Publications by authors named "Phillip M Mitchell"

23 Publications

  • Page 1 of 1

Outcomes of periprosthetic distal femur fractures following total knee arthroplasty: Intramedullary nailing versus plating.

Injury 2021 Jul 12;52(7):1875-1879. Epub 2021 May 12.

Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX, 77005, USA. Electronic address:

Background: Periprosthetic distal femur fractures (PPDFFs) present a challenge in terms of optimizing fixation in patients with poor bone quality and limited bone stock. The main treatment options include laterally based plating and intramedullary nailing. We hypothesized that treatment of PPDFFs with intramedullary nails would result in improved union rate, fewer complications, and an equivalent rate of malalignment compared to plating.

Materials And Methods: Cases of PPDFFs were identified through a query of our institutional trauma database between 2011-2018. Adult patients (>18 years) were included if they sustained a fracture of the distal femur around a total knee arthroplasty (TKA) that was not initially treated at another institution. The anatomic lateral distal femoral angle (aLDFA) and the anatomic posterior distal femoral angle (aPDFA) were measured on the follow-up radiographs.

Results: Ninety-seven PPDFFs in 97 patients, with a mean age of 76 years and 74% female were identified. Plating was used in 74 patients (76%) and 23 patients (24%) were treated with intramedullary nailing. Extension deformity in the sagittal plane was more common following intramedullary nailing compared to plating (10/23 nailing versus 10/74 plating) (p=0.002). There were 12 reoperations (12/75, 16%), and the method of fixation was not associated with rate of reoperation (p=0.9).

Conclusion: Intramedullary nailing was associated with an increased risk of malalignment, most commonly an extension deformity, in this series. However, malalignment was not associated with worse outcomes.
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July 2021

Exposure Provided by the Gibson Versus the Kocher-Langenbeck Approaches With and Without Trochanteric Osteotomy: A Cadaveric Mapping Study.

J Orthop Trauma 2021 May;35(5):234-238

Department of Orthopedic Trauma, Harris Methodist Fort Worth Hospital, Fort Worth, TX.

Objective: To determine if prevalent approaches in acetabular fracture surgery provide enhanced anterior and cranial exposure in a cadaveric model.

Methods: A Kocher-Langenbeck (K-L) approach (followed by a Gibson approach on the contralateral hip) was performed in the lateral position on 8 cadavers. A Steinmann pin was used to create holes outlining the bony surfaces available for instrumentation before and after a trochanteric osteotomy. All soft tissue was then removed from the pelvis, and a calibrated digital picture was taken. The surface area of the pelvis visualized through each approach was calculated and compared with the contralateral side to assess for a difference in exposure between the Gibson approach and the K-L approach. An increase in exposure of greater than 10% was considered significant. The extent of anterior exposure (with and without a trochanteric osteotomy) was then measured from the greater sciatic notch.

Results: In 2 of 8 cadavers (25%), the Gibson approach yielded an increase in exposure when compared with a K-L approach. The addition of a trochanteric osteotomy yielded on average 1.6 cm (range, 0.7-2.6 cm) of increased anterior exposure in the K-L approaches and 1.5 cm (range 0.9-3.1 cm) in the Gibson approaches.

Conclusion: The Gibson approach did not reliably provide increased anterior exposure compared with a K-L approach in a cadaver model. A trochanteric osteotomy can be expected to add 1-2 cm of increased anterior exposure in both approaches.
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May 2021

Radiographic Evaluation of the Tibial Intramedullary Nail Entry Point.

J Am Acad Orthop Surg 2020 Sep;28(18):e810-e814

From the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN (Dr. Maslow, Dr. Joseph, Mr. Hong, Ms. Henry, and Dr. Mitchell), and the Orthopaedic Trauma Surgery, Orthopedic Specialty Associates, Fort Worth, TX (Dr. Collinge).

Introduction: Tibia fractures are common injuries that can often be effectively treated with intramedullary nail (IMN) fixation. The ideal starting point for IMN reaming and nail placement is well described and regarded as a crucial aspect in the technique. The purpose of this study is to determine the accuracy and precision with which the starting point is established and if this is maintained after nail insertion during fracture fixation.

