North Carolina Orthopaedic Association 2015 Annual Meeting · OREF Piedmont Orthopedic Society DUMC Department of Orthopaedic Surgery Surgical Skills Acquisition Classic Education:

This continuing medical education activity is jointly provided by the NCOA and the Southern Regional Area Health Education Center

2015 Annual MeetingSpine/Basic Science/Education/Foot & Ankle/Trauma Sunday, October 11

October 9-11, 2015 • Kiawah Island Golf Resort Kiawah Island, South Carolina

North Carolina Orthopaedic Association

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THE EFFECT OF COMPUTER-

ASSISTED SURGERY TRAINING

IN THE PLACEMENT OF

ILIOSACRAL SCREWS

Elizabeth W. Hubbard, MD

NCOA October 11, 2015

Funding

OREF

Piedmont Orthopedic Society

DUMC Department of Orthopaedic Surgery

Surgical Skills Acquisition

Classic Education:

“See one, do one, teach one…”

The changing healthcare system

80 hour workweek

Reimbursement based on outcomes

The Dilemma—creating competent surgeons when

1. Trainees have less hands-on training

2. Need to teach skills in a way that is safe for patients

Computer Navigation Assisted Training

Goften et al JBJS 2007

Acetabular cup position

Computer navigation trained group:

Better accuracy

Better precision throughout training

Nousianen et al JOT 2013

Guidewire placement for femoral neck fractures

Computer navigation trained group:

Faster

Fewer attempts

No evidence of dependence on computer navigation

Goal of Study

Determine the effect of computer navigation

assisted training on learning a complex surgical skill

Overall Structure

1. Pre-test

Instructional video

All participants place S1 and S2 guidewires using

fluoroscopy

2. Randomization (Post-test)

Repeat instructional video

Expert instruction provided during guidewire placement

21 subjects: fluoroscopy; 20 subjects: computer navigation

3. Retention test—4 weeks after pre-test

4. Transfer test—4 weeks after pre-test

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Methods

41 Subjects

Surgical trainees

Senior medical students

40 completed full study (97.5% follow-up)

Data Analyzed

Total time to wire placement

Total fluoroscopy time used

Attempts at wire placement

Perforation

Overall rate

Grade of perforation (Hinsche et al CORR 2002, Zwingmann et al CORR 2009)

Set-Up

Based off a design created by Riehl

& Widmaier J Surg Ed 2011.

Fluoroscopy Computer Navigation

BrainLab Trauma (BrainLab,

Westchester, IL)

Computer Navigation (Cont.)

Set-up based off a design created by

Riehl & Widmaier J Surg Ed 2011.

BrainLab Trauma (BrainLab,

Westchester IL)

Computer Navigation (Cont.)

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Time to Wire Placement

Time to Wire

Placement

Fluoroscopy Time

Fluoroscopy Time

(min)

Perforation Grade: SI Guidewires

Perforation Grade:

S1 Guidewires

Perforation Grade: S2 Guidewires

Perforation Grade:

S2 Guidewires

Discussion

Trends towards improved accuracy regardless of training tool

Computer Navigation

Performed faster, even when using fluoroscopy

Less radiation exposure

Trend towards more accurate S1 placement

Retention and transfer test results

Lasting memory of motor skills

Subjects did not seem to develop a dependency on computer navigation

Limitations

Simulated environment

Does not account for individual patient factors that

affect surgery (body habitus, etc)

Technical issues with pelvi

Variation in fluoroscopic images between pelvi

Design of some sawbones interfered with wire

placement

Subject knowledge/skill level

Variation between medical students and surgical

trainees

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Conclusions

Computer navigation is a potential tool for teaching

complex surgical tasks

Efficient

Safe

Less radiation exposure

Performed in a controlled environment rather than on a

patient in the OR

Results suggest that trainees can transfer skills

No evidence of dependence on navigation

Thank you

Co-Authors:

Erika Templeton, MD

William C. Eward, DVM, MD

Cindy L. Green, PhD

Markku T. Nousiainen, MS, Med, MD, FRCS(C)

Robert D. Zura, MD

North Carolina Orthopaedic Association

References

1. Gofton W, Dubrowski A, Tabloie F, Backstein D: The effect of computer navigation on trainee learning of surgical skills. The Journal of bone and joint surgery American volume 2007;89:2819-2827.

2. Nousiainen MT, Omoto D, Zingg P, Weil YA, Mardam-Bey SW, Eward WC: Training Femoral Neck Screw Insertion Skills to Surgical Trainees: Computer-Assisted Surgery Versus Conventional Fluoroscopic Technique. Journal of orthopaedic trauma 2012.

3. Hinsche AF, Giannoudis PV, Smith RM: Fluoroscopy-based multiplanarimage guidance for insertion of sacroiliac screws. Clinical orthopaedics and related research 2002:135-144.

4. Zwingmann J, Konrad G, Kotter E, Sudkamp NP, Oberst M: Computer-navigated iliosacral screw insertion reduces malposition rate and radiation exposure. Clinical orthopaedics and related research 2009;467:1833-1838.

5. Riehl J, Widmaier J: A simulator model for sacroiliac screw placement. Journal of Surgical Education 2011;xx:1-4.

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A NOVEL LOCAL CANCELLOUS

AUTOGRAFT SOURCE FOR ANTERIOR

CERVICAL DISCECTOMY AND FUSION: A TECHNIQUE DESCRIPTION AND COMPARATIVE STUDY

Conor O’Neill1,2, Zakk Walterscheid1,2, Dr. Caleb Behrend1,2, Dr. Jonathan Carmouche1,2

1Virginia Tech Carilion School of Medicine2Carilion Clinic Orthopaedics-Musculoskeletal Education and Research Center

DISCLOSURES

» Conor O’Neill: None

» Zakkary Walterscheid: None

» Caleb Behrend: None

» Jonathan Carmouche:

» Member, Exhibits Committee, AAOS

» Member, Education Committee, Scoliosis Research Society

INDICATIONS FOR ACDF HISTORICAL PERSPECTIVE

Smith GW, Robinson RA. The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am. 1958;40:607–624.

ILIAC CREST BONE GRAFT

» Donor Site Morbidity reported as high as 49%

Peelle, Michael. "A Novel Source of Cancellous Autograft for ACDF Surgery: The Manubrium." J Spinal Disord Tech 20.1 (Feb 2007): 36-41. Print.

Banwart, J. C., M. A. Asher and R. S. Hassanein (1995). "Iliac crest bone graft harvest donor site morbidity. A statistical evaluation." Spine (Phila Pa 1976) 20(9): 1055-1060.

ALTERNATIVE GRAFTS

» Alternative graft materials

» Allograft

» Demineralized Bone matrix

» Mineralized Bone matrix

» Xenograft

» Synthetic Bone Graft

» Ceramics

» Hydroxyapatite

» Bioactive Materials

» Bone Morphogenic Protein

» Bone Marrow Aspirate

Anderson, DG and Albert, TJ. “Bone grafting, implants, and plating options for anterior cervical fusion.” Orthop Clin North Am (2002) 33:317-328. Print.

Chau, Anthony and Mobbs, Ralph. “Bone graft substitutes in anterior cervical discectomy and fusion.” Eur Spine J (2009) 18:449-464. Print.

