Lisa K. Cannada

Orthopaedic resident and program director opinions of resident duty hours: a national survey.

BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) established national guidelines for resident duty hours in July 2003. Following an Institute of Medicine report in December 2008, the ACGME recommended further restrictions on resident duty hours that went into effect in July 2011. We conducted a national survey to assess the opinions of orthopaedic residents and of directors of residency and fellowship programs in the U.S. regarding the 2003 and 2011 ACGME resident duty-hour regulations and the effects of these regulations on resident education and patient care. METHODS A fifteen-item questionnaire was electronically distributed by the Candidate, Resident, and Fellow Committee of the American Academy of Orthopaedic Surgeons (AAOS) to all U.S. orthopaedic residents (n = 3860) and directors of residency programs (n = 184) and fellowship programs (n = 496) between January and April 2011. Thirty-four percent (1314) of the residents and 27% (185) of the program directors completed the questionnaire. Statistical analyses were performed to detect differences between the responses of residents and program directors and between the responses of junior and senior residents. RESULTS The responses of orthopaedic residents and program directors differed significantly (p < 0.001) for fourteen of the fifteen survey items. The responses of residents and program directors were divergent for questions regarding the 2003 rules. Overall, 71% of residents thought that the eighty-hour work week was appropriate, whereas only 38% of program directors agreed (p < 0.001). Most program directors (70%) did not think that the 2003 duty-hour rules had improved patient care, whereas only 24% of residents responded in the same way (p < 0.001). The responses of residents and program directors to questions regarding the 2011 duty-hour rules were generally compatible, but the degree to which they perceived the issues was different. Only 18% of residents and 19% of program directors thought that the suggested strategic five-hour evening rest period implemented in July 2011 for on-call residents was appropriate (p > 0.05), and both groups (84% of residents and 74% of program directors) also disagreed with the limitation of intern shifts to sixteen hours (p < 0.001). Seventy percent of residents and 79% of program directors thought that the new duty-hour regulations would result in an increased number of handoffs that would be detrimental to patient care (p < 0.001). The mean responses of junior residents and senior residents differed for eight of the fifteen survey items (p < 0.001), with the responses of senior residents more closely resembling those of program directors on six of these eight questions. The mean responses and percentiles for the survey items did not differ significantly between residency directors and fellowship directors (p > 0.05). CONCLUSIONS This national survey indicated significant differences between the opinions of orthopaedic residents and program (residency and fellowship) directors regarding the 2003 ACGME resident duty-hour regulations and the effects of these regulations on resident education and patient care. However, both residents and program directors agreed that the further reductions in duty hours in the 2011 rules may be detrimental to resident education and patient care.

Incidence and risk factors of heterotopic ossification following major elbow trauma

Heterotopic ossification is a common complication of Orthopaedic Trauma Association (OTA) type C distal humerus fractures and ulnohumeral fracture dislocations. The purpose of this study was to precisely define the incidence of heterotopic ossification following major elbow trauma and to identify risk factors for the development of clinically significant heterotopic ossification and for surgical excision of elbow heterotopic ossification.Current Procedural Terminology codes identified 156 patients who underwent operative intervention for a distal humerus fracture or an ulnohumeral fracture dislocation at 2 Level I trauma centers over 6 years. The incidence of elbow heterotopic ossification was recorded at >90 days following the definitive procedure. Risk factors for the development of class 3 or 4 heterotopic ossification and for surgical excision of heterotopic ossification were evaluated using separate multivariable logistic regression analyses. Brooker class 3 or 4 heterotopic ossification occurred following 18 (14%) of 125 distal humerus fractures, 15 (22%) of 69 OTA type C distal humerus fractures, and 11 (35%) of 31 ulnohumeral fracture dislocations. Surgical excision of heterotopic ossification was performed after 12 (10%) of 125 distal humerus fractures, 10 (14%) of 69 OTA type C distal humerus fractures, and 8 (26%) of 31 ulnohumeral fracture dislocations. Sustaining a severe elbow injury (P<.05) or a delay of fixation (P=.05) was found to be independent risk factors for Brooker class 3 or 4 heterotopic ossification. Severe elbow injury (P<.05) and male sex (P<.05) were associated with operative excision of heterotopic ossification.