Methods: Fifty consecutive tibia fractures treated by IMN fixation sized 9 to 13 mm through an infrapatellar or medial parapatellar approach and 50 treated with a suprapatellar approach were evaluated. The starting point for reaming and IMN placement was measured using intraoperative fluoroscopy. Postoperative radiographs were used to determine the center of the IMN after placement. The distance between the measured points and the ideal starting point was measured.

Results: Deviation from the ideal entry point on intraoperative fluoroscopy averaged 4.6 ± 4.0 mm medially, 2.9 ± 3.7 mm anteriorly, and 2.7 ± 3.3 mm distally. In 30% of cases, the final IMN position varied from the entry point by greater than one SD in the coronal or sagittal plane. No difference between approaches was appreciated.

Discussion: Although the ideal starting point for tibial IMN fixation is known, this is frequently not the starting point accepted in practice. Final position of the IMN is independent of IMN size or approach and is not markedly different than the obtained starting point.

Level Of Evidence: Therapeutic level III.
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September 2020

Clinical Results of Acetabular Fracture Fixation Using a Focal Kocher-Langenbeck Approach Without a Specialty Traction Table.

J Orthop Trauma 2020 Jun;34(6):316-320

Department of Orthopaedic Surgery, McGovern Medical School at UTHealth Houston, TX.

Objectives: To report the clinical result of a series of patients who underwent acetabular fracture fixation using a Kocher-Langenbeck approach without a specialty traction table.

Design: Retrospective case series.

Setting: Level 1 trauma center.

Patients/participants: All patients who sustained posterior wall or posterior wall associated acetabular fractures that were treated operatively with a Kocher-Langenbeck approach over a 5-year period.

Intervention: Surgical fixation of acetabular fractures using a flat, radiolucent table.

Main Outcome Measurements: Outcomes included reduction quality and complications such as infection, heterotopic ossification, loss of reduction or fixation, medical complications, and neurologic injury.

Results: We identified 172 patients. No articular malreductions of greater than 2 mm were noted on postoperative CT scans. There were 13 surgical complications observed (8.1%). There was 1 death in our cohort (0.6%), and 3 patients had nonfatal pulmonary emboli (1.9%). There were no nerve injuries observed. There were 6 acute infections (3.1%) requiring surgical intervention. Three patients had symptomatic heterotopic bone that required excision (1.9%). Four patients (2.5%) required eventual total hip arthroplasty.

Conclusion: Overall, we report on the largest cohort in the literature undergoing a prone Kocher-Langenbeck without a specialty table for acetabular fracture fixation. We found that limited extremity prepping and draping for a prone Kocher-Langenbeck on a flat, radiolucent table did not result in an increased rate of postoperative neurological complications or malreductions of acetabular fractures.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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June 2020

Acute-Phase Reactants in Operatively Treated Upper Extremity Infections: A Retrospective Review.

Hand (N Y) 2021 Jul 11;16(4):546-550. Epub 2019 Sep 11.

Vanderbilt University Medical Center, Nashville, TN, USA.

There are limited data on the use of acute-phase markers in the diagnosis of upper extremity infections. The goal of this study was to determine the percentage of patients with elevated white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) in the setting of an upper extremity infection requiring operative debridement. In a retrospective review over 12 years, 61 patients who met the inclusion criteria were identified. C-reactive protein was the most sensitive test in the detection of culture-positive infection compared with ESR and WBC ( < .001, < .0001, respectively). Ninety percent of patients (55 of 61) presented with an abnormal CRP value. The WBC count and ESR were abnormal in 54% and 67% of our cohort, respectively. C-reactive protein is the most sensitive laboratory test when evaluating upper extremity infections that necessitate debridement. The WBC count and ESR should be interpreted with caution and can be normal even in the presence of an infection.
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July 2021

Calcaneal Avulsion Fractures: A Multicenter Analysis of Soft-Tissue Compromise and Early Fixation Failure.

J Orthop Trauma 2019 Nov;33(11):e422-e426

Department of Orthopeadic Trauma, Harris Methodist Fort Worth Hospital, Fort Worth, TX.

Objective: To characterize the presentation and outcomes of calcaneal avulsion fractures.

Design: Case series.

Setting: Two ACS Level I trauma centers.

Patients/participants: Forty-seven calcaneal avulsion fractures isolated from a cohort of 1365 calcaneus fractures treated over a 17-year period.

