Publications by authors named "Bruce H Ziran"

53 Publications

Proposal of a new shared payment model for healthcare financing in the United States: a hypothesis.

Patient Saf Surg 2020 23;14:17. Epub 2020 Apr 23.

Philadelphia College of Osteopathic Medicine, Atlanta, Georgia.

The healthcare repayment system in America is highly flawed due to several factors such as uncontrolled costs, unequal access, varied reimbursement systems, and complex patient interfaces. In fact, it is rated the worst among the eleven developed nations analyzed in the Commonwealth Fund's evaluation conducted every three years. We propose a novel three-tiered model for healthcare repayment designed to fulfill the needs of the patients, the providers, the payers and the nation as a whole. We hypothesized that our new plan may spread cost between multiple entities and offer better coverage and access to care. Our model uses a shared-cost approach wherein the total risk expenditure becomes the responsibility of various stakeholders including the government, insurance industry, hospitals, patients, providers as well as the nation's economy. While there is no perfect solution to healthcare in America, we believe our three-tiered model can create an economically balanced solution to break deadlock between party lines and result in better outcomes and patient care.
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http://dx.doi.org/10.1186/s13037-020-00242-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178933PMC
April 2020

Early Comparative Outcomes of Carbon Fiber-Reinforced Polymer Plate in the Fixation of Distal Femur Fractures.

J Orthop Trauma 2018 08;32(8):386-390

Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN.

Objective: To evaluate the early clinical results of distal femur fractures treated with carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates compared with stainless steel (SS) lateral locking plates.

Design: Retrospective comparative cohort study.

Setting: ACS Level I trauma center.

Patients/participants: Twenty-two patients (11 SS, 11 CFR-PEEK) with closed distal femur fractures treated by a single surgeon over a 6-year period.

Main Outcome Measurements: Nonunion, hardware failure, reoperation, time to full weight-bearing, and time union were assessed.

Results: The CFR-PEEK cohort was on average older (71 vs. 57 years, P = 0.03) and more likely to have diabetes (P = 0.02). Nonunion was diagnosed in 4/11 (36%) patients in the SS group and 1/11 (9%) patients in the CFR-PEEK group (P = 0.12). Hardware failure occurred in 2 SS patients (18%) compared with none in the CFR-PEEK group (P = 0.14). Time to full weight-bearing was similar between groups, occurring at 9.9 and 12.4 weeks in the CFR-PEEK and SS groups, respectively (P = 0.23). Time to radiographic union averaged 12.4 weeks in the SS group and 18.7 weeks in the CFR-PEEK group (P = 0.26). There were 4 reoperations in the SS group and 1 in the CFR-PEEK group (P = 0.12).

Conclusions: CFR-PEEK plates show encouraging short-term results in the treatment of distal femur fractures with a comparable nonunion, reoperation, and hardware failure rates to those treated with SS plates. This data suggest that CFR-PEEK plates may be a viable alternative to SS plates in fixation of these fractures.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001223DOI Listing
August 2018

Radiographic Evaluation of Acetabular Fractures: Review and Update on Methodology.

J Am Acad Orthop Surg 2018 Feb;26(3):83-93

From the Department of Orthopaedics, Denver Health Medical Center, Denver, CO (Dr. Mauffrey and Dr. Stacy), the Department of Orthopaedics, University of Colorado, Denver (Dr. York), the Department of Orthopaedics, Hughston Clinic, Atlanta, GA (Dr. Ziran), and the Department of Orthopaedics, University of Cincinnati Medical Center, Cincinnati, OH (Dr. Archdeacon).

Despite increased availability of modern imaging techniques, plain radiographs remain the initial step in the classification of acetabular fractures. The ability to interpret the injury configuration allows the surgeon to develop a thorough preoperative plan and to evaluate the quality of reduction and fixation intraoperatively. Proficiency in the mental conversion of a two-dimensional radiograph into a three-dimensional conceptual image is imperative. The widely used radiographic classification scheme developed by Judet and Letournel in the 1960s is both practical and simple. However, understanding the subtleties of the fracture pattern can be a challenge even for experienced surgeons. Current evaluation methods include CT and three-dimensional reconstructions in addition to plain radiographs. Our diagnostic algorithm uses three plain radiographs to classify the fracture into one of the 10 fracture patterns described by Judet and Letournel.
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http://dx.doi.org/10.5435/JAAOS-D-15-00666DOI Listing
February 2018

Acetabular fractures in elderly patients: a comparative study of low-energy versus high-energy injuries.

Int Orthop 2015 Jun 3;39(6):1175-9. Epub 2015 Mar 3.

Haeundae Paik Hospital, Department of Orthopaedic Surgery, Inje University, Busan, Republic of Korea.

Purpose: The goal of this study is to compare the characteristics, clinical course, and mortality rates of acetabular fractures in the elderly population with respect to two types of injury.

Methods: We reviewed 183 consecutive patients with acetabular fractures aged 60 years old and older. One hundred eighty-three patients (129 men and 54 women) were included in the study with an average age of 70.2 years. There were 186 fractures, which included three cases of bilateral fractures. Patients were divided into two groups: low-energy injuries (group I), 56, and high-energy injuries (group II), 130. Patient characteristics and fracture pattern, as well as in-hospital mortality rates were compared between the low-energy and high-energy groups.

