Publications by authors named "Frank A Liporace"

111 Publications

Temporary External Fixation to Table as a Traction Reduction Aide in the Treatment of Unstable Pelvic Ring Injuries: A Technical Note.

Hip Pelvis 2020 Dec 3;32(4):214-222. Epub 2020 Dec 3.

Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA.

Displaced pelvic ring injuries can be challenging to even the experienced orthopedic traumatologist. A temporary external fixation to table construct provides a quick, simple, and accessible means of external skeletal fixation to reliably obtain and maintain stable hemipelvis reduction on the operating room table. The contralateral hemipelvis can be stabilized to the table by use of Steinman pins safely inserted into the subtrochanteric and anterior column regions and later connected to external fixator bars attached to the table. With rigid stabilization, the displaced contralateral pelvic fragment(s) can be reduced in a more vector intentional manner with greater force than the traditional means of pelvic reduction can allow. The skeletal-table fixation technique is presented along with two cases, a combined pelvic-acetabular injury and an isolated pelvic ring injury.
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http://dx.doi.org/10.5371/hp.2020.32.4.214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724027PMC
December 2020

Reducing Dislocations of Antibiotic Hip Spacers via Hybrid Cement-screw Constrained Liner Fixation: A Case Series.

Hip Pelvis 2020 Dec 3;32(4):207-213. Epub 2020 Dec 3.

Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ, USA.

Purpose: Infection following total hip arthroplasty is a challenging and devastating complication. In two-stage revision arthroplasty, antibiotic spacers, although efficacious, can be associated with an unacceptable rate of mechanical complications (e.g., fracture, dislocation). This series describes 15 patients with infected total hip prostheses treated with hybrid cement-screw fixation constrained liner antibiotic spacers to enhance stability and minimize mechanical complications.

Materials And Methods: All patients with an infected hip prosthesis undergoing two-stage revision arthroplasty at a single academic medical center were identified and screened for inclusion. Clinical and radiographic data including patient demographics and outcome measures were collected and retrospectively analyzed.

Results: Two patients died of unrelated causes at an average of 6-week postoperatively. Infections in the remaining thirteen patients (100%) were successfully eradicated; all underwent uncomplicated revision arthroplasty at a mean duration of 99.5 days after the placement of the antibiotic spacer. No dislocations, fractures, or other mechanical failures of any spacer were observed in this series.

Conclusion: The hybrid cement-screw fixation technique for constrained liner antibiotic spacers is a reliable and effective treatment method for eradicating prosthetic joint infections without mechanical complications.
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http://dx.doi.org/10.5371/hp.2020.32.4.207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724021PMC
December 2020

Are Arthroplasty Procedures Really Better in the Treatment of Complex Proximal Humerus Fractures? A Comprehensive Meta-Analysis and Systematic Review.

J Orthop Trauma 2021 03;35(3):111-119

Department of Orthopaedic Surgery, Jersey City Medical Center-RWJ Barnabas Health, Jersey City, NJ.

Objective: A meta-analysis and systematic review was performed to compare outcomes of open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) for complex proximal humerus fractures. Data sources: MEDLINE, Embase, and Cochrane Library databases were screened. Search terms included reverse total shoulder arthroplasty, open reduction internal fixation, hemiarthroplasty, and proximal humerus fracture.

Study Selection: English-language studies published within the past 15 years evaluating outcomes of ORIF, rTSA, or HA for complex proximal humerus fractures with minimum of 1-year follow-up were included, resulting in 51 studies with 3064 total patients. Review articles, basic science studies, biomechanical studies, and cadaveric studies were excluded.

Data Extraction: The methodological quality of evidence was assessed using the Jadad scale and methodological index for nonrandomized studies.

Data Synthesis: Demographic data were compared using the χ2 test. Mean data were weighted by study size and used to calculate composite mean values and confidence intervals. Continuous data were compared using the Metan module with fixed effects. Count data were compared using the Kruskal-Wallis test. Alpha was set at 0.05 for all tests.

Conclusions: Patients undergoing rTSA had lower risks of complication (relative risk 0.41) and reoperation (relative risk 0.28) than HA patients. rTSA resulted in higher Constant scores (standard mean difference 0.63) and improved active forward flexion when compared with HA (standard mean difference 0.76). Pooled mean data demonstrated better outcome scores and active forward flexion of ORIF versus HA and rTSA, although the patients were younger and had more simple fracture patterns.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001926DOI Listing
March 2021

Expanding the horizons of clinical applications of proximal humerus locking plates in the lower extremities: A technical note.

Chin J Traumatol 2020 Dec 12;23(6):331-335. Epub 2020 Aug 12.