Main Outcome Measurements: We collected instances of soft-tissue compromise at presentation, evidence of implant failure or fracture displacement after fixation, and reoperation.

Results: Forty-one patients were treated operatively, and 6 were treated without surgery. Twenty-one patients (44.7%) had either soft-tissue compromise or an open fracture necessitating urgent treatment at the time of presentation. Of those patients treated operatively with 3-month follow-up (n = 39), 28.2% of patients (11/39) had evidence of implant failure or fracture displacement. Age was the only predictor of catastrophic fixation failure (P = 0.01). The use of washer(s), suture anchor(s), or addition of soft-tissue procedures (eg, Strayer) did not have a significant effect on failure rate. Neither the number of screws used nor size of screw impacted the failure rate. Fourteen patients (35.9%) underwent a secondary operation.

Discussion: Avulsion fractures of the calcaneus commonly present with soft-tissue compromise and have a significant rate of treatment failure and reoperation. This injury should be identified early and approached thoughtfully, acknowledging that risks are high.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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November 2019

Morphology of the Posterior Malleolar Fracture Associated With a Spiral Distal Tibia Fracture.

J Orthop Trauma 2019 Apr;33(4):185-188

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

Objective: To define the pathoanatomy of the posterior malleolus fracture associated with a spiral distal tibia fracture to guide clamp and implant placement when treating these common injuries.

Design: Retrospective cohort.

Setting: Level I trauma center.

Patients/participants: One hundred twenty-two spiral infraisthmal tibia fractures identified from a cohort of 922 tibia fractures undergoing intramedullary nailing over a 7-year period.

Main Outcome Measurements: We collected instances of intra-articular extension seen on preoperative, intraoperative, or postoperative imaging. For patients with a posterior malleolus fracture and computed tomography imaging, we used an axial image 2-3 mm above the articular surface to create a fracture map.

Results: Intra-articular extension was present in 84 patients (68.9%), with posterior malleolus fractures occurring most commonly (n = 59, 48.4%). Other fractures included plafond fractures (n = 8), medial malleolus fractures (n = 7), anterior-inferior tibiofibular ligament avulsions (n = 5), and other anterior fractures (n = 5). Forty-one of 44 (93%) posterior malleolus fractures with cross-sectional imaging were Haraguchi type I (posterolateral-oblique type) with an average angle of 24 degrees off the bimalleolar axis. The remaining 3 were type II (transverse-medial extension type) fractures. Posterior malleolus fractures were visible 61% of the time on preoperative radiographs.

Discussion: Posterior malleolus fractures occur in approximately half of spiral distal tibia fractures and are consistently posterolateral in their morphology. This study can be used to enhance evaluation of the posterior malleolus intraoperatively (eg, ∼25 degrees external rotation view), and if the typical variant of posterior malleolus is identified, clamps and lag screws might be applied accordingly.
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April 2019

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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August 2018

Sarcopenia Is Predictive of 1-Year Mortality After Acetabular Fractures in Elderly Patients.

J Orthop Trauma 2018 06;32(6):278-282

Florida Orthopaedic Institute, University of South Florida, Tampa, FL.

Objectives: To determine whether sarcopenia is an independent predictor of mortality in geriatric acetabular fractures.

Design: Retrospective cohort.

Setting: American College of Surgeons Level I trauma center.

Patients/participants: One hundred and forty-six patients over the age 60 with acetabular fractures treated at our institution over a 12-year period.

Main Outcome Measurements: The primary outcome was 1-year mortality, collected using the Social Security Death Index. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia.

Results: Using a multivariate logistic regression model, we found that low PLVI was associated with increased 1-year mortality (P = 0.046) when controlling for age, gender, Charlson Comorbidity Index, Injury Severity Score (ISS), smoking status, and associated pelvic ring injury. Increasing age and ISS also showed a relationship with 1-year mortality in this cohort (P < 0.001, P < 0.001, respectively). We defined sarcopenia as those patients in the lowest quartile of PLVI. The mortality rate of this cohort was 32.4%, compared with 11.0% in patients without sarcopenia (odds ratio 4.04; 95% confidence interval 1.62-10.1). Age >75 years, ISS >14, and sarcopenia had 1-year mortality rates of 37.1%, 30.9%, and 32.4%, respectively. In patients with all 3 factors, the mortality rate was 90%.

