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Song Y.,Vanderbilt University | Obremskey W.T.,Vanderbilt Orthopaedic Institute
Journal of Orthopaedic Trauma | Year: 2012

OBJECTIVE: To determine whether medial displacement of the glenoid with respect to the midline occurs in scapula fractures and the potential impact on fracture reduction technique. DESIGN: Retrospective case series. SETTING: Level I trauma medical center. PATIENTS: Seventy patients who sustained scapula fractures from 2004 to 2008 and a comparison group of 47 normal patients without scapula fractures. INTERVENTION: Computed tomography scans were analyzed from all 70 patients who sustained scapula fractures. Measurements were obtained from the most lateral aspect of the glenoid articular surface to the midline (vertebral spinous process) on both the injured and non-injured sides to assess medial or lateral displacement of the glenoid with respect to the midline. The same measurements were obtained bilaterally for the 47 patients in the comparison group. MAIN OUTCOME MEASUREMENT: Medial or lateral displacement of the glenoid with respect to the midline. RESULTS: Our results showed that for all 70 patients with scapula fractures, the average distance from the glenoid articular surface to the midline was 6.0 mm ± 10.1 greater for the injured shoulder than for the non-injured side (P = 0.0017), indicating lateral displacement of the glenoid. In the comparison group, the mean right-to-left difference from midline was-0.9 mm ± 9.2 (P = 0.4399). CONCLUSION: Our analysis demonstrates that in this group of patients with scapula fractures, there was slight lateral displacement of the glenoid with respect to the midline with significant variability in the degree of medial/lateral displacement. This finding provides evidence that the glenoid fragment retains its anatomic position, and the proximal scapula body fragment may be the fracture component that lateralizes. Recognizing this pattern of displacement may enhance our understanding of scapula fractures and the techniques used during open reduction and internal fixation. Copyright © 2012 by Lippincott Williams &Wilkins.


Granke M.,Vanderbilt University | Does M.D.,Vanderbilt University | Nyman J.S.,Vanderbilt University | Nyman J.S.,Vanderbilt Orthopaedic Institute
Calcified Tissue International | Year: 2015

Comprising ~20 % of the volume, water is a key determinant of the mechanical behavior of cortical bone. It essentially exists in two general compartments: within pores and bound to the matrix. The amount of pore water—residing in the vascular-lacunar-canalicular space—primarily reflects intracortical porosity (i.e., open spaces within the matrix largely due to Haversian canals and resorption sites) and as such is inversely proportional to most mechanical properties of bone. Movement of water according to pressure gradients generated during dynamic loading likely confers hydraulic stiffening to the bone as well. Nonetheless, bound water is a primary contributor to the mechanical behavior of bone in that it is responsible for giving collagen the ability to confer ductility or plasticity to bone (i.e., allows deformation to continue once permanent damage begins to form in the matrix) and decreases with age along with fracture resistance. Thus, dehydration by air-drying or by solvents with less hydrogen bonding capacity causes bone to become brittle, but interestingly, it also increases stiffness and strength across the hierarchical levels of organization. Despite the importance of matrix hydration to fracture resistance, little is known about why bound water decreases with age in hydrated human bone. Using 1H nuclear magnetic resonance (NMR), both bound and pore water concentrations in bone can be measured ex vivo because the proton relaxation times differ between the two water compartments, giving rise to two distinct signals. There are also emerging techniques to measure bound and pore water in vivo with magnetic resonance imaging (MRI). The NMR/MRI-derived bound water concentration is positively correlated with both the strength and toughness of hydrated bone and may become a useful clinical marker of fracture risk. © 2015, Springer Science+Business Media New York (outside the USA).


Richards J.E.,Vanderbilt Orthopaedic Institute | Kauffmann R.M.,Vanderbilt University | Zuckerman S.L.,Vanderbilt Orthopaedic Institute | Obremskey W.T.,Vanderbilt Orthopaedic Institute | May A.K.,Vanderbilt University
Journal of Bone and Joint Surgery - Series A | Year: 2012

