The shoulder is one of the most complex joints in the human body and, as such, presents an evalua... more The shoulder is one of the most complex joints in the human body and, as such, presents an evaluation and diagnostic challenge. The fi rst steps in its evaluation are obtaining an accurate history and physical examination and evaluating conventional radiography. The use of other imaging modalities (eg, ultrasound, magnetic resonance imaging and computed tomography) should be based on the type of additional information needed. The goals of this study were to review the current limitations of evidence-based medicine with regard to shoulder examination and to assess the rationale for and against the use of diagnostic physical examination tests. The shoulder, one of the most complex joints in the human body, presents an evaluation and diagnostic challenge because: (1) it involves the simultaneous movement of many individual bones; (2) direct observation of those motions is obscured by muscle; (3) many practitioners have less experience with the shoulder than with other joints; (4) for s...
Total knee arthroplasty is mostly done to relieve pain and disability from a severe and degenerat... more Total knee arthroplasty is mostly done to relieve pain and disability from a severe and degenerated knee. Deformities in the coronal and sagittal plane could be corrected with the help of cuts made in tibia and femur during total knee replacement as well as with ligament release. However, large deformities in the lower extremity particularly in the diaphysis region need correction prior to the total knee replacement. It helps to limit the amount of bone that will be cut and helps the ligament release. Several extra articular and intra-articular methods for the correction of diaphyseal deformity have been described. We present the case of clamshell osteotomy for the correction of diaphyseal deformity in the tibia and a total knee replacement after the osteotomy site healed.
Geriatric orthopaedic surgery & rehabilitation, 2016
Hip fractures are common in the elderly and are likely to become more prevalent as the US populat... more Hip fractures are common in the elderly and are likely to become more prevalent as the US population ages. Early functional status is an indicator of longer term outcome, yet in-hospital predictors of functional recovery, particularly time of surgery and composition of support staff, after hip fracture surgery have not been well studied. Ninety-nine consecutive patients underwent hip fracture surgery by a single surgeon between 2009 and 2013. Surgery after 48 hours was deemed as surgical delay, and surgery after 5 pm was deemed as after hours. Surgical support staff experience was determined by experts from our institution as well as documented level of training. Functional status was determined by independent ambulation on postoperative day (POD) 3. On POD3, 48 (79%) of 62 patients with no delay were able to ambulate, whereas only 14 (38%) of 37 patients with delayed surgery were able to ambulate (P < .001). This relationship persisted when adjusted for American Society of Anest...
European Journal of Orthopaedic Surgery & Traumatology, 2015
Retrograde femoral nailing is a common method to repair femoral shaft fractures in polytrauma pat... more Retrograde femoral nailing is a common method to repair femoral shaft fractures in polytrauma patients. Studies have reported varying incidences of complications associated with retrograde femoral nailing such as knee pain, nonunion, and arthrofibrosis. The objective of this retrospective study was to describe healing and complication rates of 31 patients who underwent retrograde femoral nailing at our academic medical center. Clinical notes and radiographs were reviewed retrospectively. Data points such as demographics, fracture location on femur, time to union after surgery, presence or absence of comminution, associated injuries, and complications were assessed. Average time to union was 4.69 months with no statistically significant relationship found between time to union and age, sex, comminution, or location of fracture. Knee pain was present in 23 % of patients, and distal screw removal was necessary in 19.4 % of patients. Retrograde femoral nailing is an effective method of femoral shaft fracture fixation in polytrauma patients. The healing rate of femoral shaft fractures fixed with a retrograde nail is the same regardless of location of fracture, age, sex, or comminution. Prevention of tip of nail lying into the knee and early physical therapy are important to prevent arthrofibrosis knee.
While the gold standard of treatment of nonunion is open autologous bone grafting, studies have s... more While the gold standard of treatment of nonunion is open autologous bone grafting, studies have shown that injecting bone marrow aspirate concentrates (BMAC) is effective in treating tibial nonunions with fracture gaps less than 5 mm. We aim to demonstrate that combining BMAC with osteoinductive agents can effectively treat delayed or nonunion regardless of fracture gap size, nonunion site, or osteoinductive agent used. In this non-randomized retrospective-prospective cohort study, 49 patients with tibial nonunion met the inclusion criteria and underwent BMAC injection with demineralized bone matrix (DBM) and/or recombinant human bone morphogenic protein-2 (rhBMP-2). Radiologic healing of the fracture was the primary outcome. Patients were followed until radiographic union was achieved or another procedure was performed. Radiographic healing was defined as bridging of three out of four cortices on anteroposterior and lateral films. There was no difference in the healing rate (p = 0.81) between patients with fracture gaps less than and greater than 5 mm. On multivariate analysis, the use of rhBMP-2 was associated with a lower healing rate compared to DBM (p = 0.036). Patients who underwent early intervention (within 6 months of fixation) had higher union rates (p = 0.04). This study shows that percutaneous BMAC injection combined with either DBM and/or rhBMP-2 is a safe and effective treatment for delayed or nonunion regardless of the fracture gap size or fracture site. DBM may be superior to rhBMP-2 in this procedure.
European Journal of Orthopaedic Surgery & Traumatology, 2013
Bicondylar Hoffa fractures are rare. We report a patient who sustained an open bicondylar Hoffa f... more Bicondylar Hoffa fractures are rare. We report a patient who sustained an open bicondylar Hoffa fracture with an ipsilateral transverse fracture of the patella after a high-energy motor vehicle accident.