Conclusion: Sarcopenia is an independent risk factor for 1-year mortality in elderly patients with acetabular fractures. This study highlights the importance of objective measures to assess frailty in elderly patients who have sustained fractures about the hip and pelvis.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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June 2018

Pathoanatomy of the Tongue-Type Calcaneus Fracture: Assessment Using 2- and 3-Dimensional Computed Tomography.

J Orthop Trauma 2018 05;32(5):e161-e165

Vanderbilt University Medical Center, Nashville, TN.

Objective: To define the pathoanatomy of the tongue-type calcaneus fracture and assess the appropriateness of percutaneous techniques in addressing all planes of deformity in this injury.

Design: Retrospective cohort.

Setting: ACS Level I trauma center.

Patients/participants: Fifty-six displaced Sanders 2B and 2C tongue-type calcaneus fractures identified from an initial cohort of 1118 calcaneus fractures treated over a 16-year period.

Main Outcome Measurements: We reviewed cross-sectional imaging and documented the presence of a varus/valgus (coronal plane) or adduction/abduction (axial plane) position of the tongue fragment in relation to the intact posterior facet, with greater than 10 degrees of angulation being diagnostic of displacement.

Results: When assessing for displacement and angulation in the coronal plane, 98% of tongue fragments were either in a position of valgus (77%) or neutral (21%), with a mean valgus angulation of 17.3 degrees. In the axial plane, 98% of tongue pieces were in a position of adduction (64%) or neutral (34%), with an average angulation into adduction of 15.0 degrees. Sanders 2B fractures were more likely to be in a position of valgus and adduction than those of 2C fractures.

Discussion: The tongue-type calcaneus fracture most often displaces into a position of plantarflexion, valgus, and adduction. Knowledge of this deformity may aid in achieving successful closed reduction when using the Essex-Lopresti maneuver or other less invasive techniques.
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May 2018

Damage Control Plating in Open Tibial Shaft Fractures: A Cheaper and Equally Effective Alternative to Spanning External Fixation.

J Surg Orthop Adv Summer 2017;26(2):86-93

The Vanderbilt Orthopaedic Institute Center for Health Policy, Vanderbilt University, Nashville, Tennessee.

The purpose of this study was to evaluate damage control plating (DCP) as an alternative to external fixation (EF) in the provisional stabilization of open tibial shaft fractures. Through retrospective analysis, the study found 445 patients who underwent operative fixation for tibial shaft fractures from 2008 to 2012. Twenty patients received DCP or EF before intramedullary nailing with a minimum follow-up of 3 months. Charts and radiographs were reviewed for postoperative complications. Hospital charges were reviewed for implant costs. Nine patients (45%) with DCP and 11 patients (55%) with EF were analyzed. There was no significant difference in the complication rates. The mean implant cost of DCP was $1028, whereas mean EF construct cost was $4204. Therefore, DCP resulted in significant cost savings with no difference in complication rates, making it a valuable alternative to EF for the provisional stabilization of open tibial shaft fractures.
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February 2018

Proximity and Risks of the Anterior Neurovascular and Tendinous Anatomy of the Distal Leg Relative to Anteriorly Applied Distal Locking Screws for Tibia Nailing: A Plea for Open Insertion.

J Orthop Trauma 2017 Jul;31(7):375-379

*Department of Orthopedic Surgery, Vanderbilt University, Nashville, TN; and †Campbell Clinic/University of Tennessee Health Science Center, Memphis, TN.

Purpose: To determine the proximity and potential risks to distal leg anatomy from anterior to posterior (A-P) applied distal tibia locking screws for tibial nailing.

Design: Retrospective.

Setting: ACS level I trauma center.

Patients/participants: Twenty consecutive adult patients undergoing computed tomograms with intravenous contrast (computed tomography angiograms) on uninjured legs.

Main Outcome Measurements: Simulated 5-mm distal interlocking screws placed in the A-P axis of an ideally placed tibial nail at 10-mm increments from the tibial plafond (10-40 mm) were studied in relation to the distal leg's anterior anatomy.