Results: Patient demographics and comorbidities were significantly different between the groups. In group I, the average age was 74.9 years, versus 68.2 years in group II (p < 0.001). The percent of females in each group was 39.3 % and 24.6 %, respectively (p = 0.043), and the average body mass index (BMI) was 25.6 and 28.4, respectively (p = 0.001). The Charlson comorbidity index was higher in group I (1.98 vs 0.95 in group II, p < 0.001). However, the American Society of Anesthesiologists physical status (ASA) was similar between groups (2.56 vs 2.53, respectively, p = 0.808). The proportion of surgical treatment was 44.6 % in group I and 61.6 % in group II (p = 0.019). Group II had a longer hospital stay (10.4 days vs 14.5 days, p = 0.025), but in-hospital death was not significantly different (5.3 % vs 7.9 %, respectively, p = 0.567).

Conclusion: Patients with acetabular fractures resulting from low-energy injuries were older and had lower BMI with more comorbidities. This study may highlight characteristics of fragility fractures of the acetabulum.
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http://dx.doi.org/10.1007/s00264-015-2711-0DOI Listing
June 2015

Interlocking screws placed with freehand technique and uni-planar image intensification: the "dip-stick" technique.

Injury 2014 Nov;45 Suppl 5:S21-5

Department of Orthopaedic Trauma Surgery, Federal University of São Paulo (DOT-UNIFESP), São Paulo, Brazil.

Objective: To report our experience with a novel alternative method of freehand interlocking of intramedullary nails. This method requires the use of only anterior-posterior image intensification and an intramedullary guide wire to verify screw placement. Our results are compared with historical results in the literature.

Methods: A total of 815 patients were treated using this technique from January 2008 to December 2012; 603 patients had fractures of the tibia and 212 had fractures of the femur.

Results: The mean duration of surgery for tibial shaft fractures was 55.6 minutes (range 42-60 minutes) and that for fractures of the femur was 78 minutes (range 50-90 minutes). The mean time for each distal locking was 3.8 minutes (2.5-5.1 minutes), with 7.65 seconds of exposure to radiation during each block.

Conclusions: The surgical technique is simple, easy and reproducible. Mean time of surgery and radiation exposure was less than that in the literature. A comparative study should be performed.
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http://dx.doi.org/10.1016/S0020-1383(14)70016-6DOI Listing
November 2014

Preventing eccentric reaming of the trochanter during trochanteric nailing.

J Orthop Trauma 2014 Apr;28(4):e88-90

*Department of Orthopaedic Surgery, Orthopaedic Residency Program, Atlanta Medical Center, Atlanta, GA; and †Department of Orthopaedic Surgery, Atlanta Medical Center, Atlanta, GA.

The lateralizing vector of a flexible guide wire can result in eccentric lateral reaming of the proximal femur during intramedullary nailing procedures. This effect is especially true with peritrochanteric fractures that have a fracture line exit near the entry point, and in obese patients. We present one method of maintaining a co-axial position of the guide wire and reamer assembly to help direct the portal of reaming in a more anatomic position. Use of a concave shaped retractor such as an Appendiceal or Richardson helps to "capture" the reamer shaft and control where proximal reaming occurs. We have found this method to be easy to use and effective when indicated.
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http://dx.doi.org/10.1097/BOT.0b013e3182a59c80DOI Listing
April 2014

Radiographic predictors of compartment syndrome in tibial plateau fractures.

J Orthop Trauma 2013 Nov;27(11):612-5

Atlanta Medical Center, Atlanta, GA.

Objectives: The purpose of this article was to evaluate the relationship of radiographic features of tibial plateau fractures to the development of compartment syndrome. We hypothesized that the direction and degree of initial displacement of the femur on the tibia, and the amount of tibial widening (TW), were correlated with the development of compartment syndrome.

Design: Retrospective case-control study.

Setting: Single level 1 trauma center.

Patients: Retrospective evaluation of 158 patients with 162 plateau fractures.

Intervention: Grouping with and without compartment syndrome.

Main Outcome Measures: The following data were obtained: age, sex, Schatzker and OTA/AO classification, open/closed status, TW, and femoral displacement (FD). A univariate statistical and a logistical regression analysis were performed to determine significance.

Results: The overall rate of compartment syndrome was 11%. Univariate analysis found both the TW and FD to be significant with respect to development of compartment syndrome (P < 0.05). Higher Schatzker (IV-VI) and OTA/AO grades were also correlated (P < 0.05) with increased incidence of compartment syndrome. Logistic regression found FD and Schatzker grade to be significant.

Conclusions: Our study is the first to identify easily obtained radiographic parameters that correlate to the occurrence compartment syndrome. There may also be a relationship between TW and FD, as noted by regression result. This study helps to assess which patients with a fracture are at higher risk for developing a compartment syndrome.

Level Of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0b013e31828e25b6DOI Listing
November 2013

How to negotiate with your hospital.