Background: The impact of perioperative hyperglycemia in orthopaedic surgery is not well defined. We hypothesized that hyperglycemia is an independent risk factor for thirty-day surgical-site infection in orthopaedic trauma patients without a history of diabetes at hospital admission. Methods: Patients eighteen years of age or older with isolated orthopaedic injuries requiring acute operative intervention were studied. Patients with diabetes, injuries to other body systems, a history of corticosteroid use, or admission to the intensive care unit were excluded. Blood glucose values were obtained, and hyperglycemia was defined in two ways. First, patients with two or more blood glucose levels of ≥200 mg/dL were identified. Second, the hyperglycemic index, a validated measure of overall glucose control during hospitalization, was calculated for each patient. A hyperglycemic index of ≥1.76 (equivalent to ≥140 mg/dL) was considered to indicate hyperglycemia. The primary outcome was thirty-day surgical-site infection. Multivariable logistic regression models evaluating the effect of the markers of hyperglycemia, after controlling for open fractures, were constructed. Results: Seven hundred and ninety patients were identified. There were 268 open fractures (33.9%). Twenty-one thirty-day surgical-site infections (2.7%) were recorded. Age, race, comorbidities, injury severity, and blood transfusion were not associated with the primary outcome. Of the 790 patients, 294 (37.2%) had more than one glucose value of ≥200 mg/dL. This factor was associated with thirty-day surgical-site infection, with thirteen (4.4%) of the 294 patients with that indication of hyperglycemia having a surgical-site infection versus eight (1.6%) of the 496 patients without more than one glucose value of ≥200 mg/dL (p = 0.02). One hundred and thirty-four (17.0%) of the 790 patients had a hyperglycemic index of ≥1.76, and this was also associated was thirty-day surgical-site infection (ten [7.5%] of 134 versus eleven [1.7%] of 656; p < 0.001). Multivariable logistic regression models demonstrated that two or more blood glucose levels of ≥200 mg/dL was a risk factor for thirty-day surgical-site infection (odds ratio [OR]: 2.7, 95% confidence interval [CI]: 1.1 to 6.7) after adjustment for open fractures (OR: 3.2, 95% CI: 1.3 to 7.8). A second model demonstrated that a hyperglycemic index of ≥1.76 was an independent risk factor for surgical-site infection (OR: 4.9, 95% CI: 2.0 to 11.8) after controlling for open fractures (OR: 3.3, 95% CI: 1.4 to 8.3). Conclusions: Hyperglycemia was an independent risk factor for thirty-day surgical-site infection in orthopaedic trauma patients without a history of diabetes. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2012 by The Journal of Bone and Joint Surgery, Incorporated.


Wright R.W.,University of Washington | Magnussen R.A.,Duke University | Dunn W.R.,Vanderbilt Orthopaedic Institute | Spindler K.P.,Vanderbilt Orthopaedic Institute
Journal of Bone and Joint Surgery - Series A | Year: 2011

Background: Injury to the ipsilateral graft used for reconstruction of the anterior cruciate ligament (ACL) or a new injury to the contralateral ACL is a devastating outcome following successful ACL reconstruction, rehabilitation, and return to sport. Little evidence exists regarding the intermediate to long-term risk of these events. Methods: The present study is a systematic review of Level-I and II prospective studies that evaluated the rate of rupture of the ACL graft and the ACL in the contralateral knee following a primary ACL reconstruction with use of a mini-open or arthroscopic bone-tendon-bone or hamstring autograft after a minimum duration of follow-up of five years. Results: Six studies met the inclusion and exclusion criteria. The ipsilateral ACL graft rupture rate ranged from 1.8% to 10.4%, with a pooled percentage of 5.8%. The contralateral injury rate ranged from 8.2% to 16.0%, with a pooled percentage of 11.8%. Conclusions: This systematic review demonstrates that the risk of ACL tear in the contralateral knee (11.8%) is double the risk of ACL graft rupture in the ipsilateral knee (5.8%). Additional studies must be performed to determine predictors for these injuries and to improve our ability to avoid this devastating outcome. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence. Copyright © 2011 by The Journal of Bone and Joint Surgery, Incorporated.


Birman M.V.,Columbia University | Lee D.H.,Vanderbilt Orthopaedic Institute
Journal of the American Academy of Orthopaedic Surgeons | Year: 2012

Factitious disorders of the upper extremity can manifest in many different forms; therefore, it is critical to recognize warning signs in the history and examination indicating that the patient may be creating the symptoms and physical manifestations of the presenting illness. These disorders present in such predictable patterns as lymphedema, Secretan syndrome, ulcerations and wound manipulation, clenched fist, subcutaneous emphysema, pachydermodactyly, nail deformities, and self-mutilation. Management recommendations include assigning therapeutic responsibility to one person and the involvement of a multidisciplinary team. Thorough documentation is essential for the protection of both the patient and the treating physician. Treatment of patients with factitious disorders of the upper extremity requires patience and insight to avoid being manipulated into performing unnecessary surgical procedures.


Kerkhoffs G.M.M.J.,University of Amsterdam | Servien E.,Groupement Hospitalier Nord | Dunn W.,Vanderbilt Orthopaedic Institute | Dahm D.,Mayo Medical School | And 2 more authors.
Journal of Bone and Joint Surgery - Series A | Year: 2012

