Richard E. Grant

Antibiotic therapy in gunshot wound injuries.

Protocols for antibiotic prophylaxis in the treatment of fractures caused by gunshots have not been delineated clearly in the literature to date. The current review of the literature reveals that antibiotic therapy for treatment of these fractures is predicated on the muzzle velocity of the weapon used to inflict the fracture. General consensus has been reached regarding the requirement of at least 24 hours of intravenous antibiotic treatment in fractures caused by high-velocity weapons in conjunction with the appropriate wound and fracture care. Similarly, in fractures caused by shotguns, thorough wound debridement and 24- to 48-hour administration of intravenous antibiotics is necessary. However, in fractures caused by low-velocity weapons, there is not a preponderance of the evidence showing that there is a distinct advantage to using antibiotic prophylaxis in these injuries. Special clinical consideration must be given regarding the use of antibiotics in fractures caused by gunshots that are intraarticular and those about the hand, foot, and ankle.

Evaluation of proximal femoral geometry using digital photographs

The morphologic features of the proximal femur are used in preoperative planning prior to total hip arthroplasty. Recent literature evaluating the anatomy of the proximal femur, as it relates to total hip arthroplasty, has relied heavily on radiographs or computed tomography. We used digital photographs to compare 200 cadaveric femora in individuals who died prior to 40 years of age: 25 African‐American males, 25 African‐American females, 25 Caucasian males, 25 Caucasian females. With our technique and definition, the actual angles and dimensions of the proximal femur that we normally rely on during total hip arthroplasty were measured. There were small, but statistically significant differences, between males and females in neck‐shaft angle, neck inclination, and absolute horizontal and vertical offset. Females tended to have a lower neck‐shaft angle and more neck inclination. When standardizing the offset distances with femoral head diameter, the horizontal offset ratio was higher in female specimens. There was no correlation between horizontal and vertical offset. Improved knowledge of the morphology of the proximal femora will assist the surgeon in restoring the geometry of the proximal femur during total hip arthroplasty. This information also supports the concept of modularity of the femoral neck in order to independently adjust neck‐shaft angle, neck inclination, and horizontal offset.

Orthopedic communication about osteoarthritis treatment: Does patient race matter?

To understand racial disparities in the use of total joint replacement, we examined whether there were racial differences in patient‐provider communication about treatment of chronic knee and hip osteoarthritis in a sample of African American and white patients referred to Veterans Affairs orthopedic clinics.

The evaluation of two references for restoring proximal femoral anatomy during total hip arthroplasty

The morphologic features of the proximal femur are used in preoperative planning prior to total hip arthroplasty (THA). In this study we evaluated two references that have been widely used during THA to restore the normal anatomy of the proximal femur: (1) the distance from the lesser trochanter to the center of femoral head and (2) the anatomic relationship between the greater trochanter and the center of femoral head. We used digital photographs to compare 200 cadaveric femora in individuals who died prior to 40 years of age. Preoperative measurement of the distance from lesser trochanter to the center of femoral head from the contralateral hip is accurate to predict the measurement on the operated hip with correlation coefficients (r2) of 0.87. The ratio between femoral head diameter and distance from the lesser trochanter to the center of femoral head was consistent and reliable between genders and sides with an average value of 1.01 ± 0.12. Thus, when the distance from the lesser trochanter to the center of femoral head is not discernible, this ratio can be used as a guide to determine proximal femoral geometry. Conversely, only 59% of the specimens had femoral head centers within 5 mm of the tip of greater trochanter. The correlation between sides of the relationship between the greater trochanter and the center of femoral head was moderate (r2 = 0.46). Therefore, this relationship should not be used as the sole method to determine the normal anatomy of proximal femur. Clin. Anat. 23:312–318, 2010.

Expansion of the coordinator role in orthopaedic residency program management.

The Accreditation Council of Graduate Medical Education’s (ACGME) Data Accreditation System indicates 124 of 152 orthopaedic surgery residency program directors have 5 or fewer years of tenure. The qualifications and responsibilities of the position based on the requirements of orthopaedic surgery residency programs, the institutions that support them, and the ACGME Outcome Project have evolved the role of the program coordinator from clerical to managerial. To fill the void of information on the coordinators’ expanding roles and responsibilities, the 2006 Association of Residency Coordinators in Orthopaedic Surgery (ARCOS) Career survey was designed and distributed to 152 program coordinators in the United States. We had a 39.5% response rate for the survey, which indicated a high level of day-to-day managerial oversight of all aspects of the residency program; additional responsibilities for other department or division functions for fellows, rotating medical students, continuing medical education of the faculty; and miscellaneous business functions. Although there has been expansion of the role of the program coordinator, challenges exist in job congruence and position reclassification. We believe use of professional groups such as ARCOS and certification of program coordinators should be supported and encouraged.