J Orthop Trauma 2012 Sep;26 Suppl 1:S14-7

Orthopaedic Trauma, Atlanta Medical Center, Atlanta, GA 30312, USA.

The orthopaedic trauma market place and career track have changed considerably over the last 10 years. There is an increasing demand from community hospitals for orthopaedic trauma. Understanding how to assess the practice opportunity and engage prospective employers is key to developing a successful and sustainable program and career. The article reviews the market place changes and how to approach negotiations. Lessons from other aspects of life and business are highlighted.
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http://dx.doi.org/10.1097/BOT.0b013e3182644fccDOI Listing
September 2012

A new ankle spanning fixator construct for distal tibia fractures: optimizing visualization, minimizing pin problems, and protecting the heel.

J Orthop Trauma 2013 Feb;27(2):e45-9

Atlanta Medical Center, Department of Orthopaedic Surgery and Residency Program, Atlanta, GA 30312, USA.

Pilon and ankle fractures and ligamentous injuries about the ankle often require external fixation to allow for soft tissue stabilization before definitive surgery. Often used external fixator constructs can cause obscuring of the site of injury on radiographs, pin tract infections, loosening of calcaenal pin fixation, and heel ulcerations. A novel and simple technique of placing the calcaneal pins posteriorly and using a U-shaped bar allows for a construct that reduces or eliminates many of these drawbacks during the time it takes for soft tissue swelling to permit definitive fixation.
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http://dx.doi.org/10.1097/BOT.0b013e3182604639DOI Listing
February 2013

An alternative technique for transosseous calcaneal pinning in external fixation.

J Foot Ankle Surg 2012 Jul-Aug;51(4):528-30. Epub 2012 Mar 3.

Department of Podiatry, St. Elizabeth Health Center, Youngstown, OH, USA.

The authors describe a technique in which two 5.5-mm pins are inserted from the posterior aspect of the calcaneus and advanced anteriorly on a slightly convergent vector. The 2 points of fixation, with a 5/8 ring, provide a "steering wheel" effect allowing for leverage and control of the hindfoot and ankle. The construct also allows for offloading of the posterior calcaneus.
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http://dx.doi.org/10.1053/j.jfas.2012.02.009DOI Listing
November 2012

The use of a T-plate as "spring plates" for small comminuted posterior wall fragments.

J Orthop Trauma 2011 Sep;25(9):574-6

Department of Orthopaedics, Atlanta Medical Center, Atlanta, GA 30312, USA.

In the treatment of posterior wall fractures of the acetabulum, a modified distal radius T-plate can be substituted for one third tubular spring plates for fixation of thin, small, or comminuted posterior wall fragments. This technique is described as well as a case series of 33 patients with various posterior wall acetabular fractures.
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http://dx.doi.org/10.1097/BOT.0b013e3181f8c919DOI Listing
September 2011

Treating osteomyelitis: antibiotics and surgery.

Plast Reconstr Surg 2011 Jan;127 Suppl 1:177S-187S

Pittsburgh, Pa.; Atlanta, Ga.; and Seattle, Wash. From the University of Pittsburgh School of Medicine, Atlanta Medical Center, and Veterans Affairs Puget Sound Health Care System, University of Washington.

Background: Osteomyelitis is an inflammatory disorder of bone caused by infection leading to necrosis and destruction. It can affect all ages and involve any bone. Osteomyelitis may become chronic and cause persistent morbidity. Despite new imaging techniques, diagnosis can be difficult and often delayed. Because infection can recur years after apparent "cure," "remission" is a more appropriate term.

Methods: The study is a nonsystematic review of literature.

Results: Osteomyelitis usually requires some antibiotic treatment, usually administered systemically but sometimes supplemented by antibiotic-containing beads or cement. Acute hematogenous osteomyelitis can be treated with antibiotics alone. Chronic osteomyelitis, often accompanied by necrotic bone, usually requires surgical therapy. Unfortunately, evidence for optimal treatment regimens or therapy durations largely based upon expert opinion, case series, and animal models. Antimicrobial therapy is now complicated by the increasing prevalence of antibiotic-resistant organisms, especially methicillin-resistant Staphylococcus aureus. Without surgical resection of infected bone, antibiotic treatment must be prolonged (≥4 to 6 weeks). Advances in surgical technique have increased the potential for bone (and often limb) salvage and infection remission.

Conclusions: Osteomyelitis is best managed by a multidisciplinary team. It requires accurate diagnosis and optimization of host defenses, appropriate anti-infective therapy, and often bone débridement and reconstructive surgery. The antibiotic regimen must target the likely (or optimally proven) causative pathogen, with few adverse effects and reasonable costs. The authors offer practical guidance to the medical and surgical aspects of treating osteomyelitis.
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http://dx.doi.org/10.1097/PRS.0b013e3182001f0fDOI Listing
January 2011

Sub-muscular plating of the humerus: an emerging technique.

Injury 2010 Oct;41(10):1047-52

Atlanta Medical Center, Department of Orthopaedics, Atlanta, GA, USA.

Objective: The purpose of the present study was to evaluate percutaneous sub-muscular internal fixation using a locked screw methodology for treatment of diaphyseal humeral fractures.