Missouri Orthopaedic Institute, University of Missouri, Columbia, United States.

Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws. Those plates match the contour and shape of a variety of bones allowing for optimal buttress properties. The aim of this manuscript is to highlight the benefits of applying proximal humerus locking plates in the fixation of lower extremity bones. Although designed for the proximal humerus, the low-profile plate shape and anatomic contour also provides versatile use in certain areas of the lower extremity. This technical narrative highlights the versatile and reliable use of this plate for other anatomical areas than the one to which it has been originally conceived.
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http://dx.doi.org/10.1016/j.cjtee.2020.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7718511PMC
December 2020

Reliable Method of Radial and Ulnar Nerve Identification During the Posterior Approach to the Humerus: A Clinical and Cadaveric Correlation Study.

J Orthop Trauma 2020 Aug;34(8):447-450

Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ.

Objective: To determine the reliability of using "fingerbreadths" and anatomic landmarks as reference points for predictable identification of the radial and ulnar nerves when using the posterior approach to the humerus.

Methods: A systematic approach using "fingerbreadths" to mark and measure the skin before incision. Two markings were made: the first 4 fingerbreadths proximal to the lateral epicondyle (radial nerve location) and the second 2 fingerbreadths proximal to the medial epicondyle (ulnar nerve location). Once the posterior approach was made, the same fingerbreadths were used on the radial and ulnar sides to identify the radial and ulnar nerves within the deep interval. Measurements were taken at each stage in cadaveric specimens. Clinical correlations followed. Statistical analysis was performed comparing measurements (outer vs. inner) in both cadaveric and clinical specimens.

Results: Thirty-two elbows evaluated in this study, 20 patients and 12 cadaveric specimens. In the cadaveric specimens, the mean distance of the radial nerve was 7.59 cm from the lateral epicondyle, SD ± 0.17 cm (P = 0.55), and the ulnar 3.68 cm from medial epicondyle, SD ± 0.63 cm (P = 0.302). In the clinical measurements, the radial nerve was 7.46 cm, SD ± 0.48 cm, never within 7.0 cm (P = 0.425), and the ulnar nerve was 3.14 cm, SD ± 0.31 cm (P = 0.051). Statistical analysis yielded no difference between skin marking and actual location in the deep interval, between cadaveric and clinical specimens, observer fingerbreadth widths, or between left or right arms.

Conclusions: Use of "fingerbreadths" is a reliable, efficient, and reproducible method of identifying both the radial and ulnar nerves during the posterior approach to the humerus.
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http://dx.doi.org/10.1097/BOT.0000000000001753DOI Listing
August 2020

Equivalent union rates between intramedullary nail and locked plate fixation for distal femur periprosthetic fractures - a systematic review.

Injury 2020 Apr 16;51(4):1062-1068. Epub 2020 Feb 16.

Division of Orthopedic Surgery, Department of Orthopedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, Jersey City, NJ 07302, United States. Electronic address:

Background: The incidence of periprosthetic fracture following total knee arthroplasty continues to rise as the number of knee arthroplasty procedures increases. Management of periprosthetic fractures can be complex, with locked compression plating (LCP) and intramedullary nailing (IMN) being the most commonly used treatment options. We performed a systematic review to report and compare the clinical and radiographic outcomes of patients treated with intramedullary nail fixation versus plate fixation for periprosthetic fractures of the distal femur.

Methods: Several databases were screened. Studies evaluating intramedullary nail fixation or locked plate fixation for distal femur periprosthetic fractures were included. Primary and secondary variables as mentioned below, when included, were analyzed and compared.

Results: One prospective comparative study, 9 retrospective comparative studies, and 28 retrospective case series with 1,188 patients were included in this review. No statistically significant differences were found between IMN and LCP when analyzing union rate or time to union. Plating demonstrated a statistically significant decrease in the overall complication rate and reoperation rate when compared with IMN (p<0.003). IMN demonstrated a slightly higher percentage of patients reaching full weight bearing status and a quicker time to full weight bearing (100% and 7.6 weeks) when compared to plating (94% and 15.8 weeks). A higher percentage of patients treated with IMN returned to preinjury activity when compared to those treated with plating (70.8% vs. 61.6%).

Conclusions: Both intramedullary nail and locked plate fixation offer unique benefits in terms of clinical and radiographic outcomes for treatment of periprosthetic distal femur fractures after total knee arthroplasty. While the standard of care remains controversial, an increase in the recent literature has allowed for better clarification of the significant clinicoradiologic advantages and disadvantages of both popular treatment options.
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http://dx.doi.org/10.1016/j.injury.2020.02.043DOI Listing
April 2020

Tips and Tricks for Common, Yet Difficult Osteopenic Fractures in the Community.

