Michael Suk

The incidence of soft tissue injury in operative tibial plateau fractures. A magnetic resonance imaging analysis of 103 patients

Objectives: The goal of this study was to determine the incidence of injury to soft tissue structures of the knee in tibial plateau fractures scheduled for surgery. Design: Prospective cohort. Setting: Level I academic medical center. Patients/Participants: One hundred three consecutive patients with acute tibial plateau fractures indicated for operative intervention. Intervention: Standard x-ray examinations, including anteroposterior, lateral, and oblique views, were performed in the emergency department. Subsequently all patients had magnetic resonance imaging performed. The Schatzker and AO/OTA classifications were used to classify each fracture pattern based solely on the x-rays. Soft tissue injuries were assessed by magnetic resonance imaging. Main Outcome Measurements: Fifteen categories of injury were determined as positive or negative on each magnetic resonance imaging, which included tears of the cruciates, collateral ligaments, menisci, and posterolateral corner. Results: The overall incidence of injury to soft tissues was higher than previously reported. Only 1 patient (1%) in the series had complete absence of any soft tissue injury. Seventy-nine patients (77%) sustained a complete tear or avulsion of 1 or more cruciate or collateral ligaments. Ninety-four patients (91%) had evidence of lateral meniscus pathology. Forty-five patients (44%) had medial meniscus tears. Seventy patients (68%) had tears of 1 or more of the posterolateral corner structures of the knee. The most frequent fracture pattern was a lateral plateau split-depression (Schatzker II) (60%). No pure depression injuries (Schatzker III, AO/OTA 41-B2) were seen. Conclusions: The incidence of complete ligamentous or meniscal disruption associated with operative tibial plateau fractures was higher than previously reported. Though the clinical importance of injury to each of these structures is unknown, the treating surgeon should be aware that a variety of soft tissue injuries are common in these fractures. In addition, all fractures had at least 1 cortical split visible on magnetic resonance imaging, implying that pure depression patterns are very rare or may not exist.

Evidence-based orthopaedic surgery: what is evidence without the outcomes?

With the increased emphasis on evidence-based medicine in orthopaedics, the surgeon is faced with the challenge of evaluating the effectiveness of various treatment interventions. Health care authorities are also interested in measuring competing interventions, but out of concern for controlling costs. The success or failure of an intervention is often determined based on treatment outcomes. There are many outcomes measures available in the orthopaedic literature, and it is not uncommon for different measures to produce conflicting results. The orthopaedic surgeon must have the ability to accurately evaluate an outcomes measure to determine the value of a specific intervention. Similarly, selecting the appropriate outcomes measure for research or clinical purposes is an important decision that may have far-reaching implications on reimbursement and determining treatment success. To best select outcomes measures and to select the appropriate treatment for each patient, the orthopaedic surgeon needs to understand the recommended contents of a quality instrument, the difference between clinician-based and patient-reported outcomes, and how to evaluate outcomes reported in the literature.

Orthopaedics and the law.

Abstract Understanding the relevant legal context is critical to the safe and successful practice of orthopaedic surgery. Specifically, three areas of liability are relevant to most physicians: medical malpractice, products liability, and the liability of health care organizations. Medical malpractice encompasses the professional physicianpatient relationship with its implied contract, consent, fiduciary responsibilities, and duty to provide the standard of care, as well as certain common‐law duties pertinent in special circumstances. Orthopaedic surgeons who design implants or who have a relationship with a device manufacturer are at risk for liability for a failed product. In general, the hospital entity is responsible for the actions of its physician‐employees. Still unclear is the degree to which a physician is obligated to appeal to a third‐party payor on behalf of a patient. Physicians should remember that, above all else, common sense with regard to the treatment, informed consent, and advocacy of patients is essential to avoiding many medical‐legal pitfalls.

What makes an intertrochanteric fracture unstable in 2015? Does the lateral wall play a role in the decision matrix?

Summary: Intertrochanteric (IT) fractures pose a tremendous burden to the healthcare system. Although consistently good results are obtained while treating stable IT fractures, treatment failure rates with unstable fractures are much higher, and hence, it is imperative to identify unstable patterns. Presently, the conventionally classified unstable configurations (fracture with posteromedial comminution, reverse oblique, IT with subtrochanteric extension) and the recently added fracture patterns (IT fractures with avulsed greater trochanter and lateral wall breach) qualify as unstable IT fractures; however, the list is certainly not exhaustive. Disruption of lateral wall converts an IT fracture into a reverse oblique fracture equivalent and should be given a strong consideration in the decision matrix.

Posterior Malleolar Fractures Associated with Tibial Shaft Fractures and Sequence of Fixation.