Methods: Inclusion criteria were multiple extremity fractures, open fractures, neurovascular injuries,additional ipsilateral upper extremity fractures, the inability to obtain a satisfactory closed reduction and isolated fractures with circumstances that prevented effective bracing. Exclusion criteria were immaturity, neoplasm, infection and intra-articular extensions in the same bone. Outcome measures included clinical and radiographic healing, complications, elbow and shoulder symptoms, range of motion (ROM) and Constant–Murley (CM) scores.

Results: Thirty-one patients with 32 fractures were evaluated with a mean follow-up of 16 months (3–38 months). There was radiographic healing in 31 out of the 32 fractures; the non-union was revised to open plating at 6 months and healed uneventfully. Hardware complications included two construct disengagements; one patient was revised and healed, and the other achieved union with bracing.Neurovascular complications included one preoperative nerve palsy that recovered by 3 months, two partial to complete postoperative nerve palsies that recovered by 6 months, and one intact-to-complete nerve palsy due to a bone fragment that required decompression with full recovery by 3 weeks. All patients had functional ROM with a mean CM score of 88. There were no elbow complaints and minor shoulder dysfunction occurred in two patients with ipsilateral shoulder injuries. The rate of neurovascular complications was comparable to open plating techniques and all patients had full recovery.

Conclusion: We feel sub-muscular anterior plating of the humerus using locking screw technology is a viable and useful method for diaphyseal humeral fractures.
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http://dx.doi.org/10.1016/j.injury.2010.04.021DOI Listing
October 2010

Demineralized bone matrix for fracture healing: fact or fiction?

J Orthop Trauma 2010 Mar;24 Suppl 1:S52-5

Department of Orthopaedics, Atlanta Medical Center, Atlanta, GA, USA.

Demineralized bone matrix (DBM) has been touted as an excellent grafting material; however, there are no Level I studies that use DBM alone in humans to back up this claim. DBM functions best in a healthy tissue bed but should be expected to have little impact in an anoxic or avascular tissue bed, a situation often encountered in traumatic orthopaedic pathologies. Moreover, there is some evidence of differential potencies of DBM preparations based on donor variability and the manufacturing process. DBM efficacy may also be related to its formulation and the various carriers used. The fact that DBM is an allogeneic material opens up the potential for disease transmission. In addition, DBM activity may be altered by the hormonal status or nicotine use of a patient. In summary, although DBM has proven effective for bone induction in lower form animals, the translation to human clinical use for fracture healing, and the burden of proof, remains.
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http://dx.doi.org/10.1097/BOT.0b013e3181d07ffaDOI Listing
March 2010

Use of solid and cancellous autologous bone graft for fractures and nonunions.

Orthop Clin North Am 2010 Jan;41(1):15-26; table of contents

Department of Orthopedic Surgery, Atlanta Medical Center, 303 Parkway Drive NE, Atlanta, GA 30312, USA.

Bone is the second most commonly implanted material in the human body, after blood transfusion, with an estimated 600,000 grafts performed annually. Although the market for bone graft substitutes is more than $1 billion, that of bone graft itself is still more than half that amount. Reports of autologous bone grafting date back to the ancient Egyptians, yet the modern scientific study of grafting began in the early 19th century. Since then, the indications, methodology, and science of bone grafts in nonunion and bone loss have been established and refined, and new methods of harvesting and treatment are being developed and implemented. This article describes the use of solid and cancellous bone graft in the treatment of acute bone loss and nonunion.
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http://dx.doi.org/10.1016/j.ocl.2009.08.003DOI Listing
January 2010

Intramedullary hip screw versus standard compression hip screw: early postoperative rehabilitation comparisons.

Orthopedics 2009 Feb;32(2):83

Department of Orthopedic Trauma, St. Elizabeth Health Center, 1044 Belmont Ave, Youngstown, OH 44501, USA.

Studies comparing the intramedullary hip screw and the compression hip screw for fixation of intertrochanteric hip fractures have shown little difference in final functional outcome. However, the characteristics of the rehabilitation process for these implants have not been analyzed. This study used the Functional Independence Measure (FIM Instrument; Uniform Data System for Medical Rehabilitation, Amherst, New York) to better characterize the subtle differences of the perioperative, clinical, and rehabilitative treatment of intertrochanteric fractures using the intramedullary hip screw or compression hip screw. Ninety-four patients with isolated intertrochanteric fractures were treated with either an intramedullary hip screw or compression hip screw at our institution. To reduce technical bias, only experienced surgeons were used and patient allocation was surgeon based (eg, surgeons consistently used the same preferred implant). We evaluated the following FIM categories: bed mobility, bed transfer, gait independence, and distance ambulated. Length of stay and level of discharge disposition were also evaluated. The intramedullary hip screw group performed better with bed transfers (P<.05), demonstrated better ambulatory ability at discharge (P<.06), and had an increased gait distance at discharge (P<.07). Skin-to-skin operative time and estimated blood loss was significantly less for the intramedullary hip screw group. Length of hospital stay and discharge disposition failed to reach statistical significance. Our study found that when using the FIM scores, some differences were noted in the acute rehabilitation characteristics in patients between the intramedullary hip screw and the compression hip screw. These findings may have medical and social importance as well as significant economic implications. Further study with a larger sample size and more stringent study design are recommended.
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February 2009

Efficacy of composite allograft and demineralized bone matrix graft in treating tibial plateau fractures with bone loss.