» Alternative graft Sites

» Manubrium

» Clavicle

» Rib

» Patella

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META-ANALYSIS FUSION RATES

» Range of Autograft Fusion Rate 90-100%

» Range of Allograft fusion ranges from:

» 32-100%

» Meta-Analysis Allograft Fusion Rate 78%» Floyd, Timothy. “A meta-analysis of autograft versus allograft in

anterior cervical fusion.” Eur. Spine J (2000) 9: 398-403.

Peelle, Michael. "A Novel Source of Cancellous Autograft for ACDF Surgery: The Manubrium." J Spinal Disord Tech 20.1 (Feb 2007): 36-41. Print.

Floyd, Timothy. “A meta-analysis of autograft versus allograft in anterior cervical fusion.” Eur Spine J (2000) 9: 398-403. Print.

» Graft Materials

» Alternative Graft Sites

NOVEL GRAFT SITE

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RESULTS

Pre-Op

Post-Op

0

1

2

3

4

5

6

7

8

9

10

Average Neck VAS Score

Pre-Op

Post-Op

0

1

2

3

4

5

6

7

8

9

10

Average Arm VAS Score

RESULTS

95100

0

10

20

30

40

50

60

70

80

90

100

ICBG Adjacent Vertebra

Percent Fusion following ACDF

*Fusion based upon x-ray and resolution of clinical symptoms

RESULTS

49

00

10

20

30

40

50

60

70

80

90

100

ICBG Adjacent Vertebra

Percent Reported Iliac Crest Morbidity

Banwart, J. C., M. A. Asher and R. S. Hassanein (1995). "Iliac crest bone graft harvest donor site morbidity. A statistical evaluation." Spine (Phila Pa 1976) 20(9): 1055-1060.

RESULTS

Complications Percentage

Infection 0%

Fracture 0%

Implant Subsidence 0%

Pseudoarthroses 0%

Revision Operation 0%

CONCLUSIONS

» The present study demonstrates:

» Similar rates of reduction of neck and arm pain in the published literature

» Safety and Efficacy of New Technique

» Maintenance of high fusion rate characteristic of autologous bone graft

» Technique avoids morbidity associated with second surgical site

LIMITATIONS

» Pilot study

» Small Sample Size

» Short follow-up

» Average follow-up = 10.79 months

» Fusion based upon x-ray and resolution of clinical symptoms

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REFERENCES» An, H. S., J. M. Simpson, J. M. Glover and J. Stephany (1995). "Comparison between allograft plus demineralized bone matrix versus autograft in anterior

cervical fusion. A prospective multicenter study." Spine (Phila Pa 1976) 20(20): 2211-2216.

» Anderson, DG and Albert, TJ. “Bone grafting, implants, and plating options for anterior cervical fusion.” Orthop Clin North Am (2002) 33:317-328. Print.

» Banwart, J. C., M. A. Asher and R. S. Hassanein (1995). "Iliac crest bone graft harvest donor site morbidity. A statistical evaluation." Spine (Phila Pa 1976)

20(9): 1055-1060.

» Berven, S., B. K. Tay, F. S. Kleinstueck and D. S. Bradford (2001). "Clinical applications of bone graft substitutes in spine surgery: consideration of mineralized and demineralized preparations and growth factor supplementation." Eur Spine J 10 Suppl 2: S169-177.

» Chau, A. M. and R. J. Mobbs (2009). "Bone graft substitutes in anterior cervical discectomy and fusion." Eur Spine J 18(4): 449-464.

» Cloward, R. B. (1988). "The anterior surgical approach to the cervical spine: the Cloward Procedure: past, present, and future. The presidential guest

lecture, Cervical Spine Research Society." Spine (Phila Pa 1976) 13(7): 823-827.

» Floyd, T. and D. Ohnmeiss (2000). "A meta-analysis of autograft versus allograft in anterior cervical fusion." Eur Spine J 9(5): 398-403.

» Iwasaki, K., T. Ikedo, H. Hashikata and H. Toda (2014). "Autologous clavicle bone graft for anterior cervical discectomy and fusion with titanium interbodycage." J Neurosurg Spine 21(5): 761-768.

» Jacobs, W. C., P. G. Anderson, J. Limbeek, P. C. Willems and P. Pavlov (2004). "Single or double-level anterior interbody fusion techniques for cervical

degenerative disc disease." Cochrane Database Syst Rev(4): CD004958.

» Lied, B., P. A. Roenning, J. Sundseth and E. Helseth (2010). "Anterior cervical discectomy with fusion in patients with cervical disc degeneration: a prospective outcome study of 258 patients (181 fused with autologous bone graft and 77 fused with a PEEK cage)." BMC Surg 10: 10.

» Lu, D. C., L. M. Tumialan and D. Chou (2013). "Multilevel anterior cervical discectomy and fusion with and without rhBMP-2: a comparison of dysphagia rates and outcomes in 150 patients." J Neurosurg Spine 18(1): 43-49.

» Matz, P. G., L. T. Holly, M. W. Groff, E. J. Vresilovic, P. A. Anderson, R. F. Heary, M. G. Kaiser, P. V. Mummaneni, T. C. Ryken, T. F. Choudhri, D. K. Resnick, S. Joint Section on Disorders of the, S. Peripheral Nerves of the American Association of Neurological and S. Congress of Neurological (2009). "Indications for anterior cervical decompression for the treatment of cervical degenerative radiculopathy." J Neurosurg Spine 11(2): 174-182.

» Peelle, M. W., B. A. Rawlins and P. Frelinghuysen (2007). "A novel source of cancellous autograft for ACDF surgery: the manubrium." J Spinal Disord Tech

20(1): 36-41.

» Pollock, R., I. Alcelik, C. Bhatia, G. Chuter, K. Lingutla, C. Budithi and M. Krishna (2008). "Donor site morbidity following iliac crest bone harvesting for cervical fusion: a comparison between minimally invasive and open techniques." Eur Spine J 17(6): 845-852.

» Radhakrishnan, K., W. J. Litchy, W. M. O'Fallon and L. T. Kurland (1994). "Epidemiology of cervical radiculopathy. A population-based study from

Rochester, Minnesota, 1976 through 1990." Brain 117 ( Pt 2): 325-335.

» Schnee CL, Freese A, Weil RJ, Marcotte PJ (1997) Analysis of harvest morbidity and radiographic outcome using autograft for anterior cervical fusion. Spine 22:2222–2227.

» Smith, G. W. and R. A. Robinson (1958). "The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody

fusion." J Bone Joint Surg Am 40-A(3): 607-624.

Figure 1

Figure 3 Figure 4

Figure 2

Pre-Op

Post-Op

0

2

4

6

8

10

Average Neck VAS Score

Pre-Op

Post-Op

0

2

4

6

8

10

Average Arm VAS Score

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Impact of Bone MorphogenicProtein-7 (BMP-7) on Cell Migration

on the MeniscusVictor Taylor II, Ph.D.Ian Hutchinson, M.D.Kerry Danelson, Ph.D.Cristin Ferguson, M.D.