Pelvic Fractures in Women of Childbearing Age

BackgroundPelvic fractures represent major injury. Women of childbearing age who have sustained pelvic fractures question whether they can have children and what type of delivery will be possible.Questions/purposes(1) Genitourinary and sexual dysfunction can be expected in women of child bearing age with pelvic fractures; (2) functional outcomes of women with pelvic fractures are related to fracture pattern and whether they were treated with surgery; (3) women treated nonoperatively and those treated operatively with fixation sparing the pubic symphysis can deliver children vaginally.MethodsWe retrospectively reviewed 71 women with pelvic fractures. Forty-one had stable fractures and 25 had unstable fractures; five radiographs could not be located to classify fractures. Forty women had surgery for their pelvic fractures.ResultsThirty-five women (49%) had one or more genitourinary complaints; 26 women (38%) had pain with sexual intercourse. The overall SF-12 score and physical and mental health component were lower in women who had surgical fixation of their pelvic fracture. Overall SF-12 scores were similar in women who did and did not have children after their pelvic fracture. Twenty-six women had children after their pelvic fracture: 10 (38%) delivered vaginally; 16 (62%) had a cesarean section. Four (40%) of the women who delivered vaginally had surgical fixation of their fracture, including rami screws and/or sacroiliac screws.ConclusionsOur data suggest the cesarean section rate is still more than double standard norms, but vaginal delivery after pelvic fracture, even in those treated with surgical fixation sparing the pubic symphysis, is possible.Level of EvidenceLevel III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Analysis of postoperative knee sepsis after retrograde nail insertion of open femoral shaft fractures.

Objectives: Retrograde nailing of open femoral fractures has presumed increased risk of knee sepsis. Our hypothesis was that the incidence of secondary knee infection after retrograde nailing of open femoral fractures is low. Design: Retrospective, multicenter. Setting: Four Level I trauma centers. Patients and Methods: A retrospective review of prospective trauma registries and fracture databases identified all open femoral fractures treated with retrograde intramedullary nailing from January 1, 2003, through February 15, 2007. Patients with ballistic injuries and those with less than 1 month follow up were excluded. Ninety-three open femoral fractures were identified in 90 patients. We defined a septic knee as a knee with infection that required reoperation with arthrotomy or arthroscopy. Infections at an open fracture site were defined as those treated with local irrigation and débridement and intravenously and/or orally administered antibiotics. Intervention: Open femoral shaft fractures treated with a retrograde approach. Main Outcome Measurements: Occurrence of an ipsilateral postoperative septic knee. Results: One acute septic knee was identified (1.1%; 95% confidence interval, 0.0%-3.2%) noted at time of repeat irrigation and débridement of a massive degloving wound that left no skin coverage over the knee. We also observed one late knee sepsis 2.5 years after the index procedure occurring after quadricepsplasty. The nail had been removed 1.5 years before surgery, so we did not include that case in our knee sepsis rate. Two additional infections at the open wound site did not involve the knee. Conclusions: Previous publications have argued that retrograde nailing of open femoral fractures provides a potential conduit for knee infection. Our data show that risk of a septic knee as a direct result of retrograde nailing of an open femoral fracture is relatively low (1.1%; 95% confidence interval, 0.0%-3.2%). To our knowledge, this is the first case series to document the relative safety associated with retrograde nailing of open femoral fractures.

The Jones-Powell Classification of open pelvic fractures: a multicenter study evaluating mortality rates.

BACKGROUND Historically, open pelvic fractures have a high mortality rate. The Jones-Powell Classification system was developed to assist with morbidity and mortality prediction. The purposes of our study were twofold: 1. Apply the Jones-Powell Classification to mortality rates of open pelvic fractures; 2. Because the original article published on the Jones-Powell Classification was from 1997, there have been advances in the early treatment of pelvic fractures to include the use of the pelvic binder, early diverting colostomies, and emergent angiography. We wanted to examine if any of those acute interventions affected mortality rate. METHODS This is a retrospective review of all patients presenting with open pelvic fractures at six Level I trauma centers between 2000 and 2006. RESULTS There were 64 patients with an average age of 34 years (range, 17–57 years). Fourteen had stable pelvic fracture patterns, and 50 had unstable fracture patterns. The overall mortality rate in our study was 15 patients (23%). All patients who died had an unstable pelvic fractuer and/or rectal laceration. Sixteen patients had diverting colostomies within 48 hours of injury. There were four patients with rectal lacerations and no patients with diverting colostomies who died. DISCUSSION In our population group, there was an overall mortality rate of 23%. A Jones-Powell Class 3 injury had a 38% mortality rate. The presence of a rectal laceration may serve as a marker for the severity of the patient’s injuries and increased risk of mortality. LEVEL OF EVIDENCE Epidemiologic study, level IV.

Retrograde intramedullary nailing in treatment of bilateral femur fractures.

Objective: The purpose of this study was to evaluate the use of retrograde nailing to treat patients with bilateral femur fractures. Design and Setting: A retrospective review of prospectively obtained trauma databases was completed at 9 Level 1 trauma centers. Patients: In all, 3767 patients with femur fractures were identified. Of those, 89 (46 males, 43 females) had bilateral femur fractures treated with reamed, retrograde intramedullary nails within 48 hours after injury. The charts were reviewed for pertinent data. Results: The average cohort age was 30 years (16-63 years). The average Injury Severity Score was 21 (9-50). Eighty-five patients (96%) had associated injuries. Thirteen patients (14.6%) developed adult respiratory distress syndrome; 8 had thoracic injuries. There were 4 patients (4%) with fat embolism syndrome, 2 were delayed longer than 24 hours to the operating room. There were 5 deaths (5.6% mortality) in the retrograde nailing group. Thoracic injury was found to be associated with death rate (P < 0.07). Conclusions: Bilateral femur fractures are indicative of severe injuries with mortality rates as high as 40%. There are no specific studies addressing the outcomes of bilateral femur fractures treated with retrograde nailing. In this largest retrospective study to date, the overall death rate of 5.6% was significantly lower than historical controls. The effect of timing and duration of surgery and other injuries is not completely known. In conclusion, retrograde nailing of bilateral femur fractures is an acceptable treatment for bilateral femur fractures.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Acute tibialis posterior tendon rupture associated with a distal tibial fracture.