Orthopedics 2008 Jul;31(7):649

Department of Orthopedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, Denver, CO 80204, USA.

Tibial plateau fractures with bone loss or significant comminution require grafting and stable fixation. We hypothesized a standardized protocol of internal fixation augmented with a mixture of demineralized bone matrix and corticocancellous allograft chips would result in high healing rates with minimal subsidence. Union was achieved in all 36 patients available for follow-up by a mean of 4.4 months. Mean range of motion was 2 degrees to 120 degrees. One patient developed osteomyelitis. Subsidence ranging from 2.5 to 5.7 mm occurred in 4 patients (11%). This treatment method provides sufficient structural integrity with a high union rate and a low complication rate.
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July 2008

Hidden burdens of orthopedic injury care: the lost providers.

J Trauma 2009 Feb;66(2):536-49

Department of Orthopaedic Surgery, Atlanta Medical Center, 303 Parkway Drive NE, Atlanta, GA 30312, USA.

Background: There are no previously known studies on the effects of orthopedic trauma on informal caregivers despite rich literature in other areas of caregiving. In this prospective study, we characterize personal and socioeconomic impact on orthopedic trauma caregivers.

Methods: Ninety-nine subjects were given the Caregiver Burden Scale and an original survey measuring emotional, employment, and socioeconomic burden. Demographic, patient injury, and treatment data were also collected.

Results: Seventy percent of caregivers were female family members of the patient. Fifty-four percent experienced substantial disruption to social life and emotional stress. Fifty-one percent spent more than 21 hrs/wk caregiving postinjury. Before/after injury time spent caring for the patient was statistically significant (p < 0.01). Many caregivers experienced employment stress; 8% quit their jobs. Before/after injury employment stress was statistically significant (p < 0.01). Caregivers also expressed considerable financial stress.

Conclusions: Socioeconomic impacts related to caregiving experiences extend beyond the clinical care of the patient with caregivers facing extensive stress, financial drain, and employment difficulties. Understanding the complex nature of caring for orthopedic patients may assist in connecting patients and caregivers to the appropriate services and further improve patient outcomes.
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http://dx.doi.org/10.1097/TA.0b013e31817db0bfDOI Listing
February 2009

Outcome and complications of posterior transiliac plating for vertically unstable sacral fractures.

Injury 2009 Apr 17;40(4):405-9. Epub 2008 Dec 17.

Department of Orthopaedic Surgery, Denver Health Medical Centre, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA.

Vertically unstable sacral fractures often make it difficult to achieve rigid fixation and there is no consensus on the optimal fixation technique for these injuries. The purpose of this study was to evaluate complication rate and short-term outcome of vertically unstable sacral fractures treated by posterior transiliac plate fixation. We performed a retrospective review of prospectively collected data of patients who underwent posterior transiliac plating for sacral fractures at two institutions. All patients were treated with the standard posterior approach using a 4.5-mm reconstruction plate and followed for at least 12 months. Patients' demographics, Majeed functional questionnaire surveys, and radiographic outcomes were collected. There were 19 patients with a mean age of 37.5-years. The mean follow-up was 26.3 months. The most frequent mechanism of injury was a fall from a height. According to the AO/OTA classification, there were 10 C1, 6 C2, and 3 C3, which were classified as 2 Denis I, 20 Denis II, and 2 Denis III, including 5 bilateral sacral fractures. Neurological deficit at the initial examination was recorded in 10 patients. The mean ISS was 20.7 and the mean timing of the internal fixation was 6.4 days. Anterior internal fixation of pelvic ring was added in eight patients. A Morel-Lavallee lesion was identified in 5 patients during the operation. Reductions were graded as nine excellent, seven good, and three fair according to the method of Tornetta. There were two postoperative surgical wound infections, both occurring in patients with a Morel-Lavallee lesion. All the sacral fractures united eventually and no implant failure occurred, though there were two patients with a small loss of reduction (<5mm) over the follow-up period. A total of 18 patients completed the functional assessment with a mean score of 78.5 points. Posterior plate fixation of vertically unstable sacral fractures is effective in maintaining fracture reduction even in the presence of significant posterior comminution. We caution its use in the presence of a known Morel-Lavallee lesion, as this may increase the wound complication and infection risk.
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http://dx.doi.org/10.1016/j.injury.2008.06.039DOI Listing
April 2009

Inhalant abuse of 1,1-difluoroethane (DFE) leading to heterotopic ossification: a case report.

Patient Saf Surg 2008 Oct 30;2(1):28. Epub 2008 Oct 30.

St. Elizabeth Health Center, Youngstown, OH, USA.