Introduction

• Osteoarthritis is the most frequent cause of disability among adults in the United States

• Damage or loss of meniscus tissue is associated with degeneration of the joint

Normal

OA

Meniscus Repair

• Interluekin-1 is a pro-inflammatory cytokine

– Inhibits repair processes

• BMP-7 is an anabolic growth factor

– Supports matrix synthesis in articular cartilage even in the presence of IL-1

• Limited research involving BMP-7 and meniscus repair

Objective of the Study

• Examine the effects of BMP-7 on cell migration in an in vitro meniscus repair model

• Evaluating the potential of BMP-7 to augment meniscus repair

Method

• Tissue: Porcine knees from local abattoir– Female, >/= 3 years old– 6mm meniscus explants created with a

biopsy punch• Collagen type 1 scaffold sandwiched

between meniscus explants in a cloning tube to create a one-dimensional growth factor diffusion gradient– Control– Treated scaffold

• BMP-7• PDGF-AB• IL-1a• BMP-7+ IL-1a

• Incubation for 28 days in Dulbecco Modified Eagle Medium with 10% fetal bovine serum– In untreated scaffolds- meniscus cells

migrate toward media as source of nutrition (away from scaffold Adapted from: Can platelet-rich plasma enhance anterior cruciate

ligament and meniscal repair? J Knee Surg. 2015 Feb; 28(1): 19-28.Hutchinson ID, Rodeo SA, Perrone GS, and Murray MM.

Method

• 4',6-diamidino-2-phenylindole (DAPI) histology Stain

• Cell Count between 3 zones– Inner– Middle– Outer

• Five groups– Control (n=7)– BMP-7 (n=8)– PDGF-AB (n=2)– IL-1 alpha (n=4)– BMP-7 + IL-1 (n=4)

Outer

Middle

Inner

Inner

Middle

Outer

Media

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Results

BMP-7

• Inner zone- 26%

• Middle zone- 40%

• Outer zone- 35%

PDGF• Inner zone- 23%• Middle zone- 37%• Outer zone- 40%

Control• Inner zone- 26%• Middle zone- 29%• Outer zone- 45%

Results

IL-1 alpha

• Inner zone- 23%


• Outer zone- 45%

BMP-7 + IL-1 alpha

• Inner zone- 17%


• Outer zone- 58%

Discussion

• Preliminary results suggest BMP-7 may induce cell migration in meniscus tissue

• Impact of local BMP-7 on proteoglycan production will be analyzed

• Additional cell culture based studies will compare local proliferation versus migration effects

Acknowledgements

• Cristin Ferguson M.D. (mentor)

• Kerry Danelson, Ph.D.

• Ian Hutchinson, M.D.

• Institutional Research and Academic Career Development Awards (IRACDA) (NIH/NIGMS K12 PAR-13-290)

Questions

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Whole Body Vibration Increases Cartilage Thicknessand Cancellous Bone Strength, but Not Femoral

Neck Strength or Bone MineralDensity.

William Runge, MS1, Laurence Dahners, MD1, Denis Marcellin-Little, DEDV2, Ola Harryson, PhD2, David Ruppert,

MS1,2, Paul Weinhold, PhD1

1University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

2North Carolina State University, Raleigh, NC, USA.

Introduction

• Whole body vibration (WBV) has been proposed as a non-pharmaceutical intervention for osteoporosis

• WBV provides mechanical stimulation that may drive bone growth

• Previous studies on WBV have shown modest changes in bone mineral density1, but few have assessed changes in bone strength or cartilage properties

• Optimal parameters for whole body vibration are unknown2

Hypothesis

• Short duration exposure to WBV can produce measurable changes in– Bone mineral density

– Cancellous bone strength

– Femur neck strength

– Medial epicondyle cartilage thickness

• Studying a range of treatment amplitudes might identify optimal parameters for the application of this therapy

Methods

• 80 adult Sprague-Dawley rats, divided into 5 groups of 16 animals each

• Each group was assigned to 0, 0.15, 0.3, 0.6, or 1.2g of sinusoidal vibration at 45 Hz, using an electromagnetic shaker

• 15 minutes of vibration therapy per day, for 6 weeks• Animals sacrificed at end of 6 weeks, and femurs isolated• Mechanical tests conducted at constant displacement rate on a load

cell as described 3

• Bone mineral density measured on Hologic QDR Disovery A DXA machine, using regions of interested modeled after those used in vitro4

• Cartilage thickness measured based on histologic sections of a subset of animals, using an ImageJ processing routine that averages the thickness of the cartilage across the weight-bearing area

Methods Results: Bone mineral density

No significant difference in bone mineral density between individual groups or when vibrated animals are lumped and compared to control

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Results: Mechanical strenth

• 70% increase in cancellous bone strength in the vibrated animals versus the control

• No change in femur neck strength between groups

Results: Cartilage thickness

• Vibrated animals had significantly thicker (30%) cartilage on the medial condyle compared to the control

Conclusion

• WBV over a 6-week treatment period causes a large improvement (70% increase) in strength of the distal femoral cancellous bone

• WBV also significantly increases the cartilage thickness at the medial epicondyle of the femur

• WBV does not alter bone mineral density on this treatment timeline

• WBV also does not alter femur neck strength on this treatment timeline

• No clearly optimal amplitude for vibration therapy

References

1. Verschueren et al. (2004). Journal of Bone and Mineral Research, 19(3), 352-359.

2. Wysocki et al. (2011). Annals of Internal Medicine, 155(10), 680-686, W206-13.

3. Ke et al. (1998). Bone, 23(3), 249-255.

4. Sievanen et al. (1994). Journal of Bone

and Mineral Research, 9(4), 473-478.

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A Prospective Evaluation of Three Serum Biomarkers in Hip Arthroscopy Patients and Matched Controls

Austin V. Stone MD, PhD* | Elizabeth A Howse MD‡

Christopher Stem* | Allston J. Stubbs MD, MBA*

North Carolina Orthopaedic Association 2015 Annual Meeting, Kiawah Island, SC

*Department of Orthopaedic SurgeryWake Forest School of Medicine, Winston-Salem, NC USA‡Department of Emergency Medicine, Kaiser Permanente, San Francisco, CA USA

DisclosuresAllston J. Stubbs MD, MBAFinancial relationships with the following companies:

• Consultant: Smith & Nephew

• Stock: Johnson & Johnson

• Research Support: Bauerfeind

• Department Support: Smith & Nephew Endoscopy, Depuy, Mitek

• Boards/Committees: AOSSM, ISHA, AANA

Austin V. Stone MD, PhD• Research Support: Smith & Nephew

Dr. Howse and Mr. Stem have nothing to disclose.

This study funded by the Department of Orthopaedic Surgery, Wake Forest School of Medicine.

Introduction

• Unknown predicative value of serum biomarkers

• FAI and hip dysplasia are implicated in articular cartilage destruction

• Vascular cell adhesion molecule-1 (VCAM-1) predictive of progressing to hip or knee replacement surgery

• IL-6 and cartilage oligomeric matrix protein (COMP)

Hip Arthroscopy Surgical Candidates

(n=20)

Age and Gender Matched Controls

(n=10)

Serum Biomarkers VCAM, COMP, IL-6

Serum Biomarkers VCAM, COMP, IL-6

Hip Arthroscopy

Serum Biomarkers

The serum biomarkers increased together.

R = 0.579; p=0.007

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Age, BMI, VCAM-1 and COMP were significant predictors of the Vail functional Hip Score (p=0.012). Most significant predictors were VCAM-1 level (p=0.016) and the BMI (p=0.011).