Instr Course Lect 2020 ;69:465-476

Owing to advances in medicine, the number of elderly patients is growing, concurrently leading to an increasing incidence in osteopenic fractures that often require surgical management. Some of the most common anatomic areas include the proximal humerus, the distal humerus, femoral neck fractures, and periprosthetic fractures around a total knee arthroplasty (TKA). Here, surgical strategies for these challenging clinical scenarios are reviewed, offering poignant tips and tricks to avoid pitfalls and complications.
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February 2020

Risk factors for liposomal bupivacaine resistance after total hip or knee arthroplasties: a retrospective observational cohort in 237 patients.

Patient Saf Surg 2020 30;14. Epub 2020 Jan 30.

1Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, 377 Jersey Ave, Suite 280A, Jersey City, NJ 07302 USA.

Purpose: Liposomal bupivacaine demonstrated promise decreasing postoperative pain in total hip and total knee arthroplasty (THA/TKA). Some randomized trials have shown non-superior results; however, confounding variables were not accounted for in such analyses. This study attempts to determine risk factors associated with failure of pain management in patients receiving liposomal bupivacaine.

Methods: Postoperative pain scores were collected following primary or revision arthroplasties between January 2016 and December 2017. Retrospective analysis of institutional total joint quality and outcomes registry was screened and patients undergoing primary or revision arthroplasties who completed a multi-modal pain management including liposomal bupivacaine were included in the study. Patients with a history of infection/deviated from the institutional pain management protocol were excluded.

Results: A total of 237 patients were included for analysis. Younger patients less than 64 years old had significantly higher pain scores between 0 and 12 h and > 24 h. Active smokers had significantly higher pain scores between 0 and 6 h and > 24 h. Patients with a history of opioid use/pain management had significantly higher pain scores at 6-12 h and 24-48 h. Regression analysis indicated risk factors for resistance to liposomal bupivacaine are younger patients less than 64 years old, those undergoing primary THA, and patients with a history of smoking/pain management/opioid use.

Conclusion: We identify risk factors for resistance to liposomal bupivacaine, which include younger age less than 64 years old, history of smoking/pain management/opioid use. Future studies should use these risk factors as exclusion criteria when using liposomal bupivacaine or initiating any randomized trials regarding efficacy.
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http://dx.doi.org/10.1186/s13037-020-0230-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990520PMC
January 2020

Outcomes in Multidisciplinary Team-based Approach in Geriatric Hip Fracture Care: A Systematic Review.

J Am Acad Orthop Surg 2020 Feb;28(3):128-133

From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center, RWJBarnabas Health (Dr. Patel, Dr. Klein, Dr. Liporace, and Dr. Yoon); and Department of Internal Medicine, Jersey City Medical Center, RWJBarnabas Health (Dr. Sreekumar), Jersey City, NJ.

Introduction: This systematic review analyzes the literature on the treatment of geriatric hip fractures by a multidisciplinary hip fracture service including geriatricians/internists and orthopaedic surgeons and what impact this has on patient outcomes.

Methods: A systematic review of several databases was conducted according to PRISMA guidelines. Studies comparing an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model to treat hip fractures with reported outcomes for time to surgery, length of stay, readmission rates, and postoperative mortality were included.

Results: Seventeen articles fitting the inclusion criteria were included. Differences between the results of an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model were assessed using chi-squared tests. With patients admitted under a coordinated orthogeriatrics care model or a geriatrics-led care model, there is a statistically significant decrease in time to surgery (P = 0.045), length of stay (P = 0.0036), and postoperative mortality rates (P = 0.0034).

Conclusions: Although a heterogeneous group of studies, the aggregate data from several studies using an orthogeriatrics care model or a geriatrics-led care model trend toward improvements across several clinical and cost-related outcome measures: decreased time to surgery, shorter length of stay, improved postoperative clinical outcomes, decreased mortality, and lower cost.
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http://dx.doi.org/10.5435/JAAOS-D-18-00425DOI Listing
February 2020

Impact of Surrounding Canal Size on Time to Union After Intramedullary Nailing of Femur Fractures: Are 10-mm Nails All We Need?

J Orthop Trauma 2020 Apr;34(4):180-185

Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ.

Objective: To determine whether intramedullary nail (IMN) size and its relation to the canal diameter [nail-canal (NC) diameter] impacts the union rate or time to union in the treatment of femoral shaft fractures.

Design: Retrospective review.

Setting: Two Level 1 and 1 Level 2 trauma centers.

Patients: Two hundred eighty-seven patients met the criteria and were included in the study.