Background: Heterotopic ossification (HO) is the formation of mature, lamellar bone within soft tissues other than the periosteum. There are three recognized etiologies of HO: traumatic, neurogenic, and genetic. Presently, there are no definitively documented causal factors of HO. The following factors are presumed to place a patient at higher risk: 60 years of age or older, male, previous HO, hypertrophic osteoarthritis, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, prior hip surgery, and surgical risk factors.

Case Presentation: A 33-year-old male, involved in a motor vehicle crash, sustained an irreducible acetabulum fracture/dislocation, displaced proximal humerus fracture, and an impacted pilon fracture. During the time of injury, he was intoxicated from inhaling the aerosol propellant used in "dust spray" cans (1,1-difluoroethane, C2H4F2). Radiographs identified rapid pathologic bone formation about the proximal humeral metaphysis, proximal femur, elbow, and soft tissue several months following the initial injury.

Discussion: The patient did not have any genetic disorders that could have attributed to the bone formation but had some risk factors (male, fracture with dislocation). Surgically, the recommended precautions were followed to decrease the chance of HO. Although the patient did not have neurogenic injuries, the difluoroethane in dusting spray can cause damage to the central nervous system. Signals may have been mixed causing the patient's body to produce bone instead of tissue to strengthen the injured area.

Conclusion: What is unusual in this case is the rate at which the pathological bone formation appeared, which was long outside the 4-6 week window in which HO starts to appear. The authors are not certain as to the cause of this rapid formation but suspect that the patient's continued abuse of inhaled aerosol propellants may be the culprit.
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http://dx.doi.org/10.1186/1754-9493-2-28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2584001PMC
October 2008

United States level I trauma centers are not created equal - a concern for patient safety?

Patient Saf Surg 2008 Jul 21;2:18. Epub 2008 Jul 21.

Orthopaedic Trauma Research, St. Elizabeth Health Center, Youngstown, USA.

Background: The American College of Surgeons delineates 108 requirements for level I trauma centers. Some of these requirements include: minimum of 1,200 trauma admissions per year; an average of 35 major trauma patients per surgeon; residency training programs; and 10 peer-reviewed journal submissions every three years. This study examines the variation in services provided among U.S. level I trauma centers.

Methods: 218 facilities identified as level I trauma centers in 2005 were contacted for participation. 136 centers in 37 states completed the questionnaire. Surveys queried variances in trauma, neurosurgery, plastics, and orthopaedic surgery with regard to type of center, type of accreditation, number and training of participating physicians, number of beds, dedicated OR support (staff/rooms), call pay, and research.

Results: Of the level I centers surveyed, 66% are university-affiliated facilities that employ more surgeons and staffing across trauma and all subspecialties compared to community-based or public centers. However, the community and public centers have more surgeons per capita (44% of the university-affiliated hospitals have six or more trauma surgeons on staff compared to 59% of the community and 70% of the public facilities). University-affiliated centers also provide more in-house subspecialty services (orthopaedic, neurosurgery, and plastics). Thirty-nine percent do not have ACS accreditation and are designated trauma facilities by state or local governments. Only 49% of trauma centers provide on-call pay to trauma surgeons, and these percentages decline for all subspecialties. Dedicated operating rooms and research programs are also lacking among all subspecialties.

Conclusion: Based on our findings, we conclude that there are no homogeneous criteria for being accredited as a level I trauma center. Reliable resources should be offered at any facility that claims a level I trauma designation. We do not know if such diversity of services truly impacts care or how it can be measured; nevertheless, it would be logical to presume that at some point services that fall below a minimum threshold would potentially adversely affect the quality of care. In order to develop appropriate policy to decrease possible disparities, differentiation in services between trauma centers must be further researched and described.
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http://dx.doi.org/10.1186/1754-9493-2-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515286PMC
July 2008

Economic value of orthopaedic trauma: the (second to) bottom line.

J Orthop Trauma 2008 Apr;22(4):227-33

St. Elizabeth Health Center, Youngstown, Ohio 44501, USA.

Objectives: We evaluated the economic aspects of an orthopaedic trauma section at a regional Level I, semi-academic community hospital. This study analyzes the economics of a dedicated hospital-based orthopaedic trauma program.

Methods: Institutional financial reports were analyzed for 2 time periods. In the pre-program (PRE) period (2 years), we estimated the amount of forsaken revenue resulting from cases transferred to other institutions. In the post-program (POST) period (2 years), we analyzed financial reports to evaluate fiscal solvency. Health Care Cost and Utilization Project National Inpatient Sample (HCUP-NIS) data, International Classification of Diseases, 9th Revision (ICD-90 codes, and Eclipsys software were used. Standard accounting definitions for gross revenue, net revenue, direct costs, contribution margin, indirect costs, and net profit/loss were used.

Results: In the PRE-program period 88 patients were transferred; forsaken charges were about $1.25 million/year. Based on historic collection rates, there was about $450,000/year of actual lost revenue. In the POST-program period net revenue was about $7 million with a $1.5 million contribution margin, which increased 9%-11% in year 2. With inclusion of indirect costs, there was a net loss of nearly $5 million/year, but the financial software uses the direct cost expense as a major determinant of indirect costs. Based on the definition of indirect costs (overhead for lights, maintenance, etc) and with such expenses being used prior to the program, we felt that indirect cost was not an accurate variable and contribution margin is the better measure of economic value.