Results: All A-P screws (80/80, 100%) impacted the tibialis anterior tendon, extensor hallucis longus tendon, and/or anterior tibial neurovascular (NV) bundle between 10 and 40 mm cranial to the plafond. The NV bundle was impacted in 53% of cases. The medial extent of the tibialis anterior tendon was greatest 10 mm cranial to the plafond and averaged 27 degrees (95% confidence interval, 22-33 degrees) medial to the A-P line. The maximum lateral border of the foot's common extensors, found 40 mm cranial to the plafond, averaged 71 degrees (95% confidence interval, 62-80 degrees) lateral to the A-P line.

Discussion: The anterior tibial NV bundle and foot and ankle extensor tendons are at high risk from A-P-directed distal locking screws. The tendinous anatomy of the distal leg is at risk between 33 degrees medial and 80 degrees lateral to the A-P axis of a tibial nail. Distal locking screws placed from the A-P direction should be thoughtfully applied and an open approach should be strongly considered.
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July 2017

Comparison of Ankle Fusion Rates With and Without Anterior Plate Augmentation.

Foot Ankle Int 2017 Apr 7;38(4):419-423. Epub 2016 Dec 7.

2 Elite Sports Medicine and Orthopedics, Nashville, TN, USA.

Background: The optimal fixation construct for tibiotalar arthrodesis continues to be debated. While biomechanical data and clinical series support anterior plate augmentation, comparative studies assessing its use are sparse. The purpose of this study was to compare the rates of successful tibiotalar arthrodesis with and without anterior plate augmentation of a compression screw construct.

Methods: We studied 64 patients (65 ankles) undergoing tibiotalar arthrodesis done by a single surgeon over a 10-year period (2006-2016) with anterior plate augmentation beginning in 2010. Twenty-six ankles had a construct using compression screws only and 39 ankles had anterior plate augmentation of a compression screw construct. We reviewed clinical notes, operative reports, and postoperative radiographs to evaluate for union, incidence of revision, and postoperative complications.

Results: The nonunion rate in the compression screw (CS) cohort was 15.4% and 7.7% in the anterior plate augmentation (AP) cohort ( P = .33). The revision rate was 7.7% in the CS group and 2.6% in the AP cohort ( P = .34). The use of autograft harvested through a separate incision was 19.2% and 17.9% in the CS and AP cohorts, respectively. There were 2 deep postoperative infections in the AP group and none in the patients with CS only ( P = .24). There were no superficial wound complications in either group.

Conclusion: Anterior plate augmentation was a viable fixation strategy in tibiotalar arthrodesis. In a trend toward an improved rate of fusion and decreased revision rate in the anterior plate augmentation cohort.

Level Of Evidence: Level III, retrospective comparative series.
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April 2017

The impact of resident involvement on outcomes in orthopedic trauma: An analysis of 20,090 cases.

J Clin Orthop Trauma 2016 Oct-Dec;7(4):229-233. Epub 2016 Jun 11.

The Vanderbilt Orthopaedic Institute for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232-8774, United States.

Background: Involvement in patient care is critical in training orthopedic surgery residents for independent practice. As the focus on outcomes and quality measures intensifies, the impact of resident intraoperative involvement on patient outcomes will be increasingly scrutinized. We sought to determine the impact of residents' intraoperative participation on 30-day post-operative outcomes in the orthopedic trauma population.

Methods: A total of 20,090 patients from the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2013 were identified. Patient demographics and comorbidities, surgical variables, and 30-day post-operative (wound, minor, and major) complications were collected. Chi-squared and analysis of variance statistical methods were used to compare the 30-day outcomes of patients with and without a resident's intraoperative involvement.

Results: Resident involvement had no effect in the incidence of wound and minor complications among all three anatomic sites of orthopedic trauma procedures (hip, lower extremity [LE], and upper extremity [UE]). There was no statistically significant difference in the incidence of major complications in the hip and LE groups. The UE group, however, demonstrated an increase in the rate of major complications (2.60% vs. 1.89%,  = 0.046). There was no difference in mortality or readmission rates.

Conclusions: Resident involvement in orthopedic trauma cases did not significantly impact the 30-day outcomes in nearly all domains. Our findings support continued resident involvement in the care of the orthopedic trauma patient.
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June 2016

No Incidence of Postoperative Knee Sepsis With Suprapatellar Nailing of Open Tibia Fractures.