Intervention: Patients were treated with either an antegrade or retrograde IMN. Comparisons were first performed comparing 10- versus 11- versus 13-mm nails. Patients were then divided into 3 groups based on the difference between the size of the femoral canal at the isthmus and the IMN (NC diameter). Group 1: <1.0 mm, group 2: >1.0 and <2.0 mm, and group 3: >2.0 mm.

Main Outcome Measurements: Nonunion rates, mean time to union.

Results: Two hundred eighty-seven patients with a minimum of 12-month follow-up, who were treated with size with IMN for femoral shaft fractures, were assessed for fracture characteristics, time to union, and union rate. When comparing IMN size, no statistical difference was found when comparing time to union or overall union rate. When comparing NC diameter, no significant difference was found in union rate and time to union when comparing between the groups.

Conclusion: Similar rate of union and time to union were exhibited regardless of nail size or NC diameter. This can correlate to the standard utilization of a reamed, titanium 10-mm IMN with 5.0-mm interlocking screws in the treatment of femoral shaft fractures, offering potentially less reaming, shorter operative times, and removing unnecessary stock from inventory.

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.0000000000001670DOI Listing
April 2020

Pilon Fractures: Challenges and Solutions.

Orthop Res Rev 2019 24;11:149-157. Epub 2019 Sep 24.

Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA.

Pilon fractures include a wide range of complexity. The timing and type of definitive fixation is dictated by the soft tissue injury and energy imparted to the fracture. One should have a low threshold for staged protocols and delayed definitive fixation to avoid complications. Proper radiographs and advanced imaging should be obtained for an exacting diagnosis and preoperative planning. Diligent management of the soft tissue and anatomic restoration of the articular surface, length, rotation, and axial alignment with stable fixation to the diaphysis should be obtained once feasible. Intramedullary implants with percutaneous articular fixation for simple or extra-articular patterns provide good results with little soft tissue insult in the zone of injury. Minimally invasive plate osteosynthesis techniques can help mitigate some concerns with soft tissue compromise while obtaining good articular alignment. Locking or conventional plating with lag screw fixation is used for complex articular injuries with or without fibular fixation. External fixators are generally used for temporizing measures but can be utilized as definitive fixation when indicated. There is a role for acute fusion in severely comminuted, osteoporotic, or arthritic fractures in patients with poor healing potential. This article outlines the diagnostic workup and treatment of these vexing injuries with solutions to challenges that arise.
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http://dx.doi.org/10.2147/ORR.S170956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6765393PMC
September 2019

Addressing Antibiotic Hip Spacer Instability via Hybrid Screw-cement Fixation of a Constrained Liner and Cement-rebar Interface Techniques: A Technical Narrative.

J Am Acad Orthop Surg 2020 Feb;28(4):166-170

From the Division of Orthopaedic Trauma & Complex Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ.

Prosthetic joint infection is a challenging and devastating complication after total hip arthroplasty. The benchmark for treatment remains two-stage revision arthroplasty, in which an antibiotic-impregnated spacer is used to eradicate the infection. Although several types of spacer constructs have been described, they have historically been associated with high rates of mechanical complications, namely, dislocation, spacer fracture, and periprosthetic femur fracture. Spacer dislocation is the most common, with reported rates as high as 41%. Here, the authors present a surgical technique to improve the mechanical stability of an articulating hip spacer via a hybrid screw-cement fixation technique that allows for joint motion and weight bearing during the treatment period while minimizing the risk of mechanical failure. An additional technique is described to address acetabular bone loss, which has been associated with a higher spacer dislocation rate, through a cement-rebar interface construct.
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http://dx.doi.org/10.5435/JAAOS-D-19-00116DOI Listing
February 2020

The Effects of Diabetes and Diabetic Medications on Bone Health.

J Orthop Trauma 2020 Mar;34(3):e102-e108

Orthopedic Surgery, Jersey City Medical Center, RWJ Barnabas Health, Jersey City, NJ.

The incidence and prevalence of diabetes continues to increase, and proper understanding of the adverse effects on bone metabolism is important. This review attempts to discuss the pathophysiology of the effects of diabetes and diabetic medications on bone metabolism and bone health. In addition, this review will address the mechanisms resulting in increased fracture risk and delayed bone healing to better treat and manage diabetic patients in the orthopedic clinical setting.
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http://dx.doi.org/10.1097/BOT.0000000000001635DOI Listing
March 2020

Use of Antibiotic Plates and Spacers for Fracture in the Setting of Periprosthetic Infection.

J Orthop Trauma 2019 Sep;33 Suppl 6:S21-S24

Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center, RWJ Barnabas Health, Jersey City, NJ.