Conclusion: We found that orthopaedic trauma is a financially viable program. Understanding the determination and interpretation of financial data is essential for any such analysis.
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http://dx.doi.org/10.1097/BOT.0b013e31816bae67DOI Listing
April 2008

External fixation: how to make it work.

Instr Course Lect 2008 ;57:37-49

Neoucom, St. Elizabeth Health Center, Youngstown, Ohio, USA.

The external fixator has been in use for more than a century. Wutzer (1789-1863) used pins and an interconnecting rod-and-clamp system. Parkhill (1897) and Lambotte (1900) used devices that were unilateral with four pins and a bar-clamp system. By 1960, Vidal and Hoffmann had popularized the use of an external fixator to treat open fractures and infected pseudarthroses. The complications associated with the use of external fixation in the late 20th century were predominantly caused by a lack of understanding of the principles of application, the principles of fracture healing with external fixation, and old technology. Its use was reserved for the most severe injuries and for cases complicated by infection. Thus, pin problems, nonunions, and malunions were common. Better technology and understanding have since allowed for greater versatility and better outcomes. Simultaneous with developments in the Western world, Ilizarov developed the principles of external fixation with use of ring and wire fixation. It was not until the late 1980s and early 1990s, when more interaction and exchange between the West and East (Russia) became possible, and with the help of Italians who embraced the philosophy of external fixation, that the use of external fixation was proven to be successful. Several variations of external fixation have been developed, and its use is now widespread. However, in the United States, all but a minority of surgeons still have substantial apprehension about the use of external fixation.
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September 2008

Locking plates: tips and tricks.

Instr Course Lect 2008 ;57:25-36

Denver Health Medical Center, University of Colorado, Denver, Colorado, USA.

Locking plates are fracture fixation devices that allow the insertion of fixed-angle/angular-stable screws or pegs and do not require friction between the plate and bone. The clinical care impetus for the development of these plates has been a combination of factors, including the increasing survival of patients with high-energy injuries, aging Western European and North American populations with an increasing rate of fragility fractures, and dissatisfaction of patients and surgeons with the outcomes of treatment of specific periarticular fractures. Nonclinical factors likely include a push by industry for new technology and new markets as well as the general interest of the public in "minimally invasive" surgery.
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September 2008

Technical tips in fracture care: fractures of the hip.

Instr Course Lect 2008 ;57:17-24

Department of Orthopaedics, Indiana University, Indianapolis, Indiana, USA.

Hip fracture is an increasingly common and clinically significant injury with substantial economic impact. Associated risk factors are age, gender, race, bone density, activity level, and medical disorders. Prevention efforts include treatment of osteoporosis and programs to reduce the risks of a fall. Nondisplaced or impacted fractures of the femoral neck can be treated with screw fixation. Displaced femoral neck fractures in younger, more active patients may be treated with reduction and fixation. In physiologically older patients, joint arthroplasty is indicated for displaced fractures. In patients with systemic arthritis or preexisting hip disease, total hip arthroplasty may be an appropriate treatment choice. Intertrochanteric fractures are treated with reduction and fixation using either a sliding hip screw and side plate or intramedullary nail with cephalic interlock. Key technical points for successful outcomes include proper patient positioning, using a correct starting point for the nail, achieving acceptable reduction before fixation, and the use of various reduction techniques and aids.
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September 2008

Hemipelvic amputations for recalcitrant pelvic osteomyelitis.

Injury 2008 Apr 5;39(4):411-8. Epub 2008 Mar 5.

Department of Orthopaedic Trauma, St. Elizabeth Health Center, Northeast Ohio Universities College of Medicine, Youngstown, OH 44501, United States.

Objective: To evaluate the outcome of recalcitrant deep pelvic infection that required a hemipelvic amputation.

Study Design: Retrospective cohort.

Setting: Tertiary referral centre; Level I trauma.

Patients: There were 20 patients with an infection of the pelvic girdle who developed life-threatening sepsis or had an intolerable existence due to putrefied tissues that prevented end of life care. All patients failed other more conservative treatments such as limited debridement and local wound care. The indication for amputation was life-threatening sepsis (eight patients), intolerable state with putrid tissue (four patients), and both sepsis/putrefaction (eight patients).

Intervention: A hemipelvic amputation, multidrug antibiotic treatment, and long-term suppression. Ten internal hemipelvectomies, eight external hemipelvectomies, and two hemicorporectomies were performed.

Main Outcome Measure: Survival and recurrence of infection.

Results: Six patients died within 6 months (mean time 17 weeks, range 2-24). The 14 surviving patients had a mean follow-up time of 28 weeks (9-48). Of these, 10 patients survived with no evidence of ongoing infection, and four patients had ongoing infection requiring suppressive antibiotics. All of the six deaths were in C-hosts with an average of six comorbidities each; mean age was 62 years old. Aetiologies of the infection were vasculopathy (5), spinal cord injury (4), post fracture (3), post abdominal surgery (2), gunshot wound (2), seeding from bacteraemia (4). Cierny-Mader host class was C (11) and B systemic/local (9) with an average of four (4) comorbidities each. Mean estimated blood loss=3100 cc and operative time=157 min. There were 11 cases of minor wound problems and no flap loss. Pathogens were polymicrobial (16 total pathogens) with mean of three per patient (most common was MRSA). Multi-agent antibiotic and suppression were used in all patients. In cases with putrefied tissues, appropriate nursing care was possible.