J Orthop Trauma 2017 Feb;31(2):85-89

Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN.

Objective: To evaluate the incidence of knee sepsis after suprapatellar (SP) nailing of open tibia fractures.

Design: Retrospective; Setting: ACS level 1 trauma center.

Patients/participants: We reviewed 139 open tibia fractures that underwent SP nailing as definitive treatment over a 5-year period (January 1, 2011 to January 1, 2016). Most patients (90%, n = 126) underwent intramedullary nailing at the time of their initial surgery. We defined knee sepsis as intra-articular infection requiring operative debridement, either open or arthroscopically, within 1 month's time.

Intervention: Open tibia fractures treated with an SP tibial nail.

Main Outcome Measurements: Demographic data, fracture characteristics, Gustilo and Anderson classification of open fractures, and occurrence of knee sepsis.

Results: In 139 open tibia fractures, there were no cases of knee sepsis in the 30 days after treatment with an SP intramedullary nail. Eighty-seven percent of our cohort had Gustilo and Anderson type II (41%) or type III (46%) open fractures. Most open fractures (83%) underwent primary wound closure during the index procedures. Twenty-five limbs (18%) had evidence of infection at the open fracture site of their open fracture necessitating operative intervention and/or antibiotics: none, however, developed knee sepsis.

Conclusions: Although the SP approach carries intra-articular risks, we found a low risk of knee sepsis using this technique in the treatment of open tibia fractures. Our data suggest that there is no greater risk of intra-articular infection using an SP portal as compared with an infrapatellar one.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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February 2017

Posterior to Anteriorly Directed Screws for Management of Talar Neck Fractures.

Foot Ankle Int 2016 Oct 23;37(10):1130-1136. Epub 2016 Jun 23.

Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN, USA

Background: Screws placed from posterior to anterior have been shown to be biomechanically and anatomically superior in the fixation of talar neck and neck-body fractures, yet most surgeons continue to place screws from an anterior start point. The safety and efficacy of percutaneously applied posterior screws has not been clinically defined, and functional outcomes after their use is lacking.

Methods: After institutional review board approval, we performed a retrospective review of 24 consecutive talar neck fractures treated by a single surgeon that utilized posterior-to-anterior screw fixation. Clinical, radiographic, and functional outcomes were assessed at a minimum follow-up of 12 months. Functional outcomes including the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Olerud-Molander Scores, and the Short Form 36 (SF-36) measurement were collected and reviewed. Average patient follow-up was 44 months.

Results: According to the classification system of Canale and Kelly, there were 4 type I fractures, 15 type II fractures, 4 type III fractures, and 1 type IV fracture. Four patients had open fractures. One superficial wound infection occurred, 1 patient reported FHL stiffness, and 6 complained of numbness or paresthesias in the distribution of the sural nerve (5 transient, 1 permanent). One reoperation was required to exchange a screw impinging on the talonavicular joint. Radiographically, 44% developed a positive Hawkins sign, and the specificity of this finding was 100% for talar dome viability. Avascular necrosis developed in 43% of patients, with 33% revascularizing and none going on to collapse. Subtalar arthrosis developed in 62% of patients.

Conclusion: Screws placed from posterior to anterior are a useful technique in the treatment of talar neck fractures. Functional outcomes following their use appear favorable compared with recent reports with minimal risk to local structures.

Level Of Evidence: Level IV, retrospective case series.
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October 2016

Heterotopic ossification after hemiarthroplasty of the hip - A comparison of three common approaches.

J Clin Orthop Trauma 2015 Mar 26;6(1):1-5. Epub 2014 Dec 26.

The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue S., MCE, South Tower, Suite 4200, Vanderbilt University, Nashville, TN 37232, USA.

Objective: Heterotopic ossification (HO) about the hip after total hip arthroplasty and internal fixation of the hip, pelvis, and acetabulum has been linked to surgical approach. However, no study has investigated surgical approach and HO in patients undergoing hemiarthroplasty. We therefore aimed to explore the influence of operative approach in patients undergoing hemiarthroplasty.

Methods: Through a retrospective case series at an Urban level I trauma center, we found 80 patients over the age of 60 undergoing hemiarthroplasty for femoral neck fractures from 2000 to 2009. Patient charts, operative notes, and radiographs were reviewed for demographics, operative approach (anterior: A, anterior-lateral: AL, posterior: P), and any development of HO. Fisher's exact test compared rates of HO among the three approaches. Student's t-tests compared Brooker Classification levels of HO among the approaches.