Objectives: The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns. Design: Retrospective cohort study. Patients: 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers. Intervention: Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group (“malleolus-first”) consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group (“tibia-first”) included patients in whom tibial nailing was done before posterior malleolus fixation. Outcomes Measured: Intraoperative displacement, quality of reduction. Results: Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ⩽ 0.01). Conclusion: Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in associated fracture pattern. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The reporting of functional outcome instruments in the Journal of Orthopaedic Trauma over a 5-year period.

Objectives: Orthopaedic journals, such as the Journal of Orthopaedic Trauma, frequently publish studies reporting functional outcome instruments, but little information has been provided regarding the validity and overall strength of these instruments. This study analyzes the trends in reported functional outcome instruments in articles published in the Journal of Orthopaedic Trauma over a 5-year period and examines the utilization rate, “overall” strength, and validity of these functional outcome instruments for the populations being studied. Methods: Articles that were published in the Journal of Orthopaedic Trauma from January 2006 to December 2010 were reviewed, and each article was assigned to 1 of 4 different categories, based on the subspecialty focus and body region. The total number of articles reporting the use of functional outcome instruments, articles with at least 1 functional outcome instrument found in the AO Handbook, and the total number of functional outcome instruments reported were recorded. Each functional outcome instrument was assigned to 1 of 3 categories (generic, nonvalidated, validated), and each validated instrument was also examined to determine whether the category of interest for which it was used was one in which it was previously validated in. Results: A total of 171 articles (34%) of the articles initially reviewed met the inclusion criteria. The average number of articles per year that reported functional outcome instruments was 56% (range, 47%–65%), and the average number of articles that reported at least 1 validated outcome instrument was 51% (range, 44%–61%). The average percentage of validated scores that were appropriately used within the category of interest was 23% (range, 13%–41%). Conclusions: Even though the 56% utilization rate of functional outcome instruments in The Journal of Orthopaedic Trauma is much higher than other journals, it is still low given the importance of measuring and attaining excellent functional outcomes. It is clear that future effort should be given to validating outcome measures for correct evaluation of orthopaedic trauma patients.

Obesity Is Associated With High Perioperative Complications Among Surgically Treated Intertrochanteric Fracture of the Femur

Objectives: To document the complications among obese patients who underwent surgical fixation for intertrochanteric femur (IT) fractures and to compare with nonobese patients. Design: Retrospective cohort study. Setting: Four level I trauma centers. Patients: 1078 IT fracture patients. Interventions: None. Main Outcome Measures: Patient and fracture characteristics, surgical duration, surgical delay intraoperative and postoperative complications, inpatient mortality, and length of stay. Method: A retrospective review at 4 academic level I trauma centers was conducted to identify skeletally mature patients who underwent surgical fixation of intertrochanteric fractures between June 2008 and December 2014. Descriptive data, injury characteristics, OTA fracture classification, and associated medical comorbidities were documented. The outcomes measured included in-hospital complications, length of stay, rate of blood transfusion, change in hemoglobin levels, operative time, and wound infection. Results: Of 1078 unique patients who were treated for an IT fracture, 257 patients had a Body mass index (BMI) of 30 or greater. Patients with a high BMI (≥30) had a significantly lower mean age (73 vs. 77 years, P < 0.0001), higher percentage of high-energy injuries (18% vs. 9%, P = 0.0004), greater mean duration of surgery (96 vs. 86 minutes, P = 0.02), and higher mean length of stay (6.5 vs. 5.9 days, P = 0.004). The high-BMI group (n = 257) had significantly higher percentages of patients with complications overall (43% vs. 28%, P < 0.0001), respiratory complications (11% vs. 3%, P < 0.0001), electrolyte abnormalities (4% vs. 2%, P = 0.01), and sepsis (4% vs. 1%, P = 0.002). Patients with BMI ≥ 40 had a much higher rate of respiratory complications (18%) and wound complications (5%) than obese (BMI: 30–39.9) and nonobese patients (BMI < 30). Conclusion: Intertrochanteric hip fracture patients with a BMI of >30 kg/m2 are much more likely to sustain systemic complications including respiratory complications, electrolyte abnormalities, and sepsis. In addition, morbidly obese patients are more likely to sustain respiratory complications and wound infections than obese (BMI: 30–39.9 kg/m2) and nonobese patients (BMI: < 30 kg/m2). The findings from this study can help direct surgeons in the counseling to obese patients and their family, and perhaps increase hospital reimbursement for this group of patients. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous and Mucocutaneous Exposure Among Orthopaedic Surgeons: Immediate Management and Compliance With CDC Protocol.