Spinal cord injury caused by gunshot wounds: the cost of rehabilitation

The current authors did a retrospective review of the medical records of 47 patients with spinal cord injury secondary to gunshot wounds who were admitted to National Rehabilitation Hospital between 1993 and 1999. There were 44 male patients and three female patients; the mean age of the patients was 24.7 years (range, 15–56 years). Thirty-seven patients had paraplegia (27 had complete paraplegia, 10 had incomplete paraplegia) as a result of their gunshot wounds, and 10 had quadriplegia (eight had complete quadriplegia, two had incomplete quadriplegia). None of the weapons were identified. The most common firearm types were low-velocity weapons. The length of acute hospitalization increased with the number of associated injuries. Rehabilitation total length of stay was proportional to the injury classification (paraplegia, quadriplegia). The daily occupancy fee in the National Rehabilitation Hospital was approximately

A synopsis of urban firearm ballistics: Washington, DC model.

1900. Patients were admitted to the hospital when acute medical and surgical problems had been cleared and when they were ready to participate in rehabilitation and therapy.

A Modified Ogata-Goldsand Technique for Simplified Intraoperative Measurement of Femoral Version.

Although current statistics are available pertaining to weapon retrieval rates, the evolution of ballistics in most metropolitan areas has not been critically examined and correlated with the resultant impact on public health. Of special concern to law enforcement agencies and urban Level 1 trauma centers is the unabated increase in the availability of firearms with accelerated firepower capable of increased kinetic energy and reduced time to exhaust the weapons magazine. The firearms statistics from the Washington, DC area were examined retrospectively by review of the records of the Firearms and Toolmark Examination section of the Metropolitan Police Department. The data from 1999 indicate that 57% of the firearms confiscated during criminal apprehension and prosecution were semiautomatic weapons. However, 51% of the firearms recovered during amnesty programs were revolvers and 23% were semiautomatic weapons. In the District of Columbia, during a 4.5-month period in 1999, the cost of medical treatment of patients with gunshot wound injuries averaged 15,000.00 US dollars per patient with costs of rehabilitation reaching an estimated 40,000.00 US dollars per patient.

Has Diversity Increased in Orthopaedic Residency Programs since 1995

Background: Femoral anteversion can be difficult to determine intraoperatively, particularly in cases with complicated deformity. Although biplanar methodology exists for measuring femoral anteversion, the measurements are generally based on the proximal femur, without consideration for the femoral bow. Methods: We directly measured femoral version in 70 mature cadaveric femora. Using the standard Ogata-Goldsand approach, femoral version was geometrically calculated after measuring apparent neck-shaft angle and the &bgr;-angle, which is the angle between the femoral neck and proximal femoral shaft on a direct lateral view. We then used a modified &bgr;-angle, measured between the femoral neck and a line representing the entire femur. Results: Mean anatomic femoral anteversion was 20±11 degrees. Mean calculated femoral version using the standard Ogata-Goldsand technique was 32±13 degrees, whereas mean calculated femoral version using the modified Ogata-Goldsand technique was 22±12 degrees. Repeated measures ANOVA analysis found an overall statistically significant difference between the 3 groups (P<0.0001). Pairwise comparisons revealed a significant difference between directly measured version and the standard Ogata-Goldsand technique (P<0.0001) but not between directly measured version and the modified Ogata-Goldsand technique (P=0.76). Conclusions: Standard biplanar imaging techniques do not account for the femoral bow and can significantly overestimate femoral anteversion. If a line is drawn from the posterior femoral condyles to the posterior aspect of the greater trochanter, femoral anteversion is better approximated. Intraoperatively, we obtain this line by positioning a marker over the skin under fluoroscopy. Clinically, if one aims for a modified &bgr;-angle of 5 degrees, a postosteotomy anteroposterior radiograph is no longer necessary, given the knowledge that with apparent neck-shaft angles ranging from 115 to 155 degrees, version will lie within a generally accepted range between 2 and 11 degrees. Clinical Relevance: In complex operative cases where imaging is desired to measure intraoperative femoral version, we recommend a modified and simplified lateral view measurement technique, which improves accuracy by accounting for the femoral bow.