Leading an Organization in the 21st Century: The Importance of Environmental Sustainability, Social Responsibility, and Good Governance.

The concept of environmental sustainability, social responsibility, and good governance (ESG) is now well established in the corporate world and in for-profit organizations. However, it is not a concept that has reached medical and surgical association boardrooms in a meaningful way. It is important to define the concept of physician and corporate author expertise and objectives of ESG, provide a rationale for using ESG within orthopaedic organizations, and identify specific areas (primarily the "S" and the "G") where the American Academy of Orthopaedic Surgeons and other groups can align with this strategy.

Recurrent episodes of micturition with expulsion of symphyseal plate screws following pelvic ring fixation: case report.

BACKGROUND: Based on a computer-assisted literature search, this case is the first description of repeated loosening of metallic internal fixation implants after pelvic ring stabilization, associated with intravesical metal migration and micturition with expulsion of two bone screws. CASE PRESENTATION: A 62-year old woman was seen after the urinary expulsion of a 6.5 mm diameter cancellous screw. About seven years earlier, she had been hit by a motorcyclist while crossing the street. On admission at the time of the initial injury, thoraco-abdominal computerized tomography with intravenous contrast material revealed a bladder injury and pelvic ring fractures. An anterior-posterior type injury to the pelvic ring was diagnosed with symphyseal pubis disruption, and widening of the left sacroiliac joint with an associated sacral fracture. Explorative laparotomy revealed two bladder lacerations of both the posterior and the anterior bladder wall, which were repaired primarily. Orthopedic surgeons reduced the pelvis and stabilized it with two plates and screws. Seven years after the original injury, the patient presented with recurrent abdominal pain after expelling a screw into the toilet while urinating. Planar radiographs showed only five of the original screws remaining in the two symphyseal plates, and all screws appeared to have loosened when compared to the original fixation radiograph. CONCLUSION: This clinical report emphasizes the importance of symphyseal plate positioning and the sequelae of imprecise positioning, especially postero-superiorly adjacent to the Retzius space. The presence of protruding metal prominences, even smooth ones like a plate corner or screw head, might endanger the bladder. When using superior plates, imprecise contouring may lead to plate edge protrusion which could damage the bladder even long after application.

Coding Basics and Guidelines for Musculoskeletal Office Evaluation and Management.

¼ In documenting a patient encounter, the orthopaedic evaluation consists of 3 key components: "History," "Physical Examination," and "Medical Decision-Making." ¼ The level of service coded must be supported by the complexity of the problem, the care provided, and the documentation of the encounter. ¼ Determining whether the patient is new or established is the first step in the evaluation and management (E/M) process and relies on same-practice/same-specialty rules. ¼ Careful attention must be paid to documentation and coding to allow for appropriate care of the patient and efficient use of the orthopaedist's time. The available step-by-step guidelines include all necessary criteria to accomplish this. ¼ Continue to monitor for the U.S. Centers for Medicare & Medicaid Services (CMS) changes to stay up-to-date on changes in the guidelines.

Antegrade locked nailing of open humeral shaft fractures.

This retrospective study of 21 patients evaluates the effectiveness of primary antegrade locked intramedullary nailing for open humeral shaft fractures. Study participants were culled from the patient database of Harborview Medical Center, an urban level-1 trauma center in Seattle, Wash. Patients were evaluated for infection, nerve injury, shoulder function, range of motion, union, and healing. All 21 fractures united. Nineteen united in an average of 9.5 weeks. Two complications united in an average of 42 weeks. Seven patients had preoperative nerve palsies with complete recovery in 4 and incomplete recovery in 2 weeks. At final follow-up, 4 patients had clinically significant shoulder pain.

Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates.