Prosthetic joint infection is a common cause of hip revision surgery, typically managed with a staged protocol and an antibiotic cement spacer. Patients being treated for prosthetic joint infection are at risk of fracture below the level of the spacer. Fracture in the setting of periprosthetic infection is a complex problem that requires the treating surgeon to use multiple techniques to achieve a successful outcome. The purpose of this case report is to highlight surgical strategies to successfully manage periprosthetic fractures complicated by infection.
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http://dx.doi.org/10.1097/BOT.0000000000001570DOI Listing
September 2019

Nail and Plate Combination Fixation for Periprosthetic and Interprosthetic Fractures.

J Orthop Trauma 2019 Sep;33 Suppl 6:S18-S20

Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ.

Nail plate combination technique can be applied in the setting of periprosthetic and interprosthetic fractures to promote reliable healing with a biomechanically favorable construct. Here, technical aspects and discussion of the technique are reviewed through a case of an 87-year-old woman who suffered from an interprosthetic "floating" total knee arthroplasty (TKA); a supracondylar distal femur fracture in between a total hip arthroplasty and a TKA, with a proximal tibial metaphyseal fracture below the TKA tibial base plate.
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http://dx.doi.org/10.1097/BOT.0000000000001571DOI Listing
September 2019

Maximizing outcomes in the treatment of radial head fractures.

J Orthop Traumatol 2019 03 23;20(1):15. Epub 2019 Mar 23.

Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center at RWJ Barnabas Health, 355 Grand Street, Jersey City, NJ, 07302, USA.

The radial head plays a critical role in the stability of the elbow joint and its range of motion. Injuries may occur across a spectrum of severity, ranging from low energy non-displaced fractures to high energy comminuted fractures. Multiple classification systems exist to help characterize radial head fractures and their associated injuries, as well as to guide treatment strategies. Depending on the type of fracture, non-operative management may be possible if early range of motion is initiated. Other options include open reduction and internal fixation or excision followed by arthroplasty. A lateral approach is typically used for adequate surgical exposure. Controversy still remains regarding operative management of more severe fractures, but studies have shown good outcomes after radial head replacement for these fractures. We will review the current treatments available for radial head fractures, highlighting gaps in knowledge, as well as providing recommendations for the care of these injuries.Level of evidence: Level V.
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http://dx.doi.org/10.1186/s10195-019-0523-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6431334PMC
March 2019

Use of a stainless steel locking calcaneal plate for quadrilateral plate buttress in the treatment of acetabular fractures.

Eur J Orthop Surg Traumatol 2019 Jul 8;29(5):1141-1145. Epub 2019 Mar 8.

Division of Orthopedic Trauma and Adult Reconstruction, Department of Orthopedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, Jersey City, NJ, USA.

Operative fixation of acetabular fractures involving the quadrilateral surface presents a challenging clinical scenario. Classically, quadrilateral plate buttress was achieved via the use of a "seven" plate. More recently, the use of an anatomic, pre-contoured design has been gaining popularity due to its pre-contoured shape and larger footprint, allowing for a wider quadrilateral plate buttress. The current study presents using a stainless steel locking calcaneal plate to obtain similar surface area coverage as the modern pre-contoured quadrilateral plate, but at a lower cost.Level of evidence IV.
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http://dx.doi.org/10.1007/s00590-019-02413-7DOI Listing
July 2019

Unusual anatomic variant of the axillary nerve challenging the deltopectoral approach to the shoulder: a case report.

Patient Saf Surg 2019 14;13. Epub 2019 Feb 14.

1Division of Orthopaedic Trauma & Complex Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, 377 Jersey Ave, Suite 280A, Jersey City, NJ 07302 USA.

Background: The deltopectoral approach is a well-described surgical approach to the proximal humerus and glenohumeral joint. One of the structures at risk during this approach is the axillary nerve. Typically, the axillary nerve arises off the posterior cord of the brachial plexus and courses lateral to the proximal humerus and inferior to the glenohumeral joint, exiting the axilla through the quadrangular space. We describe a case of an aberrant axillary nerve, coursing anteriorly across the glenohumeral joint within the deltopectoral groove encountered during a reverse total shoulder arthroplasty.

Case Presentation: A 73-year-old female presented complaining of atraumatic progressive right shoulder pain of several months duration. Clinical and radiographic findings were consistent with advanced rotator cuff arthropathy. After failing appropriate non-operative treatment, the patient elected to undergo reverse total shoulder arthroplasty. During the deltopectoral approach to the glenohumeral joint, the axillary nerve was found to be coursing deep to the cephalic vein within the deltopectoral interval. The nerve was isolated and protected, and the glenohumeral joint was accessed via a small window in the anterior deltoid muscle. The remainder of the procedure was performed without complication. The patient was found to be healing well and with normal axillary nerve function at 4-month follow-up.