Background: Orthopaedic surgeons are at a high risk of sustaining a percutaneous or mucocutaneous exposure to blood and body fluids. The Center for Disease Control and Prevention recommends a wash with soap and water and notification of the concerned hospital authorities after any percutaneous/mucocutaneous exposure, but a systematic amenability with these guidelines is not always seen. This cross-sectional study was undertaken to determine current knowledge and practices of orthopaedic surgeons in case of a percutaneous sharp injury exposure, emphasizes the immediate first aid steps taken after an exposure, the degree of reporting, and to explore the reasons for noncompliance. Finally, we sought to create awareness about the prevailing Center for Disease Control and Prevention guidelines after any exposure to blood or body fluids. Materials and Methods: We conducted a cross-sectional survey using an anonymous prepared questionnaire. The study population included exclusively orthopaedic surgeons, including residents, fellows, and attending physicians at 4 US institutions. The questionnaire was also available online on the OTA Web site as a part of survey monkey. The questionnaire comprised 9 multiple choice questions, and more than 1 response could be given for some questions. The questions addressed previous needle stick/sharp injury exposure, number of times that had happened, whether reported to the hospital administration, reason for nonreporting, and risk perception for transmission of blood-borne pathogens (human immunodeficiency virus, HBsAg, and hepatitis C virus). The questions were also asked based on what should be done in four different clinical settings based on respondents risk perception. Results: Of fifty eight attendings, 7 fellows, 45 residents, and 7 respondents who did not indicate their position participated in the survey for a total of 117 respondents. Out of 99, 24 had sustained it once, 18 twice, 11 three times, and 35 at least 4 times. When questioned about informing the incident to the hospital administration, 38% had always reported the incident, 33% had never reported the incident, and the remaining 29% had not reported it every time. Of note, 87% gave the correct response about the risk of transmission of human immunodeficiency virus after an exposure. On questioning about the risk of hepatitis B transmission, from an HBsAg- and HBeAg-positive source, 13% gave the correct response, whereas from HBsAg-positive and HBeAg-negative source, 30% gave the correct response. Regarding transmission of hepatitis C virus from a positive source, 36% responded correctly. The surgeons seemingly attempted to risk stratify their exposure, and they were more likely to report their exposure in the higher risk scenarios. Conclusions: This study demonstrates that orthopaedic surgeons of all levels of training are at high risk of occupational exposure to blood-borne pathogens. Moreover, despite the level of training, the majority of surgeons do not follow the recommended steps, although we do not know the reasons for such behavior. Also, there is a low awareness of the significant risk of hepatitis transmission among orthopaedic surgeons treating a population with a high prevalence of undiagnosed hepatitis.

Nail Length in the Management of Intertrochanteric Fracture of the Femur.

Intramedullary devices are used increasingly to treat intertrochanteric femur fractures, especially those with unstable patterns. In spite of the considerable use of nails in the management of these fractures, opinions differ about the correct length of intramedullary nail. Long nails were developed to address the risk of diaphyseal fracture associated with earlier short nail designs and to extend the indications for use to include diaphyseal and subtrochanteric fractures. Several recent studies, however, have found no differences between modern short nails and long nails with regard to union and complication rates. In the absence of existing guidelines, the treating surgeon’s preference and fracture characteristics continue to influence the decision of whether to use short nails or long nails. The surgeon needs to consider the fracture configuration and related factors, including whether osteoporosis is present and the cost and risk of revision surgery, when selecting the appropriate nail length.

Outcomes after orthopedic trauma: Are we meeting patient expectations?—A prospective, multicenter cohort study in 203 patients

Background: Clinical orthopedic research needs better ability to assess patient expectations with regard to orthopedic trauma surgery outcomes. The aim of this study was to investigate to which extent patient expectations prior to surgery could be met after surgery. Methods: Patients (≥18 years) with surgical ankle fractures were prospectively recruited at 5 orthopedic trauma clinics in the United States (USA), Canada, and Brazil and followed up for 12 months. Patients were asked to complete a previously validated trauma expectation factor (TEF) questionnaire prior to surgery and a trauma outcome measure (TOM) 1 year after surgery. Results: At 1 year, 155 patients had provided complete records. Almost half (49%; 76/155) had a 1-year TOM score equaling or exceeding their preoperative TEF score (95% CI: 41–57%). The remaining scores failed to meet patient expectations. TOM scores matched or exceeded patient expectations for 33% of patients in the USA and 47% in Canada, but for 69% in Brazil (p = 0.001 (USA); p = 0.024 (Canada)). This geographical effect was attributable to higher patient expectations in North America as compared to Brazil (average TEF scores: 36 (North America) versus 31 (Brazil); p < 0.001). Patients with lower household income or smokers were more likely to be satisfied with their treatment (p = 0.02 and p = 0.05, respectively). Furthermore, patients with severe type C fractures had better rates of satisfaction (62%) than patients with simpler B (50%) or type A fractures (33%) (p = 0.01 [C type versus A type]). Conclusions: Orthopedic surgeons have difficulty in meeting or exceeding presurgical patient expectations of long-term outcomes for ankle fracture surgery. This study provides evidence that culture, geography, and surgeon—patient communication have considerable influence on patient expectations.