Vail Hip Score

significant correlations

modified Harris hip score (R = 0.671; p<0.001)

SF-36 (R = 0.702; p=0.007)

NHS (R = 0.880; p<0.001)

MHOT total score (R=0.765; p<0.001)

Discussion

VCAM-1, IL-6, and COMP were not different between pre-arthritic hip pain patients and matched controls.

Elevated pre-arthritic markers may predict patient functional outcomes reported in the Vail Hip Score.

Acknowledgements

Wake Forest School of Medicine Hypertension and Vascular CenterDr. Bridget Brosnihan

Hypertension Core Laboratory

Funding provided by a Wake Forest School of Medicine Medical Student Research Grant and the Department of Orthopaedic Surgery.

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The July Effect:

Does Time During the Academic Year and

Level of Resident Involvement Affect

Complication Rates in Lower Extremity

Orthopaedic Trauma?

Aaron J. Casp MD1, Brendan M. Patterson, MD2,

Benjamin R. Parker MD2, Joshua N. Tennant MD2

1University of Virginia Department of Orthopaedic Surgery2University of North Carolina Department of Orthopaedics

Introduction

• Surgical complications are becoming more

important in the current regulatory

landscape

• The “July effect”: is it real?

Edelstein et al., Impact of Resident Involvement on Orthopaedic Surgery Outcomes. JBJS. 2014 96(15):e131.

Schoenfeld et al., The Impact of Resident Involvement on Post-Operative Morbidity and Mortality Following Orthopaedic

Procedures. Arch Orthop Trauma Surg 2013 133(11):1483-91.

• July effect in orthopaedic trauma has not

been previously investigated

• Association between level

of resident and complication

rates is unknown

Introduction

Edelstein et al., Impact of Resident Involvement on Orthopaedic Surgery Outcomes. JBJS. 2014 96(15):e131.

Schoenfeld et al., The Impact of Resident Involvement on Post-Operative Morbidity and Mortality Following Orthopaedic

Procedures. Arch Orthop Trauma Surg 2013 133(11):1483-91.

Methods

• Identified top 2 ACGME resident case

requirements for lower extremity fractures:» Operative fixation of hip fractures

» Operative fixation of femoral fractures, or tibial shaft

fractures

• Utilized American College of Surgeons

National Quality Improvement Program

(NSQIP) database, 2005-2012

Methods – Cases Analyzed

Lower Extremity Trauma Procedures Analyzed

Procedure Description CPT code

Percutaneous Hip Pinning 27235

Hip hemiarthroplasty 27236

Sliding hip screw for hip fracture 27244

Intramedullary nail fixation of hip fracture 27245

Intramedullary nail fixation of femoral shaft fracture 27506

Plate & screw fixation of femoral shaft fracture 27507

Plate & screw fixation of tibial shaft fracture 27758

Intramedullary nail fixation of tibial shaft fracture 27759

Methods - Analysis

• Compared complication rates in the first

academic quarter with that of the rest of

the year

• Analysis was completed for all residents,

then separately for junior residents

(PGY1,2 or 3) and senior residents

(PGY4,5 or 6)

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Methods – Outcome Variables Serious Adverse Events

Any Adverse Events Results – Serious Adverse Events

†P-value= 0.0324

Results – Any Adverse Events

†P-value= 0.0444

‡P-value= 0.0238

Conclusions

• There is no evidence of a July effect in lower

extremity orthopaedic trauma surgery» This holds true for all residents, and separately for junior and

senior residents

» In agreement with previous literature on elective orthopaedic

surgery

• Senior residents have a higher Any Adverse

Event rate than junior residents in the first half

of the year» More supervision at the beginning of the year?

Bohl et al., “The ‘July Effect’ in Primary Total Hip and Knee Arthroplasty.” J Arthroplasty. 2014 29(7):1332-8

Bohl et al., “‘July Effect’ in Elective Spine Surgery.” Spine 2014. 39(7):603-11.

.

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Thank You References• Bohl et al., The ‘July Effect’ in Primary Total Hip and Knee Arthroplasty. J

Arthroplasty. 2014 29(7):1332-8.

• Bohl et al., ‘July Effect’ in Elective Spine Surgery. Spine 2014. 39(7):603-11.

• Edelstein et al., Impact of Resident Involvement on Orthopaedic Surgery

Outcomes. JBJS 2014. 96(15):e131.

• Pugely et al., The Effect of Resident Participation on Short-term Outcomes

After Orthopaedic Surgery. CORR 2014 472(7):2290-2300

• Schoenfeld et al., The Impact of Resident Involvement on Post-Operative

Morbidity and Mortality Following Orthopaedic Procedures. Arch Orthop

Trauma Surg 2013. 133(11):1483-91.

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Gabriella Ode, MD; Bryan Loeffler, MD; R. Chris Chadderdon, MD; Nikkole Haines, MD; Brian Scannell, MD;

Joshua Patt, MD, MPH; Glenn Gaston, MD

Background

Wrist Arthroscopy

• Challenging discipline to gain proficiency

• Limited exposure during residency

Background

Computer Simulated Arthroscopy Training

• Shown to improve user proficiency in knee arthroscopy.

• No wrist arthroscopy simulation models are readily available.

• No studies exist which evaluate the translatability of joint-specific arthroscopy skills to other anatomic joints.

Purpose

• To investigate whether simulated knee arthroscopy training translates to improved wrist arthroscopy proficiency.

MethodsSubjects

• 26 orthopaedic residents (April 2014 – Aug 2014) participated in arthroscopy simulation training program over a 4-week period.

– 21 PGY1 to PGY5 from the 20132014 academic year

– 5 matriculating PGY1 from the 20142015 year (PGY0).

Methods• Preparation Materials

– 5 minute Demo video of test landmarks performed by experienced Hand Surgeon

– Wrist Anatomy Review

– 2 Book chapter excerpts on wrist arthroscopy• Hand Surgery, 1st Ed. “Principles of Portal Placement and Anatomy”

• Green’s Operative Hand Surgery. “Chapter 18 – Wrist Arthroscopy: Anatomy and Diagnosis”

– JAAOS Review on Wrist Arthroscopy• “ Wrist Arthroscopy: Principles and Clinical Applications – Gupta et al”

– VuMedi.com Videos

• “Wrist Arthroscopy Portal Placement”

• “Arthroscopic Anatomy of the Wrist”

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MethodsBaseline Assessment

• Subjects video-recorded performing cadaveric diagnostic wrist arthroscopy

• 10 minutes allotted to ID 23 anatomic landmarks in 4 portals

• Arthroscopy footage synchronized with video of the trainees’ de-identified hands.

MethodsTest Objectives

Test Objectives (10 min. allotted)

3, 4 portal:

Scaphoid

Scaphoid facet

RSC ligament

Long RL

ligament

RSL ligament

Short RL

ligament

Interfossal

ridge

Lunate

Lunate facet

TFCC

SL ligament

6, R portal:

Ulnar

extrinsic

ligaments

TFCC

LT ligament

Mid-carpal

ulnar portal:

Capitate

Capitohamate

joint

LT ligament

Lunate

SL ligament

Arcuate

ligament

Mid-carpal

radial

portal:

Capitate

SL

ligament

LT ligament

MethodsIntervention

Subjects given 4 weeks to complete a diagnostic knee arthroscopy module on the ArthroSim knee simulator (Touch of Life Technologies, Aurora, CO). ArthroSim:

high fidelity, virtual reality simulator that features haptic feedback and real-time manipulation of a leg to simulate the movements of the leg when performing knee arthroscopy.