Background: The increase in the number of individuals with an unhealthily high body weight is particularly relevant in the United States. Obesity (body mass index ≥30 kg/m2) is a well-documented risk factor for the development of osteoarthritis. Furthermore, an increased prevalence of total knee arthroplasty in obese individuals has been observed in the last decades. The primary aim of this systematic literature review was to determine whether obesity has a negative influence on outcome after primary total knee arthroplasty. Methods: A search of the literature was performed, and studies comparing the outcome of total knee arthroplasty in different weight groups were included. The methodology of the included studies was scored according to the Cochrane guidelines. Data extraction and pooling were performed. The weighted mean difference for continuous data and the weighted odds ratio for dichotomous variables were calculated. Heterogeneity was calculated with use of the I 2 statistic. Results: After consensus was reached, twenty studies were included in the data analysis. The presence of any infection was reported in fourteen studies including 15,276 patients (I2, 26%). Overall, infection occurred more often in obese patients, with an odds ratio of 1.90 (95% confidence interval [CI], 1.46 to 2.47). Deep infection requiring surgical debridement was reported in nine studies including 5061 patients (I2, 0%). Deep infection occurred more often in obese patients, with an odds ratio of 2.38 (95% CI, 1.28 to 4.55). Revision of the total knee arthroplasty, defined as exchange or removal of the components for any reason, was documented in eleven studies including 12,101 patients (I2, 25%). Revision for any reason occurred more often in obese patients, with an odds ratio of 1.30 (95% CI, 1.02 to 1.67). Conclusions: Obesity had a negative influence on outcome after total knee arthroplasty. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2012 by The Journal of Bone and Joint Surgery, Incorporated.


Richards J.E.,Vanderbilt Orthopaedic Institute
Orthopedics | Year: 2012

Tibia plafond fractures have historically demonstrated high complication rates. The purpose of this study was to assess the outcomes of tibia plafond fractures following treatment with definitive external fixation vs delayed open reduction and internal fixation (ORIF). Sixty patients were enrolled in a prospective cohort trial at 1 Level I trauma center. No differences were noted between the 2 treatment groups in terms of age, smoking history, presence of comorbidities, mechanism of injury, incidence of open fractures, or Orthopaedic Trauma Association fracture classification. Complete 12-month follow-up was available for 18 patients in the definitive external fixation group and 27 patients in the ORIF group. No difference was noted in articular reduction between the groups at 6 and 12 months postoperatively. Delayed union or non-union occurred in 4 (22.2%) of 18 patients in the external fixation group and 1 (3.7%) of 27 patients in the ORIF group (P=.05). Deep infection was equally likely in either group (P=.33). The ORIF group had improved Iowa Ankle Scores at 6 (23.6 ± 12.1 vs 11.1 ± 7.7; P<.05) and 12 months (5.5 ± 2.2 vs 3.1 ± 1.7; P<.05) postopertively and improved Short Form-36 Physical Function scores at 6 months (49.7 ± 30.1 vs 25.5 ± 8.0; P<.05) postoperatively compared with the external fixation group.External fixation and ORIF can attain bony union with adequate articular reduction and similar infection rates. Patients treated with ORIF appeared to have improved union rates and early outcomes with ankle function and Short Form-36 Physical Function scores. Copyright 2012, SLACK Incorporated.


Lee D.H.,Vanderbilt Orthopaedic Institute
Hand Clinics | Year: 2011

This article provides an overview of the current state of linked total elbow arthroplasty. Discussed are the general indications for using a linked implant and currently available implants. Disease-specific indications, contraindications, surgical technique, and rehabilitation are discussed. The overall results and disease-specific results, as well as complications after a linked elbow arthroplasty, are reviewed. © 2011 Elsevier Inc.


Biber Brewer R.,Vanderbilt Orthopaedic Institute | Gregory A.J.M.,Vanderbilt Orthopaedic Institute
Sports Health | Year: 2012

Context: Chronic lower leg pain in athletes can be a frustrating problem for patients and a difficult diagnosis for clinicians. Myriad approaches have been suggested to evaluate these conditions. With the continued evolution of diagnostic studies, evidence-based guidance for a standard approach is unfortunately sparse.Evidence Acquisition: PubMed was searched from January 1980 to May 2011 to identify publications regarding chronic lower leg pain in athletes (excluding conditions related to the foot), including differential diagnosis, clinical presentation, physical examination, history, diagnostic workup, and treatment.Results: Leg pain in athletes can be caused by many conditions, with the most frequent being medial tibial stress syndrome; chronic exertional compartment syndrome, stress fracture, nerve entrapment, and popliteal artery entrapment syndrome are also considerations. Conservative management is the mainstay of care for the majority of causes of chronic lower leg pain; however, surgical intervention may be necessary.Conclusion: Chronic lower extremity pain in athletes includes a wide differential and can pose diagnostic dilemmas for clinicians. © 2012 American Orthopaedic Society for Sports Medicine.


Stinner D.J.,Vanderbilt Orthopaedic Institute | Mir H.,Vanderbilt Orthopaedic Institute
Orthopedic Clinics of North America | Year: 2014

Despite poor early results with intramedullary nailing of extra-articular proximal tibia fractures, improvements in surgical technique and implant design modifications have resulted in more acceptable outcomes. However, prevention of the commonly encountered apex anterior and/or valgus deformities remains a challenge when treating these injuries. It is necessary for the surgeon to recognize this and know how to neutralize these forces. Surgeons should be comfortable using a variety of the reduction techniques presented to minimize fracture malalignment. © 2014 Elsevier Inc.

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