Conclusion: Patients requiring hemipelvectomies usually present with sepsis or an intolerable state. Despite expected complications, we found that hemipelvectomy is an effective palliative tool in selected cases. Age and vascular disease seemed to be associated with worse outcomes.
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http://dx.doi.org/10.1016/j.injury.2007.12.002DOI Listing
April 2008

Repetitive posterior iliac crest autograft harvest resulting in an unstable pelvic fracture and infected non-union: case report and review of the literature.

Patient Saf Surg 2007 Dec 17;1(1). Epub 2007 Dec 17.

Department of Orthopedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA.

Fractures of the pelvic ring have been well studied, and the biomechanical relationship between the anterior and posterior elements is an important concept to understand these complex injuries. The vast majority of these injuries are due to trauma. However, in rare circumstances, autogenous bone graft harvesting may lead to an unstable pelvic ring. In this case report, we describe a rare complication in a 70-year old female patient who developed an unstable pelvis and an infected non-union secondary to repeated posterior iliac graft harvest. The orthopaedic surgeon should be aware of this detrimental complication associated with extensive or repeated posterior iliac crest graft harvest.
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http://dx.doi.org/10.1186/1754-9493-1-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2241775PMC
December 2007

Bias towards publishing positive results in orthopedic and general surgery: a patient safety issue?

Patient Saf Surg 2007 Nov 27;1(1). Epub 2007 Nov 27.

Department of Orthopedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA.

Background: Research articles reporting positive findings in the fields of orthopedic and general surgery appear to be represented at a considerably higher prevalence in the peer-reviewed literature, compared to published studies on negative or neutral data. This "publication bias" may alter the balance of the available evidence-based literature and may affect patient safety in surgery by depriving important information from unpublished negative studies.

Methods: A comprehensive review of all published articles in a defined 7-year period was performed in 12 representative journals in the fields of orthopedic and general surgery. Every article published in all volumes of these journals between January 2000 and December 2006 was reviewed and rated by three investigators. Rating of articles was performed according to a uniform, standardized algorithm. All original articles were stratified into "positive", "negative" or "neutral", depending on the reported results. All non-original papers were excluded from analysis.

Results: A total of 30,197 publications were reviewed over a 7-year time-period. After excluding all non-original articles, a total of 16,397 original papers were included in the final analysis. Of these, 12,251 (74%) articles were found to report positive findings, 2,709 (17%) reported negative results, and 1,437 (9%) were neutral. A similar publication pattern was found among all years and all journals analyzed. Altogether, 91% of all original papers reported significant data (positive or negative), whereas only 9% were neutral studies that did not report any significant findings.

Conclusion: There is a disproportionately high number of articles reporting positive results published in the surgical literature. A bias towards publishing positive data will systematically overestimate the clinical relevance of treatment effects by disregarding important information derived from unpublished negative studies. This "publication bias" remains an area of concern and may affect the quality of care of patients undergoing surgical procedures.
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http://dx.doi.org/10.1186/1754-9493-1-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2241774PMC
November 2007

A retrospective analysis of comminuted intra-articular fractures of the tibial plafond: Open reduction and internal fixation versus external Ilizarov fixation.

Injury 2008 Feb 31;39(2):196-202. Epub 2008 Jan 31.

Department of Orthopaedic Surgery, Denver Health Medical Centre, University of Colorado School of Medicine, Denver, CO 80204, USA.

Intra-articular fractures of the tibial plafond are complex injuries which continue to challenge orthopaedic surgeons in achieving anatomic reduction, while allowing early weight bearing and return to activity. Although a wide range of treatment options has been described for fixation of pilon fractures, the unique characteristic of each injury makes it difficult to advocate a general method of choice. We have attempted to compare a subset of AO/OTA type C pilon fractures treated either by a staged procedure of external fixation and conversion to open reduction and internal fixation (ORIF) versus definitive external Ilizarov fixation. Between 1998 and 2004, 42 patients admitted to our level 1 trauma centre underwent either procedure and were followed prospectively. Twenty-eight patients were treated with ORIF and 14 were treated by Ilizarov ring fixator. The outcome measures included time to union, as well as the rates of union, nonunion, malunion and infection. Although the ORIF group had a longer time to heal, the rates of nonunion, malunion and infection were lower compared to the Ilizarov group. However, these differences between the groups were not statistically significant. Thus, based on these results, no clinical recommendation can be made as to which procedure is better and safer for the patient. Future prospective randomised trials are required to determine with more scientific accuracy the optimal treatment strategy for these challenging injuries.
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http://dx.doi.org/10.1016/j.injury.2007.09.003DOI Listing
February 2008
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