Endorsed by AAOS for knee simulation training

Completion = Achieve at least 80% proficiency in all modules for a simulated diagnostic knee scope.

Methods

Post-Simulation Assessment (@ 4 weeks)

Repeat of video-recorded diagnostic arthroscopy procedure on same cadaver wrist

Pre- and Post-Simulation performance on wrist arthroscopy performance reviewed and graded in double-blinded fashion by 3 experienced hand surgeons.

ASSET (Arthroscopic Surgery Skill Evaluation Tool)

• Likert Scale:

– 1= Novice; 3 = Competent; 5 = Expert

– Range of 9-41 pts

• Domains:

– Safety (1-5pt)

– Field of View (1-5pt)

– Camera Dexterity (1-5pt)

– Instrument Dexterity (1-5pt)

– Bimanual Dexterity (1-5 pt)

– Flow of Procedure (1-5pt)

– Quality of Procedure (1-5pt)

– Autonomy (1-3pt)

– Added Complexity of Procedure (1-3pt)

Objective Data

• Composite Score

– ASSET Global Rating Scale

– Task Completion Score

– Completion Time Bonus• Max time allotted (600s) – Time spent (s) ÷ 10

Total Score = ASSET + Completion Score + Time Score

100% 75%-99% 50%-74% 25%-49% >25%

20pts 15pts 10pts 5 pts 0 pts

9/24/2015

3

Subjective Data

• Resident Pre- and Post-Simulation Surveys

– Demographics

• Age, Sex, Program year, handedness, video game experience

– Estimated Arthroscopy Case Experience

– Subjective level of comfort and proficiency

Results - ASSET

• Inter-rater Reliability

– Good to Excellent Inter-rater Reliability between graders

• Construct Validity

– Wrist arthroscopy competency no correlation with previous wrist or knee arthroscopy experience or program level

Results –Subjective OutcomesFound ArthroSim Helpful in Improving Wrist Arthroscopy Skills (Y/N)

Program Year Yes/No % Yes

All Residents

PGY-5

PGY-4

PGY-3

PGY-2

PGY-1

PGY-0

17/9

2/1

2/2

1/4

3/2

4/0

5/0

65.4%

33.3%

50%

20%

60%

100%

100%

Perceived Change in Level of Comfort Performing Wrist Arthroscopy

Improved 17 68.2%

No Change 8 27.3%

Worse 1 4.5%

Percieved Areas of Improvement in Technical Wrist Arthroscopy Skills

Camera Dexterity 16 61.5%

Flow of Procedure 13 50%

Bimanual Dexterity 9 34.6%

Instrument Dexterity 6 23.1%

Quality of Procedure 5 19.2%

None 5 19.2%

Safety 3 11.5%

65% of residents found ArthroSim intervention helpful and perceived improved wrist arthroscopy proficiency.

Greatest improvements in Camera dexterity and flow of procedure

More junior residents (PGY found the intervention helpful than senior residents

PY0 PY0 PY0 PY0 PY0 PY1 PY1 PY1 PY1 PY2 PY2 PY2 PY2 PY2 PY3 PY3 PY3 PY3 PY3 PY4 PY4 PY4 PY4 PY5 PY5 PY5Han

dSurg.

Pre-Sim 32 35 72 25 12 54 83 22 21 30 53 39 40 12 26 36 53 54 23 36 47 47 40 20 66 43 90

Post-Sim 23 40 63 40 10 43 79 20 33 32 29 25 44 26 52 41 61 50 36 50 35 62 45 17 62 36 90

0

10

20

30

40

50

60

70

80

90

100

Co

mp

osi

te S

core

Pre-Sim Post-Sim

PGY-0 PGY-1 PGY-2 PGY-3 PGY-4 PGY-5HandSurg

Results - Pre vs Post-Sim Scores

Results

• ArthroSim training no significant change for all subjects

– ASSET scores

– task completion rates

– completion times

– overall score

Discussion

– Prospective study with standardized intervention and double-blinded assessment

– ASSET validated objective measure of assessment

– Small sample size Likely affected significance

– Minimal clinically significant difference for ASSET remains unknown

– Effect of increasing duration of knee simulation training unknown

9/24/2015

4

Summary

• The ASSET Global Rating Scale is a reliable assessment tool for evaluating proficiency in wrist arthroscopy however, construct validity not demonstrated.

• A majority of subjects reported subjective improvement with greatest value among junior residents.

• Knee arthroscopy simulation training did not objectively improve wrist arthroscopy competency among orthopaedic residents.

• Wristspecific arthroscopy training exercises are needed to aid in wrist arthroscopy competency among orthopaedic residents.

References

• Gomoll AH, O’Toole RV, Czarnecki J, Warner JJP. Surgical experience correlates with performance on a virtual reality simulator for shoulder arthroscopy. Am J Sports Med. 2007;35:883-888.

• Arthroscopy Association of North America: Suggested guidelines for the practice of arthroscopic surgery. Arthroscopy 2011;5:A28.

• Hall MP, Kaplan KM, Gorczynski CT, Zuckerman JD, Rosen JE. Assessment of arthroscopic training in U.S. orthopaedic surgery residency programs: A resident self-assessment. Bull NYU Hosp Jt Dis. 2010;68:5-10.

• Modi CS, Morris G, Mukherjee R. Computer-simulation training for knee and shoulder arthroscopy. Arthroscopy. 2010;26:832-840

• Koehler RJ, Nicandri GT. Using the arthroscopic surgery skill evaluation tool as a pass-fail examination. J Bone Joint Surg Am. 2013 Dec 4;95(23):e1871-6. doi: 10.2106/JBJS.M.00340. PubMed PMID: 24306710.

• Koehler RJ, Amsdell S, Arendt EA, Bisson LJ, Braman JP, Butler A, Cosgarea AJ, Harner CD, Garrett WE, Olson T, Warme WJ, Nicandri GT. The Arthroscopic Surgical Skill Evaluation Tool (ASSET). Am J Sports Med. 2013 Jun;41(6):1229-37. PubMed PMID: 23548808.

• Coughlin RP, Pauyo R, Sutton JC, Bergeron SG. A Validated Orthopaedic Surgical Simulation Model for Training and Evaluation of Basic Arthroscopic Skills. J Bone Joint Surg Am. 2015 Sept;97:1465-71

9/24/2015

1

Differences between Various Methods of

Measuring the Size of Posterior Malleolus

Fracture Fragments

D. Landry Jarvis, MD PGY2

Wake Forest Orthopaedic Resident

October 11, 2015

Wake Forest Baptist Medical Center

Authors

Sharon N. Babcock, MD; Alejandro Marquez-Lara

MD; Kerry Danelson, PhD; Robert Morgan, BS;

Eben A. Carroll, MD; Anna N. Miller, MD;

Primary Faculty Contributor: Jason J. Halvorson, MD

2


Disclosures

I have no financial relationship with or interest in

any commercial entity that may have a direct

interest in the subject matter of this presentation.