Tibialis posterior tendon ruptures associated with closed medial malleolar fractures are rare. This article describes the association of tibialis posterior tendon ruptures with closed, high-energy, distal tibia fractures. Tendon ruptures are likely to be identified intraoperatively or missed if clinical evaluation at acute injury is limited. A high index of suspicion is required to diagnose this injury. The consequences of an unrecognized tibialis posterior tendon rupture include progressive, painful pes planus deformities due to the unopposed action of the peroneus brevis muscle and lack of support of the medial longitudinal arch. Secondary operative intervention may be required. This article describes an intraoperative tenodesis technique between the tibialis posterior and flexor digitorum longus tendons when direct repair is not possible.A 48-year-old woman sustained a closed AO/Orthopaedic Trauma Association type 43A right lower-extremity distal tibia fracture and a traumatic left knee arthrotomy. Temporary stabilization with an external fixator was performed, followed by open reduction and internal fixation of the distal tibial fracture 6 days later. A periarticular nonlocking medial plate was applied, and the tibialis posterior tendon was shortened. We performed a direct tenodesis to the flexor digitorum longus tendon. At 1-year follow-up, the patient had made excellent progress, with no detectable muscle weakness, and was able to perform a single-leg toe raise.A review of the literature suggested which features of radiological evidence of tendon rupture should be examined, which may be useful in the current era considering most high-energy distal tibia or pilon fractures undergo examination with computed tomography.

Pregnancy outcomes after orthopedic trauma.

BACKGROUND This study was performed to determine the effects of orthopedic trauma on pregnancy outcomes in pregnant trauma patients. METHODS This was an observational study completed after electronically linking databases for the obstetric service and the trauma service at our Level I trauma center. All pregnant women who presented during the years 1995 to 2007 were eligible for inclusion. Selected pregnancy outcomes in women who delivered at our trauma center during or after their trauma admission were evaluated according to the presence of orthopedic injuries. Statistical analyses were performed using χ, Students t test, and Wilcoxon rank-sum test; and p < 0.05 are considered statistically significant. RESULTS There were 65 pregnant women with orthopedic injuries (6%) and 990 without orthopedic injuries. Women with orthopedic trauma had an average gestational age of 28 weeks versus 31 weeks for women without orthopedic trauma. Compared with the patients without orthopedic injuries, patients with orthopedic injuries had a significant increased risk of preterm birth before 37 weeks of gestation (31% vs. 3%; p < 0.001), an increased risk of placental abruption (8% vs. 1%; p < 0.001), and an increased risk of perinatal mortality (8% vs. 1%; p < 0.001). CONCLUSIONS Our findings indicate that traumatized pregnant women with orthopedic injuries are high-risk obstetrical patients and may benefit from referral to a medical center capable of handling both the primary injury and the potential preterm birth associated with the injury.

A Retrospective Review of High-Energy Femoral Neck-Shaft Fractures

Objectives: To determine the incidence of femoral neck fractures with high-energy shaft fractures and to determine whether there was a correlation of neck fractures with antegrade or retrograde intramedullary nailing. We also evaluated the timing of diagnosis and the treatment options and outcomes. Design and Setting: A retrospective review of patients with femoral shaft fractures treated at 8 level 1 trauma centers from 2001 to 2005. Two thousand eight hundred ninety-seven fractures were identified, and 89 patients had 91 femoral neck-shaft combinations (3.2%). Patients: Average age: 36 years (15-72 years) and average Injury Severity Score: 18 (9-66). Seventy-eight patients had associated injuries; 67 of 91 femoral neck fractures were discovered before nailing. Results: There were 24 missed femoral neck fractures, 11 discovered intraoperatively and 13 postoperatively. Of these 24 patients, 15 had retrograde fixation and 9 had antegrade femoral shaft fixation. There was a high rate of open femur fractures (34%) and an increased incidence of associated injuries (88%) with neck-shaft combinations. In 12 of 67 patients with a preoperative computed tomography scan, the scan did not demonstrate a femoral neck fracture. Conclusions: This study found a similar rate of neck-shaft combinations (3.2%), a higher rate of open fractures, and increased incidence of associated injuries compared with the literature. Most importantly, our data indicate that even with a negative preoperative computed tomography scan, a femoral neck fracture can be present. A trend also indicated more missed femoral neck fractures with retrograde nailing, which may be attributed to less fluoroscopic imaging of the hip with this technique. Patients with femoral shaft fractures should have good quality radiographs after femoral nailing to minimize the risk of missed femoral neck fractures.