BACKGROUND: Plate fixation of comminuted bicondylar tibial plateau fractures remains controversial. This retrospective study was performed to evaluate the perioperative results and functional outcomes of medial and lateral plate stabilization, through anterolateral and posteromedial surgical approaches, of comminuted bicondylar tibial plateau fractures. METHODS: Over a seventy-seven-month period, eighty-three AO/OTA type-41-C3 bicondylar tibial plateau fractures were treated with medial and lateral plate fixation through two exposures. Injury radiographs were rank-ordered according to fracture severity. Immediate biplanar postoperative radiographs were evaluated to assess the quality of the reduction. The Musculoskeletal Function Assessment (MFA) questionnaire was used to evaluate functional outcome. RESULTS: Twenty-three male and eighteen female patients (average age, forty-six years) who completed the MFA questionnaire were included in the study group. The mean duration of follow-up was fifty-nine months. Two patients had a deep wound infection. Complete radiographic information was available for thirty-one patients. Seventeen (55%) of those patients had a satisfactory articular reduction (< or =2-mm step or gap), twenty-eight patients (90%) had satisfactory coronal plane alignment (medial proximal tibial angle of 87 degrees +/- 5 degrees ), twenty-one patients (68%) demonstrated satisfactory sagittal plane alignment (posterior proximal tibial angle of 9 degrees +/- 5 degrees ), and all thirty-one patients demonstrated satisfactory tibial plateau width (0 to 5 mm). Patient age and polytrauma were associated with a higher (worse) MFA score (p = 0.034 and p = 0.039, respectively). When these variables were accounted for, regression analysis demonstrated that a satisfactory articular reduction was significantly associated with a better MFA score (p = 0.029). Rank-order fracture severity was also predictive of MFA outcome (p < 0.001). No association was identified between rank-order severity and a satisfactory articular reduction (p = 0.21). The patients in this series demonstrated significant residual dysfunction (p < 0.0001), compared with normative data, with the leisure, employment, and movement MFA domains displaying the worst scores. CONCLUSIONS: Medial and lateral plate stabilization of comminuted bicondylar tibial plateau fractures through medial and lateral surgical approaches is a useful treatment method; however, residual dysfunction is common. Accurate articular reduction was possible in about half of our patients and was associated with better outcomes within the confines of the injury severity.

The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures.

BACKGROUND: Isolated coronal plane fractures of the distal femoral condyles (Hoffa fractures) occur uncommonly, are difficult to diagnose, and may be challenging to treat. The combination of supracondylar distal femoral fractures and these coronal plane fractures is thought to occur rarely. The purposes of the present study were to identify the frequency of the association between supracondylar-intercondylar distal femoral fractures and coronal fractures of the femoral condyle and to describe the radiographic evaluation of these injuries. METHODS: One hundred and eighty-nine patients with 202 supracondylar-intercondylar distal femoral fractures were retrospectively evaluated clinically and radiographically. RESULTS: Coronal plane fractures were diagnosed in association with seventy-seven (38.1%) of the 202 supracondylar-intercondylar distal femoral fractures. Fifty-nine (76.6%) of these coronal fractures involved a single condyle, and eighteen involved both the medial and lateral femoral condyles. Eighty-five percent of the coronal fractures involving a single condyle were located laterally. Patients with an open distal femoral fracture were 2.8 times more likely to have a coronal plane fracture than patients with a closed fracture were (95% confidence interval, 1.54 to 5.25). Coronal plane fractures were diagnosed in 47% of the 102 knees that were evaluated with computerized tomography, compared with 29% of the 100 knees that were not (p = 0.008). Ten coronal plane fractures that had been unrecognized preoperatively were identified only at the time of operative fixation of the distal femoral fracture; none of these fractures occurred in patients who had been evaluated with computerized tomographic scanning preoperatively. CONCLUSIONS: Coronal plane fractures frequently occurred in association with high-energy supracondylar-intercondylar distal femoral fractures; in the present study, the prevalence of associated coronal plane fractures was 38%. The lateral condyle was involved more frequently than the medial condyle was. Coronal plane fractures of both condyles were observed commonly, and the majority of coronal plane fractures were associated with open wounds. Since the surgical tactic for the treatment of a supracondylar-intercondylar distal femoral fracture may be altered by the additional diagnosis of a coronal plane fracture component, preoperative computerized tomographic scanning of the injured distal part of the femur, particularly when there is an associated open wound, is strongly recommended.

Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique.