3 Wake Forest Baptist Medical Center

BackgroundTrimalleolar Ankle Fractures


Trimalleolar Fractures• Poorer functional outcomes when compared to ankle fractures that do

not involve posterior malleolus1-3

• Generally accepted to fix posterior malleolus fragments with greater

than 25% of articular surface13

• Poor reliability and accuracy in measuring percentage involvement7-10


Measuring the Posterior Fragment

6

Linear Measurements

Lateral Radiograph Midpoint Sagittal CT Scan

9/24/2015

2


Measuring the Posterior Fragment

7

Surface Area Measurements

2 Dimensional 3 DimensionalAxial CT Scan Mimics Software


Study DesignRetrospective Chart Review


Subjects

• Single Hospital, Level 1 Trauma Center

• Trimalleolar fractures that underwent ORIF during a

5 year period (2009-2014)

• Inclusion criteria: Skeletally mature, acceptable

lateral radiograph, preoperative CT Scan with a

located ankle, 3 month follow up.

• 270 charts reviewed; 91 patients included


Methods

• A single resident obtained measurements from all 91

subjects using the 4 previously described methods

• Primary Aims: Accuracy of different measurement

methods, correlation to posterior fragment fixation

• Secondary Outcome Measures: Range of motion,

complications, pain, length of stay

• Statistical analysis using ANOVA, Pearson

correlation, and logistical regression models

10


ResultsDemographics and Outcomes


Demographics

12

52.9

Years Old

72.5%

Female

36.3%

Smokers

73.6%

Twisting injury Mechanism

91.2%

Closed

85.7%

Medial Malleolus Fracture

9/24/2015

3


Variations in Measurements by Method

13

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

% F

ragm

ent

(Lat

eral

x-r

ay)

% Fragment (Sagittal CT)

r = 0.485, p < 0.001



14

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

% F

ragm

en

t (S

agit

talC

T)

2D CT % Fragment Surface Area

r = 0.567, p <0.001

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

% F

ragm

en

t (L

ate

ral

x-ra

y)

2D CT % Fragment Surface Area

r = 0.554, p < 0.001

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0 0.2 0.4 0.6 0.8

% F

ragm

en

t(S

agit

talC

T)

3D-Reconstruction % Fragment Surface Area

r = 0.476, p < 0.001

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0 0.2 0.4 0.6 0.8

% F

ragm

en

t(L

ate

ral

x-ra

y)

3D-Reconstruction % Fragment Surface Area

r = 0.545, p < 0.001


Lateral X-Ray

• 23.9% ± 11.1

Sagittal CT

• 26.4% ± 8.6

2D Surface Area

• 16.4% ± 11.8

3D Surface Area

• 28.7% ± 12.0


15

P = 0.02 P < 0.001P < 0.001


Posterior Fragment Fixation

16

53.8% treated without fixation(n = 49)

46.2% treated with fixation(n = 42)


Size of Fragment by Decision to Fix

17

Lateral X-Ray

22.5%

25.8%

0.139

Sagittal CT

24.0%

29.1%

0.008

2D Surface Area

16.4%

17.5%

0.651

3D Surface Area

28.3%

29.5%

0.614

Not Fixed

Fixed

P-value


DiscussionAnalysis and Conclusions

9/24/2015

4


Conclusions

• Although there was a moderate positive correlation between

the 4 methods of measurement, there was a great variability

in the estimated posterior fragment size.

• Axial CT scans underestimated size, where as 3D

Reconstruction imaging overestimated size.

• There was no significant difference in the outcomes of

fractures treated with or without posterior fragment fixation.

• Sagittal CT scan and lateral radiographs appear to both be

sufficiently appropriate for measuring posterior malleolus

fragments


References

20

• 1.Heim UF. Trimalleolar fractures: late results after fixation of the posterior fragment. Orthopedics 1989;12:1053-1059.

• 2.Wei SY, Okereke E, Winiarsky R, Lotke PA. Nonoperatively treated displaced bimalleolar and trimalleolar fractures: a 20-year follow-

up. Foot & ankle international 1999;20:404-407.

• 3.De Vries J, Struijs PA, Raaymakers EL, Marti RK. Long-term results of the Weber operation for chronic ankle instability: 37 patients

followed for 20-30 years. Acta orthopaedica 2005;76:891-898.

• 4.Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic

stability. Clinical orthopaedics and related research 2006;447:165-171.

• 5.Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw

fixation. Clinical orthopaedics and related research 2010;468:1129-1135.

• 6.van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic

review of the literature. The Journal of trauma 2009;66:279-284.

• 7.Buchler L, Tannast M, Bonel HM, Weber M. Reliability of radiologic assessment of the fracture anatomy at the posterior tibial plafond

in malleolar fractures. Journal of orthopaedic trauma 2009;23:208-212.

• 8.Wang L, Shi ZM, Zhang CQ, Zeng BF. Trimalleolar fracture with involvement of the entire posterior plafond. Foot & ankle

international 2011;32:774-781.

• 9.Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. The Journal of the American Academy of Orthopaedic Surgeons

2013;21:32-40.

• 10.Gonzalez O, Fleming JJ, Meyr AJ. Radiographic assessment of posterior malleolar ankle fractures. The Journal of foot and ankle

surgery : official publication of the American College of Foot and Ankle Surgeons 2015;54:365-369.

• 11.Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. The Journal of bone and

joint surgery American volume 2006;88:1085-1092.

• 12.Mangnus L, Meijer D, Stufkens SA, et al. Posterior Malleolar Fracture Patterns. Journal of orthopaedic trauma 2015.

• 13.McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result study. Clinical orthopaedics and related research

1977:37-45.

• 14.Mingo-Robinet J, Lopez-Duran L, Galeote JE, Martinez-Cervell C. Ankle fractures with posterior malleolar fragment: management

and results. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons

2011;50:141-145.

• 15.Bartonicek J, Rammelt S, Kostlivy K, Vanecek V, Klika D, Tresl I. Anatomy and classification of the posterior tibial fragment in ankle

fractures. Arch Orthop Trauma Surg 2015;135:505-516.

• 16.Black EM, Antoci V, Lee JT, et al. Role of preoperative computed tomography scans in operative planning for malleolar ankle

fractures. Foot & ankle international 2013;34:697-704.

• 17.Ferries JS, DeCoster TA, Firoozbakhsh KK, Garcia JF, Miller RA. Plain radiographic interpretation in trimalleolar ankle fractures

poorly assesses posterior fragment size. Journal of orthopaedic trauma 1994;8:328-331.

• 18.Purnell GJ, Glass ER, Altman DT, Sciulli RL, Muffly MT, Altman GT. Results of a computed tomography protocol evaluating distal

third tibial shaft fractures to assess noncontiguous malleolar fractures. The Journal of trauma 2011;71:163-168.


Thank You

9/25/2015

1

Major Perioperative Complications Are

Higher In Ankle Fusion Than Total Ankle

Arthroplasty: Results of a Matched

Cohort Study

Susan Odum, PhDBryce Van Doren, MPA, MPH

Robert B. Anderson, MDW. Hodges Davis, MD

Introduction

• Ankle fusion is the traditional surgical treatment for end stage arthritis

• Total ankle arthroplasty (TAA) utilization is

increasing as technique and implants improve

• Evidence suggests that clinical outcomes are superior with TAA

• Little is known of the perioperative complication rate

Purpose

To compare the national rates of

perioperative (in-hospital) complications

between patients undergoing

ankle fusion and total ankle arthroplasty

Methods

• 2002-2012 releases of the Nationwide Inpatient Samples were analyzed.

• 3,638 TAA patients and 15,053 ankle fusion patients were identified using ICD-9-CM procedure codes (81.11 and 81.56, respectively).