Conclusions: Neurologic lesions are well-documented complications of reverse total shoulder arthroplasty. The integrity of the axillary nerve is of particular importance to reverse total shoulder arthroplasty as it innervates the deltoid and post-operative function of the extremity is dependent upon a functioning deltoid muscle. Extreme care must be taken to avoid insult to the axillary nerve and any aberrant paths it may course around the glenohumeral joint.
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http://dx.doi.org/10.1186/s13037-019-0189-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376685PMC
February 2019

Intrapelvic component retrieval via anterior inferior iliac spine osteotomy in revision total hip arthroplasty.

Hip Int 2019 Mar 13;29(2):222-225. Epub 2018 Nov 13.

1 Department of Orthopaedic Surgery, Division of Orthopaedic Trauma and Complex Adult Reconstruction, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA.

Introduction:: In the revision setting, intrapelvic acetabular components provide a unique set of challenges for the treating surgeon. Retrieval is complicated by complex anatomical relationships within the pelvis and historically, surgeons have used multiple approaches to safely retrieve the cup.

Case Presentation:: We present the case of a 53-year-old female with intrapelvic migration of the acetabular components of her total hip arthroplasty. Patient was treated through a novel, single incision approach with utilisation of an anterior inferior iliac spine (AIIS) osteotomy.

Results:: An AIIS osteotomy allows for improved visualisation within the pelvis and safe retrieval through a single exposure without compromising the ability to perform definitive, revision reconstruction. At 1-year follow-up, the patient has had no complications related to infection or failure of the implants. Ambulation is performed with the aid of a cane in the community with mild, occasional pain.
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http://dx.doi.org/10.1177/1120700018812128DOI Listing
March 2019

Nail Plate Combination Technique for Native and Periprosthetic Distal Femur Fractures.

J Orthop Trauma 2019 Feb;33(2):e64-e68

Department of Orthopaedic Surgery, Division of Orthopaedic Trauma & Complex Adult Reconstruction, the Orthopedic Institute, Jersey City Medical Center-RWJBarnabas Health, Jersey City, NJ.

In the elderly, low-energy distal femur fractures (native or periprosthetic) can be devastating injuries, carrying high rates of morbidity and mortality, comparable with the hip fracture population. Poor, osteoporotic bone quality facilitates fracture in a vulnerable anatomical region, and as a result, operative fixation can be challenging. With goals of early mobilization to reduce subsequent complication risk, using the nail plate combination technique can offer stable, balanced fixation allowing for immediate weight bearing and early mobilization. We outline the rationale, technical steps, and early clinical outcomes after nail plate combination in the treatment of osteoporotic distal femur (native or periprosthetic) fractures.
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http://dx.doi.org/10.1097/BOT.0000000000001332DOI Listing
February 2019

Algorithmic treatment of Busch-Hoffa distal femur fractures: A technical note based on a modified Letenneur classification.

Injury 2018 Aug 4;49(8):1623-1629. Epub 2018 Jun 4.

Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, School of Medicine of Ribeirão Preto, University of São Paulo, Brazil; Missouri Orthopedic Institute, University of Missouri, Columbia, United States.

Treatment of distal femur fractures in the coronal plane can be challenging. Depending on fracture line orientation, topography and associated comminution, decision-making regarding approach and fixation is not straightforward and can result in complications. Therefore, treatment of coronal plane distal femur fractures (Busch-Hoffa fractures) should be approached in a systematic manner, leading to efficient planning and operative execution. Here, we offer a proposed treatment algorithm, guiding treatment, approach and fixation based on the modified Letenneur classification of coronal plane distal femur fractures.
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http://dx.doi.org/10.1016/j.injury.2018.06.008DOI Listing
August 2018

Reduction of Blood Loss by Tranexamic Acid Following Total Hip and Knee Arthroplasty: A Meta-Analysis.

JBJS Rev 2018 May;6(5):e1

Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, RWJBarnabas Health - Jersey City Medical Center, Jersey City, New Jersey.

Background: This study involved a meta-analysis of 36 published studies to examine the efficacy of intravenous (IV) and intra-articular (IA) tranexamic acid (TXA) in reducing blood loss, drain output, thromboembolic complications, and hospital stay following total hip and total knee arthroplasty. This study also evaluated whether treatment with a combination of both IA and IV TXA has an effect on these outcomes. Lastly, this study attempted to analyze the method and technique of TXA administration in order to establish a best practice for its use in reducing overall blood loss in arthroplasty procedures.