OBJECTIVES: Single incision open reduction and double plate fixation of complex tibial plateau fractures has been associated with high wound complication rates. Minimally invasive methods have been recommended to decrease the wound complication rates as compared with open techniques. Additionally, laterally applied fixed-angle devices appear to minimize late varus deformity without the need for additional medial stabilization. Accurate reduction of comminuted lateral and/or medial articular surfaces, however, often requires visualization through an open reduction. This study reports the complications, infection rate, and radiographic assessment of reduction associated with double plating complex AO/OTA 41-C3 tibial plateau fractures utilizing 2 incisions. DESIGN: Retrospective clinical review. SETTING: Urban level 1 university trauma center. PATIENTS: Over a 77-month period, 83 patients were treated for a complex bicondylar tibial plateau fracture at our institution utilizing a 2-incision technique. INTERVENTION: Dual plating using anterolateral and posteromedial incisions. MAIN OUTCOME MEASURE: Type and incidence of septic and non-septic complications and radiographic assessment of articular reduction and axial alignment. RESULTS: Eleven fractures were open (13.3%) and classified according to Gustilo as type II (1 patient), type III-A (7 patients), type III-B (2 patients), and type III-C (1 patient). Compartment syndrome was diagnosed and treated with fasciotomies in 12 patients (14.5%). The average time interval from injury to definitive surgical treatment was 9 days. Seven patients developed deep wound infections (8.4%). Three of these had an associated septic arthritis (3.6%). Clinical resolution of infection occurred after an average of 3.3 additional procedures. The presence of a dysvascular limb requiring vascular reconstruction was statistically associated with a deep wound infection (P = 0.006). Secondary procedures for complications included 13 patients who required removal of implants secondary to local discomfort, 5 patients who required a knee manipulation, 2 patients that were managed with excision of heterotopic ossification to improve knee motion, 1 patient that required an equinus contracture release, and 1 patient treated for a metadiaphyseal nonunion. Sixteen patients (19.3%) incurred deep venous thromboses. No patient was diagnosed with pulmonary embolism. Sixty-two percent of patients demonstrated satisfactory articular reductions, 91% demonstrated satisfactory coronal alignment, 72% demonstrated satisfactory sagittal alignment, and 98% demonstrated satisfactory condylar width. CONCLUSIONS: Comminuted bicondylar tibial plateau fractures can be successfully treated with open reduction and medial and lateral plate fixation using 2 incisions. Dysvascular limbs requiring vascular repair are at increased risk for deep sepsis. The use of 2 incisions, temporary spanning external fixation, and proper soft-tissue handling may contribute to a lower wound complication rate than previously reported.

Extensor mechanism-sparing paratricipital posterior approach to the distal humerus.

Adequate exposure of the articular surface of the distal humerus and elbow joint is required for operative stabilization of bicolumnar distal humerus fractures. The transolecranon approach, which provides complete posterior visualization and access to the distal humerus, is commonly used. Nevertheless, an olecranon osteotomy and other extensor mechanism-disrupting approaches have risks and possible complications. Alternative exposures have been described primarily for total elbow arthroplasty, but these involve extensive and potentially devascularizing dissections. In extra-articular (OTA type A) and simple articular distal humeral fractures with simple or multifragmentary metaphyseal involvement (OTA type C1 and C2), extensile approaches may not be necessary. For these fracture patterns, an alternative exposure is the extensor mechanism-sparing paratricipital posterior approach to the distal humerus through a midline posterior incision. This approach avoids an osteotomy and mobilizes the triceps and anconeus muscle off the posterior humerus and the intermuscular septae and provides adequate exposure for open reduction and internal fixation.

Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads.

OBJECTIVE: To conduct a biomechanical comparison of a new triangular osteosynthesis and the standard iliosacral screw osteosynthesis for unstable transforaminal sacral fractures in the immediate postoperative situation as well as in the early postoperative weight-bearing period. DESIGN: Twelve preserved human cadaveric lumbopelvic specimens were cyclicly tested in a single-limb-stance model. A transforaminal sacral fracture combined with ipsilateral superior and inferior pubic rami fractures were created and stabilized. Loads simulating muscle forces and body weight were applied. Fracture site displacement in three dimensions was evaluated using an electromagnetic motion sensor system. INTERVENTION: Specimens were randomly assigned to either an iliosacral and superior pubic ramus screw fixation or to a triangular osteosynthesis consisting of lumbopelvic stabilization (between L5 pedicle and posterior ilium) combined with iliosacral and superior pubic ramus screw fixation. MAIN OUTCOME MEASURES: Peak loaded displacement at the fracture site was measured for assessment of initial stability. Macroscopic fracture behavior through 10,000 cycles of loading, simulating the early postoperative weight-bearing period, was classified into type 1 with minimal motion at the fracture site, type 2 with complete displacement of the inferior pubic ramus, or type 3 with catastrophic failure. RESULTS: The triangular osteosynthesis had a statistically significantly smaller displacement under initial peak loads (mean +/- standard deviation [SD], 0.163 +/- 0.073 cm) and therefore greater initial stability than specimens with the standard iliosacral screw fixation (mean +/- SD, 0.611 +/- 0.453 cm) ( = 0.0104), independent of specimen age or sex. All specimens with the triangular osteosynthesis demonstrated type 1 fracture behavior, whereas iliosacral screw fixation resulted in one type 1, two type 2, and three type 3 fracture behaviors before or at 10,000 cycles of loading. CONCLUSION: Triangular osteosynthesis for unstable transforaminal sacral fractures provides significantly greater stability than iliosacral screw fixation under in vitro cyclic loading conditions. In vitro cyclic loading, as a limited simulation of early stages of patient mobilization in the postoperative period, allows for a time-dependent evaluation of any fracture fixation system.

ICD 10: "what orthopedic surgeons should know, how it will affect them and the cost of implementation?".

Orthopedic surgeons will be required to use ICD-10-CM codes for reimbursement and to substantiate the medical necessity for their services beginning October 1, 2014. Implementation of ICD10 will require significant changes in the clinical and administrative processes of orthopedic offices and hospital practices. As in other countries, implementation added costs and resulted in disruptions in physician practices with concomitant decreases in productivity and practice revenue. Through education and planning, orthopedic surgeons can mitigate the anticipated changes and reduce the potential impact these changes will have on their practices. Changes anticipated in the diagnostic part of the ICD10 coding system are reviewed with examples pertinent to orthopedic surgeons. Many will need to improve the accuracy and specificity of their documentation by using anatomically precise nomenclature and obtaining a more detailed history and physical examination. This will require eliciting external causes of patients' problems, the precise activity of causation, and the place of occurrence.

Finding your ideal job and negotiating your contract: where to get the information and numbers you need to know.

The process of finding the ideal orthopaedic practice and negotiating a satisfactory employment agreement may be arduous and stressful. The keys to success are similar to attaining proficiency in orthopaedic surgery and include having an insight into your personality, your future needs, and desires; and committing the requisite time for preparation, planning and study to accumulate sufficient knowledge for the tasks. The internet permits access to diverse sources of information, which allows for planning, retrieval of reference materials and for benchmarking contracts and job offers. As professional recruitment and employment are 2 facets of a rapidly evolving health care environment, the "numbers" you need to know are dynamic. Access to information that is updated frequently is invaluable to the prospective employee. Multiple sources of favorable information are referenced with web site addresses. A well-written contract is essential for both the employee and the employer. A thoughtful contract should clarify mutual understandings, expectations, and serve as a guide for resolving both anticipated and unanticipated events. A review of common employment benefits and contract provisions is listed for quick reference. If emotional involvement is a concern to the prospective employee, consider hiring an intermediary to help with the negotiations, contract evaluation, and provisions.

Intramedullary fixation of fibular fractures associated with pilon fractures.

OBJECTIVES: The purpose of this study was to determine the ability of intramedullary fibular fixation to maintain reduction until healing and to determine the overall complication rate in high-energy pilon fractures associated with fibular fractures. DESIGN: Retrospective study. SETTING: Level I university trauma center. PATIENTS/PARTICIPANTS: From 2000 to 2007, 972 pilon fractures were treated at our institution, 38 of which were treated with an intramedullary device for the associated fibular fracture. Two patients had acute amputations and two died; 1-year follow-up was obtained in 27 of the remaining patients. Average length of follow-up was 21 months. INTERVENTION: A retrospective chart and radiograph review was conducted of all patients for data extraction. MAIN OUTCOME MEASUREMENTS: Fibular fixation type and length, fibular healing, and complications. RESULTS: Average patient age was 36 years (range, 18-59 years). Four of the fibular fractures were segmental. All fractures had at least 50% of the cortex intact to prevent shortening. The average height of the fibular fractures from the distal tip was 6.9 cm (range, 1.3-22.2 cm). In 20 patients, a 3.5-mm fully threaded cortical screw was used for stabilization, and in the remaining seven, a 2.5-mm wire was used. The intramedullary implant extended 8.5 cm above the most proximal fracture line on average (range, 1.6-29.8 cm). Fibular alignment was within 3 degrees of anatomic in all cases after initial fixation. At final follow-up, fibular alignment had not changed more than 1 degrees in any case. No complications related to the fibular incision occurred, and all fibula fractures healed within 3 months. CONCLUSIONS: In axially and rotationally stable fibular fracture patterns associated with pilon fractures, intramedullary fibular stabilization was effective in maintaining fibular alignment. This technique led to reliable fracture healing in appropriately selected fractures and may be particularly advantageous in patients with compromised lateral and posterolateral soft tissues.

Isolated locked compression plating for Vancouver Type B1 periprosthetic femoral fractures.

OBJECTIVE: Report treatment results of periprosthetic femoral fractures adjacent or at the tip of a stable femoral stem (Vancouver Type B1) using a locked compression plate as the sole method of fracture stabilisation. DESIGN: Retrospective case series. SETTING: Academic Level I Trauma Centre. PATIENTS: Patients operatively treated at our institution with locked compression plating for Vancouver Type B1 periprosthetic fractures between 2002 and 2006 with at least 12 weeks of clinical follow-up were included. Patient demographics, hip arthroplasty implant characteristics, and AO/OTA fracture type were recorded. INTERVENTION: Open reduction internal fixation using a locked-plate spanning a majority of the femur through a lateral soft-tissue sparing approach. No cortical onlay allografts or cerclage devices (wires or cables) were used. MAIN OUTCOME MEASUREMENTS: Clinical union was defined at a minimum of 12 weeks as ability to walk, with or without the use of a walking aide, without pain at or around the fracture site. Radiographic union was defined by bridging bone spanning two or more cortices on orthogonal radiographs of the femur. RESULTS: Ten subjects met the inclusion criteria and were followed for a mean of 27 weeks (range 14-97 weeks). All achieved fracture union at a mean of 17 weeks (range 12-27 weeks). There were no hardware failures or changes in fracture alignment from operative radiographs. There were no major complications that necessitated reoperation. CONCLUSIONS: Open reduction internal fixation of Vancouver Type B1 periprosthetic femoral fractures using a lateral locked-plate that spans the full extent of the femur as the sole method of stabilisation is a successful treatment method that minimises soft-tissue dissection and provides adequate fixation strength to maintain fracture alignment to fracture union.

Severity of injury and outcomes among obese trauma patients with fractures of the femur and tibia: a crash injury research and engineering network study.

OBJECTIVE: To understand the influence of obesity on the morbidity and mortality outcomes of patients who have sustained fractures of the femur and tibia. DESIGN: Retrospective review. SETTING: Multicenter level I trauma facilities. PATIENTS/PARTICIPANTS: Motor vehicle crash victims enrolled in multicenter databases were reviewed. MAIN OUTCOME MEASUREMENTS: Outcome measurements for obese (body mass index, BMI > or = 30 kg/m) versus nonobese (BMI < 30 kg/m) patients included Injury Severity Score, Abbreviated Injury Scores, OTA fracture types, length of hospital stay, disposition, complications, and 36-Item Short Form Survey Instrument. RESULTS: We included 665 cases from the database, of which 461 (69%) were nonobese and 204 (31%) were obese. There was no difference in sex, mechanism of injury, Injury Severity Score, and Abbreviated Injury Score. The obese population was older with a mean age of 44 years compared with 41 years for the nonobese (P < 0.01) and had a greater incidence of reported baseline cardiac disease (P < 0.01) and diabetes (P < 0.01). Obese patients had more severe injury patterns (OTA B and C type) in the distal femur fractures (90% versus 61%, P < 0.01). Mortality rates did not show a statistically significant difference (5.6% versus 9.4%, P = 0.07). The baseline physical component on the 36-Item Short Form Survey Instrument was lower among the obese but not statistically different (P = 0.08). At 6 and 12 months post injury, a decline was noted in both groups; however, no differential decline was noted between the groups (P > 0.05). CONCLUSIONS: Obese patients are significantly more likely to have more severe distal femur fractures compared with nonobese when involved in motor vehicle crashes. In this study, there was no statistically significant difference in length of stay, complications, or mortality in obese patients.

Early limited internal fixation of diaphyseal extensions in select pilon fractures: upgrading AO/OTA type C fractures to AO/OTA type B.

Fractures of the tibial pilon may present an array of problems and potential complications. Staged treatment with initial spanning external fixation of the ankle has proven to be a successful strategy for the treatment of these difficult fractures in many cases. A subset of the tibial pilon fractures, with an oblique extension to the diaphysis may constitute a treatment problem, as these long fractures may be difficult to reduce at the time of definitive fixation, often 1-3 weeks post-injury due to interposed soft tissues, hematoma and/or early callus. Anatomic reduction of this fracture may thus require more extensive dissection than might be desirable in this injury. We offer a technique to assist in the treatment of the subset of these difficult fractures. In appropriate cases, a small fragment plate may be applied to the diaphyseal component of the fracture in an anti-glide type plate application, through a small incision proximal to the area of greatest injury. This re-establishes the length, rotation and alignment of this fragment which is commonly attached to either the Chaput anterolateral or the Volkmann posterolateral fragment. It additionally provides the intimate contact that may favor early union or minimize the need for secondary procedures. The fracture is thereby converted from a complete articular AO/OTA 43-C type pattern to a partial articular, or AO/OTA 43-B type pattern.

The safety of fluoroscopically-assisted thoracic pedicle screw instrumentation for spine trauma.

BACKGROUND: Pedicle screw fixation is considered biomechanically superior to other stabilization constructs. However, the potential for severe complications have discouraged its use in the thoracic spine. Our goal is to determine the incidence of major perioperative complications following the placement of thoracic pedicle screws using anatomic landmarks and intraoperative fluoroscopy in patients with spine fractures. METHODS: Retrospective review of 245 consecutive patients with spine fractures requiring pedicle screw fixation between T1 and T10 at a regional Level I trauma center between 1995 and 2001. Database and medical record review were used to identify the incidence of major perioperative complications. A major complication was defined as a potentially life-threatening vascular injury, neurologic deterioration, pneumothorax or hemothorax, and tracheoesophageal injury. Patients were monitored for these complications from the time of surgery until discharge. RESULTS: In all, 1,533 pedicle screws were placed between T1 and T10 in 245 patients. No patient sustained a major complication related to screw placement. Three patients (1.2%) required a secondary procedure for prophylactic revision of four (0.26%) malpositioned screws. CONCLUSIONS: This study supports the safety of pedicle screws in the thoracic spine using preoperative imaging evaluation, standard posterior element landmarks and intraoperative fluoroscopy.

It is money that matters: decision analysis and cost-effectiveness analysis.

Clinical decisions must be made, often under circumstances of uncertainty and limited resources. Decision analysis and cost-effectiveness analysis are methodologic tools that allow for quantitative analysis and the optimization of decision-making. These methods can be useful for decisions regarding individual patient evaluation and treatment options or in formulating healthcare policy. We overview the methodology of expected value decision analysis and of cost-effectiveness analysis, including cost-identification, cost-effectiveness, cost-benefit, and cost-utility analyses. Examples are provided of these methods and a user's guide to cost-effectiveness analysis is outlined.