Results: 82 hemiarthroplasties (26 A, 32 AL, 24 P) were included for analysis. 22 patients (27%) had HO. There was no significant difference in the development of HO based upon surgical approach: A: 19% (n = 5); AL: 34% (n = 11); P: 25% (n = 6). There was a significant difference in the grade of HO based on Brooker Classification (BC) with the posterior approach resulting in significantly lower grade of HO: A (BC: 2.60); AL (BC: 2.64); P (BC: 1.50) (p = 0.012).

Conclusions: Our data is the first to evaluate surgical approach and HO in patients with hemiarthroplasty. Patients have a significant risk of developing higher grade HO based on surgical approach (A or AL). Orthopedists should be mindful of these risks when considering A or AL approaches.
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March 2015

Orthopaedic trauma and the evolution of healthcare policy in America.

J Orthop Trauma 2014 Oct;28 Suppl 10:S2-4

Vanderbilt Orthopaedic Institute Center for Health Policy, Nashville, TN.

Healthcare policy has changed drastically, and with the 50-year anniversary of the passage of Medicare approaching in 2015, the authors evaluate the development of the current healthcare system and its relationship to the development of modern orthopaedic trauma. With more changes in healthcare policy forthcoming, it is increasingly important for the orthopaedic traumatologist to understand how changes in policy will affect practice. Historically, the motivators for change have remained largely the same over the past 50 years. The development of diagnosis-related groups, the resource-based relative value scale, and the sustainable growth rate are 3 defining policies that were designed to control costs, but which had an unexpected effect on those caring for the trauma population. Healthcare reform has a unique effect on those systems where care is dictated by a defining event or injury. Evaluating the development of trauma systems, the authors find that legislation directed toward the trauma population has been driven by the study of patient outcomes, providing an opportunity for orthopaedic traumatologists to contribute to future changes in policy. As healthcare policy changes begin to take effect, having a thorough understanding of reform and its drivers will be increasingly important in taking an active role in advocating for the field of orthopaedic trauma and its patients.
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October 2014

Surgical training using three-dimensional simulation in placement of cervical lateral mass screws: a blinded randomized control trial.

Spine J 2015 Jan 4;15(1):168-75. Epub 2014 Sep 4.

Vanderbilt Orthopaedic Department, 1215 21st Ave S, Suite 4200 Nashville, TN 37232, USA.

Background Context: The skills and knowledge that residents have to master has increased, yet the amount of hours that the residents are allowed to work has been reduced. There is a strong need to improve training techniques to compensate for these changes. One approach is to use simulation-training methods to shorten the learning curve for surgeons in training.

Purpose: To analyze the effect of surgical training using three-dimensional (3D) simulation on the placement of lateral mass screws in the cervical spine on either cadavers or sawbones.

Study Design: A blinded randomized control study.

Methods: Fifteen orthopedic residents, postgraduate year (PGY) 1 to 6, were asked to simulate Magerl lateral mass screw trajectories from C3-C7 on cadavers using a navigated drill guide, but with no feedback as to the actual trajectory within the bone (Baseline 1). This was repeated to determine baseline accuracy (Baseline 2). They were then randomized into three groups: Group 1, control, did not receive any training, whereas Groups 2 and 3 received 3D navigational feedback as to the intended drill trajectory on sawbones and cadavers, respectively. All three groups then performed final simulated drilling (final test). All 3D images were deidentified and reviewed by a blinded single fellowship-trained orthopedic spine surgeon. Each image/screw was measured for the starting site, caudad/cephalad angle, and medial/lateral angle to determine trajectory accuracy.

Results: The aggregate mean difference from a perfect screw was compiled for each session for each group. A negative difference shows improvement, whereas a positive difference shows regression. The difference between final test and Baseline 1 in the control group was 2.4°, suggesting regression. In contrast, the differences for groups sawbone and cadaver were -8.2° and -7.2°, respectively, suggesting improvement. When comparing the difference in aggregate sum angle for the sawbones and cadaver groups with the control group, the difference was statistically significant (p<.0001).

Conclusions: Training with 3D navigation significantly improved the ability of orthopedic residents to properly drill simulated lateral mass screws. As such, training with 3D navigation may be a useful adjunct in resident surgical education.
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January 2015

Clinical and economic implications of early discharge following posterior spinal fusion for adolescent idiopathic scoliosis.

J Child Orthop 2014 May 27;8(3):257-63. Epub 2014 Apr 27.

Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA, 30329, USA,

Objective: To evaluate the clinical and economic impact of a novel postoperative pathway following posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS).

Methods: Patient charts were reviewed for demographic data and to determine length of surgery, implant density, use of osteotomies, estimated blood loss, American Society of Anesthesiologists (ASA) score, length of hospital stay, and any subsequent complications. Hospital charges were divided by charge code to evaluate potential savings.

Results: Two hundred and seventy-nine of 365 patients (76.4 %) treated with PSF carried a diagnosis of AIS and had completed 6 months of clinical and radiologic follow-up, a period of time deemed adequate to assess early complications. There was no difference between groups in age at surgery, sex, number of levels fused, or length of follow-up. Patients managed under the accelerated discharge (AD) pathway averaged 1.36 (31.7 %) fewer days of inpatient stay. Operative time was associated with a shorter length of stay. There was no difference in complications between groups. Hospital charges for room and board were significantly less in the AD group ($1.885 vs. $2,779, p < 0.001).

Conclusions: A pathway aimed to expedite discharge following PSF for AIS decreased hospital stay by nearly one-third without any increase in early complication rate. A small but significant decrease in hospital charges was seen following early discharge. Early discharge following PSF for AIS may be achieved without increased risk of complications, while providing a small cost savings.
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May 2014

Decreased infection rates following total joint arthroplasty in a large county run teaching hospital: a single surgeon's experience and possible solution.

J Arthroplasty 2014 Aug 21;29(8):1610-6. Epub 2014 Mar 21.

Vanderbilt University School of Medicine, Nashville, TN.

Total joint arthroplasty is a common orthopaedic procedure producing valuable improvements in patient's quality of life. A dreaded complication of this procedure is deep seated, periprosthetic infection. This complication can lead to multiple reoperations and upwards of $100,000 of increased cost burden. At one 900 bed county run teaching hospital, with a historically high infection rate in total joints, the total joint service was closed and restarted using a new protocol, dropping infection rates from 12.9% to 1.9% (P = 0.007).
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August 2014

Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement.

Am J Sports Med 2013 Oct 26;41(10):2392-9. Epub 2013 Jul 26.

John W. Xerogeanes, Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park Drive South, Suite 1000, Atlanta, GA 30329.

Background: The autograft of choice for anterior cruciate ligament (ACL) reconstruction remains controversial. The quadriceps tendon is the least utilized and least studied of the potential autograft options.

Purpose: To determine if the quadriceps tendon has the anatomic characteristics to produce a graft whose length and volume are adequate, reproducible, and predictable when compared with the other commonly used autografts.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Axial proton density magnetic resonance imaging (MRI) scans of 60 skeletally mature patients (30 male and 30 female) were evaluated. Volumetric analysis of 3-dimensional models of the patellar and quadriceps tendons was performed before and after the removal of a 10 mm-wide graft from both tendons. Length, thickness, and width measurements of the quadriceps tendon were made at predetermined locations. Anthropometric data were collected, and subgroup analysis, sex analysis, and linear regression were performed.

Results: The mean percentage of volume remaining after removal of a 10 mm-wide graft from the patellar tendon was 56.6%, compared with 61.3% when harvesting an 80 mm-long graft of the same width from the quadriceps tendon. The intra-articular volume of the proposed quadriceps tendon graft was 87.5% greater than that of the patellar tendon graft. The mean length of the quadriceps tendon was 73.5 ± 12.3 mm in female patients and 81.1 ± 10.6 mm in male patients. These measurements were most highly correlated with patient height. The width of the quadriceps tendon decreased as one proceeded proximally from its insertion, and the thickness of the quadriceps tendon remained relatively constant.

Conclusion: The quadriceps tendon has the anatomic characteristics to produce a graft whose length and volume are both reproducible and predictable, while yielding a graft with a significantly greater intra-articular volume than a patellar tendon graft with a similar width.
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October 2013