• ICD-9-CM diagnosis codes used to identify patients that experienced major or minor perioperative complications.

Minor Complications ICD-9 Codes Conditions

Circulatory

451.11, 451.19, 451.81,

451.89, 453.40-453.42,

453.50-453.52, 453.6,

453.9

phlebitis, thrombophlebitis, venous embolism

thrombosis

Respiratory 518.5 pulmonary insufficiency

Other systems, unclassified

997.1, 997.2, 997.39, 997.4,

997.5, 997.91, 997.99

cardiac, periphera; vascular, digestive, urinary,

respiratory

Other medical care, unclassified

999.2, 999.39, 999.5, 999.6,

999.7, 999.88-999.9

vascular; serum, injection, infusion and

transfusion reactions

Other procedure, unclassified

998.11-98.13, 998.59,

998.81, 998.83, 998.89

wound, hematoma, seroma, infection,

emphysema

Major Complications ICD-9 Codes Conditions

Circulatory and Respiratory

427.5, 415.11, 415.12,

415.19

cardiac arrest, iatrgenic pulmonary embolism

and infarction; septic pulmonary embolism

Specific Procedure

996.40-996.49, 996.66,

996.67, 996.77-996.79

internal orthopedic device, implant or graft;

including infection

Other systems, unclassified

997.00-997.02, 997.09,

997.31, 997.79

nervous system, central nervous system,

iatrogenic cerebrovascular infarction or

hemorrhage, vascular, respiratory

Other medical care, unclassified 999.4 anaphylactic shock

Other procedure, unclassified

998.0, 998.30, 998.32,

998.4, 998.51, 998.7

postoperative shock, foreign body left, surgical

wound disruption, infected seroma

Methods

• Statistical matching

identified 3,424 exact

matches of ankle fusion

and TAA patients

matched on

– age

– gender

– race

– hospital type

– geographical region

– # comorbidities

– diabetes status

• Perioperative

complications (including in-

hospital mortality) were

compared between

procedures using

– bivariate statistics

(unadjusted rates)

– multivariate logistic

regression (adjusted

rates)

9/25/2015

2

Results: Mortality

Mortality

Yes No P value

Ankle Fusion 6 (0.2%) 3418 (99.8%)

0.53Total Ankle 4 (0.1%) 3420 (99.9%)

After controlling for patient demographics and case-mix, ankle fusion patients were 50% more likely to die during hospitalization than TAA patients (OR: 1.50, 95% CI: 0.42-5.35).

Results: Major Complications

Major Complications

Yes No P-value

Ankle Fusion 482 (14%) 2,942 (86%)

.01Total Ankle 220 (6%) 3,204 (94%)

After adjusting for patient demographics and case mix, ankle fusion patients were 2.43 times more likely to experience major complications (OR: 2.42, 95% CI 2.05-2.88).

Results: Minor Complications

Minor Complications

Yes No P-value

Ankle Fusion 133 (4%) 3,291 (96%)0.17

Total Ankle 156 (5%) 3,268 (95%)

After adjusting for patient demographics and case-mix, ankle fusion patients were 15.7% less likely to experience a minor complication (OR: 0.84, 95% CI 0.66-1.07).

Conclusion

• Compared to a matched cohort of TAA patients, ankle fusion patients have

significantly higher risk of a major perioperativecomplications.

• The risk of a minor perioperative complication and mortality are similar between the groups

• These findings suggest that TAA may be a safer surgery than ankle fusion.

Thank you

9/24/2015

1

Duke University Medical Center

Predictors of Failure for Delayed Surgical Management of Closed Ankle Fracture-

dislocations

Andrew P. Matson, MD, Cynthia L. Green, PhD, Shepard R. Hurwitz and Robert D. Zura, MD


Department of Orthopaedic Surgery


Disclosures

None


Background

Ankle fracture-dislocations require urgent reduction

Protocol for management at DUMC

1) Reduction in ED

2) If congruent, splint and then clinic follow-up to schedule surgery

3) If incongruent, ORIF vs ex-fix based on soft tissue swelling

Difficult to predict which injuries can be adequately reduced


Fracture 1 Fracture 2

Background


Fracture 1: Unstable


Fracture 2: Stable

9/24/2015

2


Hypothesis

Unstable injuries will have:

Greater initial fracture displacement

Greater radiographic syndesmotic disruption

Larger posterior malleolus fracture size


Methods

243 patientsOperatively treated ankle

fractures (2008-2012)

Excluded:

Open fracture

Pilon

No reduction

Polytrauma

56 patients

Included:

Supination

Pronation

Bi/trimalleolar

Isolated

36 patients 20 patients

Unstable

-delayed ORIF

Stable

-urgent ORIF or ex-fix


Results: CategoricalUnstable Stable P-value

N 36 20

Injury Mechanism 0.728

Supination 28 (77.8%) 17 (85.0%)

Pronation 8 (22.2%) 3 (15.0%)

Fibular Comminution 0.760

None 8 (22.2%) 6 (30.0%)

Mild-moderate 20 (55.6%) 9 (45.0%)

Severe 8 (22.2%) 5 (25.0%)

Posterior Malleolus 0.084

Fractured 31 (86.1%) 12 (63.2%)

Intact 5 (13.9%) 7 (36.8%)

Talus Displacement

(coronal plane)

0.449

None 6 (17.6%) 5 (26.3%)

0-50% 14 (41.2%) 10 (52.6%)

50-100% 10 (29.4%) 2 (10.5%)

>100% 4 (11.8%) 2 (10.5%)

Talus Displacement

(sagittal plane)

0.864

None 20 (58.8%) 11 (57.9%)

0-50% 5 (14.7%) 4 (21.0%)

50-100% 7 (20.6%) 4 (21.0%)

>100% 2 (5.9%) 0 (0%)

Medial Injury 0.443

Bony 29 (87.9%) 15 (79.0%)

Ligamentous 4 (12.1%) 4 (21.0%)Duke University Medical Center

Results: ContinuousUnstable (mm) Stable (mm) P-value

N 36 20

MM Fragment Size 12.6 ± 6.6 9.0 ± 7.0 0.073

MM Fragment Displacement 12.7 ± 9.2 8.4 ± 8.9 0.107

Medial Clear space 5.9 (4.6, 8.4) 5.7 (4.7, 7.5) 0.886

Fibular Shortening 6.5 (3.7, 13.8) 4.4 (0.0, 5.7) 0.050

Fibular Sagittal Displacement 9.9 ± 8.4 6.4 ± 3.9 0.105

PM Fragment Size 6.2 (4.2, 8.5) 3.2 (0.0, 5.1) 0.011

PM Fragment Size (no zeros) 7.2 (5.1, 9.0) 4.8 (3.7, 6.7) 0.039

PM Intact Articular Surface 26.1 (20.0, 29.2) 23.1 (0.0, 29.1) 0.264

TF Clear Space 7.6 (4.8, 13.6) 6.2 (4.9, 8.0) 0.244

TF Overlap (AP view) 5.3 ± 4.5 6.1 ± 4.3 0.574

TF Overlap (mortise view) 0.0 (0.0, 4.2) 2.3 (0.0, 4.2) 0.509


Results

12 (52%)

19 (73%)

11 (48%)

7 (27%)

