in first-year resident musculoskeletal PE skills. The PE should continue to be taught and objectively assessed throughout residency to confirm that budding surgeons have mastered these fundamental skills before going into practice.

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.

Risk factors for complications after primary repair of Achilles tendon ruptures

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.

The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures

Purpose To identify patient characteristics associated with adverse events in Achilles tendon rupture (ATR) surgical repair cases. Methods A high risk (HR) cohort group of ATR patients were compared to healthy controls in the ACSNSQIP database with multivariate regression analysis. Results Overall, 2% (n = 23) of the group sustained an AE postoperatively, most commonly superficial SSI (0.9%, n = 10). Multivariate analysis did not reveal any patient characteristics to be significantly associated with the occurrence of an AE or superficial SSI. Conclusions Obesity, diabetes and a history of smoking did not predispose patients to significantly more AEs in the 30 day postoperative period following ATR repair in this study.