Methods: MEDLINE, Embase, and the Cochrane Library database were screened. Studies comparing IV TXA with IA TXA or with combined IV and IA TXA were included. Data including total blood loss, drain output, thromboembolic complications, and hospital stay, where available, were analyzed using meta-analysis with fixed effects. Results are presented as the standardized mean difference (SMD), and meta-regression was employed to explore plausible demographic contributions to heterogeneity.

Results: Twenty-eight randomized controlled trials, 3 prospective cohort studies, and 5 retrospective cohort studies with 5,499 patients were included in this review. IA administration during total knee arthroplasty showed a significant advantage in terms of total blood loss (SMD = -0.14, 95% confidence interval [CI] = -0.027 to -0.02, I = 78.2%) and drain output (SMD = -0.30, 95% CI = -0.43 to -0.18). There was no significant difference between IV and IA administration in total hip arthroplasty. Combined IA plus IV TXA was associated with a significant reduction in blood loss versus IV TXA alone in both total knee arthroplasty and total hip arthroplasty. IV TXA dosing varied, as 14 (39%) of the studies used a weight-based approach while 22 (61%) used a standard dose. Twenty-seven (96%) of 28 studies of IA administration used standard dosing while 1 study followed a weight-based protocol. There was no difference in symptomatic thromboembolic complications, with overall rates in total knee arthroplasty and total hip arthroplasty of 1.0% and 1.0% for IV administration and 1.1% and 0.3% for IA administration, respectively. There was no difference in length of hospital stay for IV versus IA TXA administration.

Conclusions: IA TXA, either alone or in conjunction with IV TXA, reduces total blood loss and/or drain output in total knee arthroplasty and total hip arthroplasty. Optimal methodology remains to be clarified; however, there are substantial economic benefits of utilizing either IV or IA TXA, with greater cost benefits when using IA TXA.

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/10.2106/JBJS.RVW.17.00103DOI Listing
May 2018

Strategies for Management of Periprosthetic Joint Infection.

Bull Hosp Jt Dis (2013) 2018 Mar;76(1):55-61

Periprosthetic joint infection (PJI) is one of the most catastrophic and difficult to manage complications following total hip and total knee arthroplasty. As the number of total joint arthroplasties continues to increase, the burden of PJI will continue to further strain resources. As such, orthopedic surgeons consider four principles crucial in appropriately managing difficult or complex cases of PJI: identification, debridement, antibiotics, and patience. Indications and techniques for nonoperative treatment, debridement with implant retention, and one- and two-stage exchange arthroplasty are reviewed. Despite optimal care, a subset of patients will experience failure and the role of resection, fusion, and amputation is discussed. Understanding appropriate patient selection, pathogens, and improved surgical techniques should form the basis of managing PJI.
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March 2018

Impact of Intramedullary Nailing in the Treatment of Femur Fractures An Evolutionary Perspective.

Bull Hosp Jt Dis (2013) 2018 Mar;76(1):9-13

Today intramedullary nails (IMN) are the gold standard in the treatment of femur fractures. Since its inception, improved design and understanding of the surrounding anatomy has exponentially increased successful patient treatment and outcomes by promoting early mobilization and reliable union. In this review, we provide an in-depth look into the evolutionary process that has led IMN to becoming today's gold standard in femur fractures.
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March 2018

Periprosthetic Fractures About the Hip and Knee: Contemporary Techniques for Internal Fixation and Revision.

Instr Course Lect 2018 Feb;67:223-239

Chairman, Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center, RWJBarnabas Health, Jersey City, New Jersey.

The number of periprosthetic fractures is expected to increase given the growing number of elderly individuals who are living longer and advances in technology that allow for total hip and knee arthroplasty in younger patients. Evolving technologies in combination with a better understanding of required total hip and knee reconstruction has allowed for continued improvements in applied fixation strategies and patient outcomes. Current fixation and revision options have led to reliable, reproducible management of periprosthetic fractures about the hip and knee, including proximal femur and supracondylar femur fractures, which are common, and fractures about an acetabular component and between proximal and distal hip and knee prostheses, which are rare. Orthopaedic surgeons should understand the most contemporary techniques, strategies, and formulas for the successful management of periprosthetic fractures about the hip and knee.
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February 2018

Practical Surgical Techniques for Revision Total Hip Arthroplasty.

Instr Course Lect 2018 Feb;67:191-205

Assistant Professor of Orthopedic Surgery, Department of Orthopaedic Surgery, Orlando Health, Orlando, Florida.