0

5

10

15

20

25

30

≤5 > 5

Nu

mb

er

(Pa

tien

ts)

Fibular Shortening (mm)

Stable

Unstable


Results

10 (59%)8 (24%)

2 (14%)

7 (41%)

26 (76%)

12 (86%)

0

10

20

30

40

≤ 0.1 > 0.1 > 0.2

Nu

mb

er

of

Pa

tien

ts

Posterior Malleolus Fracture Ratio

Unstable

Stable

9/24/2015

3


Results

Proportion Unstable

Fibular Shortening < 5mm and PM Ratio < 0.1 55.6% (5/9)

Fibular Shortening > 5mm and PM Ratio > 0.1 88.9% (16/18)

Fibular Shortening > 5mm and PM Ratio > 0.2 100% (6/6)


Results

Unstable Stable


Conclusions

Radiographic measurements can predict injury stability:

Posterior malleolus fragment size

Fibular shortening

Medial malleolus fragment size

Syndesmotic measurements, and talar displacement did not predict

injury stability

Further investigation

Outcomes with early vs. delayed operative management

Clinical utility of radiographic criteria

9/24/2015

1

Treatment trends of clavicular

shaft fractures

Brendan M. Patterson

North Carolina Orthopaedic

Association

October 2015

Background

Neer. JAMA. 1960

“reduction is practically impossible to maintain, and

patients do well with non-operative management”

Neer, CS. Rockwood and Green. 2nd ed.

Non-op vs ORIF

COTS. JBJS, 2007

P<0.01 for each time point

Non-op vs ORIF

COTS. JBJS, 2007

P<0.01

P=0.04

P=0.05 P<0.01

Non-op vs ORIF

COTS. JBJS, 2007

• ORIF:

• Higher satisfaction

• Improved cosmetic result

• Decreased complication rate

• Improved clinical outcomes

• Decreased non-union rate (3% vs 14%)

• Decreased time to union (16 weeks vs 28 weeks)

9/24/2015

2

Trends

Yang, et al. JPO. 2015

P < 0.001

P < 0.001

P < 0.001

Trends

Yang, et al. JPO. 2015

P = 0.007

P < 0.001

P < 0.001

Purpose

• Investigate the trends of operative vs non-operative treatment

• Determine if treatment trends differ based on patient age or sex

Methods

• Data obtained from the PearlDiver patient records database

» Database queried from 2007-2011

» Patients >20 years of age

» Diagnosis of closed clavicular shaft fracture. (ICD-9 810.02).

» Treatment with open vs closed treatment. (CPT 23500 vs 23515)

Methods

• Statistical analysis

» Rates of operative and non-operative treatment calculated

» Subgroup analysis performed based on patient age and sex

• Chi-squared analysis used to compare rates from 2007-2011

Results

25%

27%

29%

31%

33%

35%

37%

39%

41%

43%

45%

2007 2008 2009 2010 2011

% t

rea

ted

wit

h O

RIF

Year

Rate of operative fixation

9/24/2015

3

Results

15%

20%

25%

30%

35%

40%

45%

20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69

% t

rea

ted

wit

h O

RIF

Patient age

Operative treatment based on patient age

Results

30%

31%

32%

33%

34%

35%

36%

37%

38%

39%

40%

Male FemalePerc

en

t u

nd

erg

oin

g o

pera

tiv

e f

ixati

on

Patient sex

Operative treatment based on patient sex

Conclusions

• Trends in the treatment of clavicle fractures have increased

from 2007-2011.

• These trends are more pronounced among a younger, male

population.

• Increased rates of surgical management likely due to recent

literature to support operative fixation.

• This data provides an example of the impact of evidence based

medicine in orthopaedic surgery.

9/24/2015

1

Radiographic Measurements of Hip Dysplasia Correlate with Decreased Size of Acetabular Posterior Wall Fractures

Jason J. Halvorson, MD | Austin V. Stone, MD, PhD

Anna N. Miller, MD | Eben A. Carroll, MD

Department of Orthopaedic SurgeryWake Forest School of Medicine, Winston-Salem, NC

North Carolina Orthopaedic Association 2015 Annual Meeting, Kiawah Island, SC


Disclosures

Austin V. Stone MD, PhD

• Research Support: Smith & Nephew, LLC

Anna N. Miller, MD

• Consultant: Depuy-Synthes, Inc.

Eben A. Carroll, MD

• Consultant: Smith & Nephew, LLC; Depuy-Synthes, Inc.

• Institutional Support: Smith & Nephew, LLC; Depuy-Synthes, Inc.

Dr. Halvorson does not have anything to disclose.

Hypothesis

To determine if radiographic hip dysplasia measurements correlates to traumatic hip dislocation and posterior wall fragment size in acetabular fractures

648 reviewed105 posterior wall fractures

21 hip dislocations

Total patients = 126

Outcome Measures

• Radiographic• Injured LCE

• Cross over sign

• Posterior wall sign

P=0.004 P=0.57

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Posterior wall fracture size with traumatic hip dislocation

0% n=21

<40% n = 44

≥40% n=58

P=0.044

Discussion

Traumatic hip dislocations with smaller posterior wall fractures are associated with increased hip dysplasia\

Classic definitions of stable posterior wall may not be reflect stability in dysplastic hips

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Older Patients Really do

Break More Easily: Patient Age is Inversely Associated with Energy

of Collision Causing Fracture

Austin Stone, MD, PhD PGY 4



CONTRIBUTING AUTHORS

Usoro AO1, Weaver AA2, Wuertzer S3, Stitzel J2,

Lenchik L3, Miller AN4

1Wake Forest School of Medicine, Winston-Salem, NC2Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC3Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC4Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC


INTRODUCTION

Increasing Age of US Population

↓

Increasing Number of Older Drivers

↓

Increased Geriatric Trauma Involved in

Motor Vehicle Crashes

Wake Forest Baptist Medical Center 4

Crash Injury Research and

Engineering Network (CIREN)

http://www.sbes.vt.edu/ciren/cirennetwork.html


STUDY DEMOGRAPHICS

THORAX

HEAD/FACE

UPPER EXTREMITY

SPINE

PELVIS/LOWER EXTREMITY

868 PATIENTS 60+ YEARS

900 PATIENTS 20 – 50 YEARS


RESULTS

Older Age is Associated with Decreased ∆V

R2 = 0.005

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Similar Trend Across Multiple Body Regions Similar Trend Seen for ∆Energy•


Energy Levels By Age Group

Fracture Type Ages 60+

p-value

Ages 20-50

p-valueThorax

- ∆V

- ∆Energy

<0.0001

<0.0001

<0.0001

<0.0001

Spine

- ∆V

- ∆Energy

<0.0001

<0.0001

0.80

0.80

Upper Extremity

- ∆V

- ∆Energy

<0.0001

0.001

0.93

0.13

Pelvis/ Lower Extremity

- ∆V

- ∆Energy

<0.0001

<0.0001

0.002

0.84


CLINICAL IMPLICATIONS

• Geriatric drivers require less energy to

sustain the same fractures as younger

drivers

• Age is correlated with energy required to

cause fracture

• Bone density may be important contributor

to fracture (even in “high energy” motor

vehicle crashes)

Documents

North Carolina Orthopaedic Association 2015 Annual Meeting · OREF Piedmont Orthopedic Society DUMC Department of Orthopaedic Surgery Surgical Skills Acquisition Classic Education: