Improving Patient Understanding of Femoroacetabular Impingement Syndrome With Three-Dimensional Models.

INTRODUCTION: Three-dimensional (3D) printed models may help patients understand complex anatomic pathologies such as femoroacetabular impingement syndrome (FAIS). We aimed to assess patient understanding and satisfaction when using 3D printed models compared with standard imaging modalities for discussion of FAIS diagnosis and surgical plan. METHODS: A consecutive series of 76 new patients with FAIS (37 patients in the 3D model cohort and 39 in the control cohort) from a single surgeon's clinic were educated using imaging and representative 3D printed models of FAI or imaging without models (control). Patients received a voluntary post-visit questionnaire that evaluated their understanding of the diagnosis, surgical plan, and visit satisfaction. RESULTS: Patients in the 3D model cohort reported a significantly higher mean understanding of FAIS (90.0 ± 11.5 versus 79.8 ± 14.9 out of 100; P = 0.001) and surgery (89.5 ± 11.6 versus 81.0 ± 14.5; P = 0.01) compared with the control cohort. Both groups reported high levels of satisfaction with the visit. CONCLUSION: In this study, the use of 3D printed models in clinic visits with patients with FAIS improved patients' perceived understanding of diagnosis and surgical treatment.

Outcomes After Operative Reconstruction of Symptomatic Rib Nonunions.

OBJECTIVE: To assess the outcomes of patients after rib nonunion reconstruction. DESIGN: Retrospective case series. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Between January 2007 and August 2019, 25 consecutive patients with 51 nonunions with disabling pain or chronic instability were treated for nonunited rib fractures. INTERVENTION: Rib nonunion reconstructions performed using plate and screw fixation, recannalizing the medullary canal and augmented with autogenous iliac crest bone graft. MAIN OUTCOME MEASUREMENTS: Patient demographics, mechanism of injury, number of rib nonunions, and postoperative radiographs were assessed. Satisfaction, patient-reported complications, return to occupation and activity, and general health measures were captured using patient questionnaires. RESULTS: In 25 patients, 51 painful rib nonunions were surgically treated. The average length from injury to surgical rib reconstruction was 25.1 months (range = 3-118 months; median = 12 months). Follow-up was obtained in 18 of 25 patients (72%) with a mean of 46.1 months (range = 13-139 months). All ribs achieved radiographic union at an average of 12.3 weeks (range = 8-24 weeks) after surgery. Sixteen of 18 patients (89%) reported satisfaction with surgery and 15 patients (83%) reported mild to no pain at final follow-up. Five patients had complications that all resolved after subsequent treatment. CONCLUSIONS: Successful treatment of symptomatic rib nonunion is possible using rib plates in conjunction with bone grafting and has high union rates, satisfactory results, and limited complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury.

PURPOSE: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients. METHODS: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern. RESULTS: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034). CONCLUSION: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

Revision of Failed Sternal Fixation Using Tricortical Iliac Crest In-Lay Autograft and Mesh Plate: A Case Report.

CASE: We present the case of a 57-year-old woman who sustained a comminuted transverse sternal fracture that failed primary open reduction internal fixation (ORIF). The patient underwent staged nonunion reconstruction with a tricortical iliac crest bone graft and mesh plate. With 18 months of a sustained successful outcome, we propose a treatment strategy for a challenging clinical problem. CONCLUSION: When primary ORIF fails, bone healing and resolution of a painful sternal nonunion can be effectively managed with a tricortical iliac crest in-lay autograft and locking mesh plate.

Implementation and Impact Evaluation of a Virtual Orthopaedic Continuing Medical Education Conference in a Low-Resource Country.

OBJECTIVE: The Haitian Annual Assembly of Orthopaedic Trauma (HAAOT) is an annual continuing medical education (CME) conference for Haitian orthopedists and trainees converted to a pilot virtual format in 2020 due to the COVID-19 pandemic. We evaluated this virtual format's effectiveness at teaching, facilitating bilingual discussion, and encouraging cross-cultural exchange of experiences - all aimed at improving orthopedic knowledge in a low-resource country like Haiti. DESIGN: Planned collaboratively between North American and Haitian colleagues, the conference involved 4 bilingual weekly Zoom meetings comprised of 4 to 6 prerecorded presentations and live-translated discussion. Pre- and postmeeting knowledge assessments in French (Haitian language of medical instruction) were administered weekly with results compared via 2-sample t-tests. An online postconference survey evaluated attendee satisfaction with the virtual format. SETTING: Virtual. PARTICIPANTS: Weekly attendance involved approximately 50 Haitian orthopedists and trainees, with 20 to 25 completing pre- and postmeeting assessments. RESULTS: Statistically significant increases between pre/post scores were seen during 3 of 4 sessions. Session-wide significant score increases occurred for residents and attending surgeons with <10 years of experience. 85.7% of attendees reported the virtual platform exceeded expectations and 100% indicated likely or extremely likely participation in further virtual events. CONCLUSIONS: The pilot virtual HAAOT was extremely well received with high desire for future sessions. Beyond short-term knowledge retention among attendees, nonmeasurable benefits included collaboration between orthopedists and trainees in the United States, Canada, United Kingdom, Haiti, and Burkina Faso. As COVID-19 spurs online learning in high-income nations, the successful low-resource context adjustments and local partnership underlying this model attest that travel restrictions need not impede delivery of virtual CME conferences in lower-income nations. Attendee learning and the decreased cost and travel requirements allude to this platform's sustainability and reproducibility in facilitating future international education and capacity building. Further studies will assess long-term retention of presented material.

Operative Management of a Nonunion at the Superior Angle of the Scapula: A Case Report.

CASE: We present the case of a 40-year-old man with a fracture to the superior angle of the scapula who was treated nonoperatively for 10 months-leading to a symptomatic nonunion. The patient underwent reconstruction of the nonunion for a painful shoulder and was followed clinically for 3 years. He demonstrated major improvement in function and symptoms. CONCLUSION: Nonunions of the scapular superior angle can be effectively managed with surgical reconstruction.

Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI).

BACKGROUND: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI. METHODS: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI. RESULTS: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034). CONCLUSION: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI. LEVEL OF EVIDENCE: Therapeutic, level IV.

Malunions and Nonunions of the Acromion and Coracoid Proceses: A Comparison of Functional Outcomes Before and After Reconstruction.

OBJECTIVES: To assess surgical and functional outcomes in a cohort of patients having operatively reconstructed scapula process malunions and/or nonunions. DESIGN: Retrospective case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Between 2003 and 2018, we identified 16 patients who presented to our institution with symptoms associated with a nonunion or malunion of closed, displaced fractures of the scapula processes after acute injury mechanisms. INTERVENTION: Surgical osteotomy of the malunion or debridement of the nonunion and subsequent reconstruction. MAIN OUTCOME MEASUREMENTS: The primary outcome measured included range of motion, strength, and DASH. Return to work was a secondary outcome. RESULTS: Among 13 of the 16 (81%) patients with ≥12 months follow-up, the mean follow-up was 34 months (range, 12-112 months). Three patients were lost to follow-up. The mean DASH score improved from 56.4 ± 22.4 preoperatively to 23.4 ± 22.2 postoperatively (P < 0.001). Among the patients with ≥1-year follow-up, range of motion improved from preoperative to final follow-up in abduction (P = 0.020). Among the 15 of 16 patients for whom occupation data are available, 73% either returned to their original occupation (n = 7) or did not due to reasons other than their reconstructive surgery (n = 4). Two postoperative complications occurred including failure of acromion nonunion fixation at 4 months and went on to heal after revision surgery. All reconstructions united without malunion. CONCLUSIONS: Reconstruction of the scapula process malunion and nonunion is possible, providing restoration of function and symptom relief, with a low complication rate. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.