Although total hip arthroplasty is an extremely successful procedure, the continual increase in the number of total hip arthroplasties that are performed is associated with the substantial burden of revision total hip arthroplasty. Modes of total hip arthroplasty failure include instability, aseptic loosening, infection, periprosthetic fracture, hardware failure, and component wear, all of which are indications for revision total hip arthroplasty. Surgeons must have a sound preoperative revision total hip arthroplasty plan and must be familiar with a variety of component removal and exposure techniques, such as the extended trochanteric osteotomy. Alternative surgical plan(s) and extra implants for reconstruction on both the acetabular and femoral sides should be available in anticipation of unexpected findings. Component removal and exposure techniques can be refined to avoid complications and achieve a successful outcome in patients who undergo revision total hip arthroplasty.
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February 2018

Treatment of Spinopelvic Dissociation: A Critical Analysis Review.

JBJS Rev 2018 01;6(1):e7

Division of Orthopaedic Trauma, Jersey City Medical Center, RWJBarnabas Health, Jersey City, New Jersey.

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http://dx.doi.org/10.2106/JBJS.RVW.16.00119DOI Listing
January 2018

Can preoperative nasal cultures of Staphylococcus aureus predict infectious complications or outcomes following repair of fracture nonunion?

J Infect Public Health 2018 Jul - Aug;11(4):521-525. Epub 2017 Oct 31.

Hospital for Joint Diseases at NYU Langone Medical Center, New York, NY, United States; Jamaica Hospital Medical Center, Jamaica, NY, United States. Electronic address:

Introduction: Much has been studied with reference to methicillin resistant Staphylococcus aureus (MRSA) and methicillin sensitive S. aureus (MSSA) colonization and associated outcomes and comorbidities. In the area of Orthopedic surgery, literature predominantly comes from the field of arthroplasty. Little is known about outcomes of fracture and Orthopedic trauma patients in the setting of S. aureus colonization. We believe that MRSA/MSSA colonization in and of itself may be a weak marker for generally poor protoplasm, potentially with complex medical history including previous hospitalization or rehab placement. This milieu of risk factors may or may not contribute to poorer outcomes after fracture and fracture nonunion surgery. The purpose of this study is to determine if nasal swabbing for S. aureus (MRSA or MSSA) carriage can predict operative culture, complications, or outcomes following fracture nonunion surgery.

Methods: Sixty-two consecutive patients undergoing surgery for fracture nonunion were prospectively followed. Data analyses were performed using grouped MRSA and MSSA carriers (Staphylococcus carriers: SC). Outcomes analyzed included time to healing, need for additional surgery, and persistent nonunion.

Results: Twenty-six percent of patients (16/62) were identified as MSSA carriers, an additional 6.5% (4/62) carried MRSA. Follow-up of at least 12-months was obtained on 90% (56/62) of patients. White blood cell counts, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values did not differ between SCs and non-carriers pre-operatively. Carriers were just as likely as non-carriers to culture positively for any pathogen at the time of surgery. Although SC's were three times as likely as non-carriers to grow S. aureus (15% vs. 5%), this difference did not reach statistical significance (p=0.3). Post-operative wound complications, antibiotic use, pain at follow-up and progression to healing did not differ between groups.

Conclusions: Ultimately, pre-operative nasal swabbing for S. aureus is a simple and non-invasive diagnostic tool with prognostic implications in patients undergoing fracture nonunion surgery. This study found that MRSA and MSSA colonized patients with fracture nonunion of long bones do not have an increased association with positive cultures or a predisposition towards greater post-operative infectious complications.
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http://dx.doi.org/10.1016/j.jiph.2017.10.007DOI Listing
November 2018

Distal Radius Fractures: Reconstruction Approaches, Planning, and Principles.

Am J Orthop (Belle Mead NJ) 2017 Sep/Oct;46(5):238-244

Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Orlando Regional Medical Center, Orlando, FL.

Distal radius fracture (DRF) is a common injury. Treatment options have evolved and now several can be used to address even the most complex fracture patterns. Complex fractures of the distal radius and ulna can be challenging, and specific goals must be kept in mind to achieve definitive anatomical and functional restoration. This article summarizes the concepts, principles, and surgical options regarding complex DRF reconstruction.
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June 2018

What's new in ankle fractures.

Injury 2017 Oct 9;48(10):2035-2041. Epub 2017 Aug 9.

Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, Jersey City, NJ, United States. Electronic address:

The diagnosis and treatment of ankle fractures has evolved considerably over the past two decades. Recent topics of interest have included indications for operative treatment of isolated lateral malleolus fractures, need for fixation of the posterior malleolus, utilization of the posterolateral approach, treatment of the syndesmosis, and the potential role of fibular nailing. In this update, we concisely review these topics and what to expect in the future literature.
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http://dx.doi.org/10.1016/j.injury.2017.08.016DOI Listing
October 2017