Bisphosphonates are the most commonly used drugs worldwide for treating osteoporosis. Atypical fe... more Bisphosphonates are the most commonly used drugs worldwide for treating osteoporosis. Atypical femoral fractures most commonly are associated with prolonged bisphosphonate use. They also may occur with denosumab use or in patients without a history of using these drugs. In this article, we provide a comprehensive review of the mechanism of action of bisphosphonate and the definition, incidence, epidemiology, pathogenesis, diagnosis, management, and prevention of atypical femoral fractures.
A 14-year-old right-hand dominant female lacrosse player presented with a complaint of right shou... more A 14-year-old right-hand dominant female lacrosse player presented with a complaint of right shoulder and upper posterior thorax pain of 8 days’ duration. She had been playing lacrosse at the attack wing and midfielder positions and experienced insidious pain after a game. She had no history of trauma to that shoulder during that game and had not experienced an injury in the past. Six days after the pain developed, she woke up one night with a sudden increase in the pain, which brought her to tears and caused slight difficulty with breathing. The pain was located anteriorly just lateral to the right sternoclavicular joint and posteriorly in the paraspinal muscles in the upper thoracic region. Physical examination suggested a first-rib stress fracture, which was subsequently confirmed by chest and shoulder radiographs.
European Journal of Orthopaedic Surgery & Traumatology, 2012
Fracture of the tibia in the area of a pre-existing implant is not common. We report two cases of... more Fracture of the tibia in the area of a pre-existing implant is not common. We report two cases of a fracture of the distal tibia at the distal interlocking screw site. We are not aware of any similar reports in the literature.
Chinese journal of traumatology = Zhonghua chuang shang za zhi / Chinese Medical Association, 2012
Breakage of surgical instruments and implants during operative procedures is not uncommon in any ... more Breakage of surgical instruments and implants during operative procedures is not uncommon in any surgical discipline. The need for removal and the outcome of leaving the broken instruments and implants in the surgical area have not been described in detail. Few studies have suggested removal if they are lying loosely in the tissues or joint, close to neurovascular structures. Challenges and the amount of time spent in the retrieval of broken instruments and implants are well known among surgeons, so most choose to leave them in situ. We reported a novel method of retrieval of a broken drill bit in the femoral medullary canal during internal fixation of a type C distal femoral fracture.
The shoulder is one of the most complex joints in the human body and, as such, presents an evalua... more The shoulder is one of the most complex joints in the human body and, as such, presents an evaluation and diagnostic challenge. The fi rst steps in its evaluation are obtaining an accurate history and physical examination and evaluating conventional radiography. The use of other imaging modalities (eg, ultrasound, magnetic resonance imaging and computed tomography) should be based on the type of additional information needed. The goals of this study were to review the current limitations of evidence-based medicine with regard to shoulder examination and to assess the rationale for and against the use of diagnostic physical examination tests. The shoulder, one of the most complex joints in the human body, presents an evaluation and diagnostic challenge because: (1) it involves the simultaneous movement of many individual bones; (2) direct observation of those motions is obscured by muscle; (3) many practitioners have less experience with the shoulder than with other joints; (4) for s...
Total knee arthroplasty is mostly done to relieve pain and disability from a severe and degenerat... more Total knee arthroplasty is mostly done to relieve pain and disability from a severe and degenerated knee. Deformities in the coronal and sagittal plane could be corrected with the help of cuts made in tibia and femur during total knee replacement as well as with ligament release. However, large deformities in the lower extremity particularly in the diaphysis region need correction prior to the total knee replacement. It helps to limit the amount of bone that will be cut and helps the ligament release. Several extra articular and intra-articular methods for the correction of diaphyseal deformity have been described. We present the case of clamshell osteotomy for the correction of diaphyseal deformity in the tibia and a total knee replacement after the osteotomy site healed.
Geriatric orthopaedic surgery & rehabilitation, 2016
Hip fractures are common in the elderly and are likely to become more prevalent as the US populat... more Hip fractures are common in the elderly and are likely to become more prevalent as the US population ages. Early functional status is an indicator of longer term outcome, yet in-hospital predictors of functional recovery, particularly time of surgery and composition of support staff, after hip fracture surgery have not been well studied. Ninety-nine consecutive patients underwent hip fracture surgery by a single surgeon between 2009 and 2013. Surgery after 48 hours was deemed as surgical delay, and surgery after 5 pm was deemed as after hours. Surgical support staff experience was determined by experts from our institution as well as documented level of training. Functional status was determined by independent ambulation on postoperative day (POD) 3. On POD3, 48 (79%) of 62 patients with no delay were able to ambulate, whereas only 14 (38%) of 37 patients with delayed surgery were able to ambulate (P < .001). This relationship persisted when adjusted for American Society of Anest...
European Journal of Orthopaedic Surgery & Traumatology, 2015
Retrograde femoral nailing is a common method to repair femoral shaft fractures in polytrauma pat... more Retrograde femoral nailing is a common method to repair femoral shaft fractures in polytrauma patients. Studies have reported varying incidences of complications associated with retrograde femoral nailing such as knee pain, nonunion, and arthrofibrosis. The objective of this retrospective study was to describe healing and complication rates of 31 patients who underwent retrograde femoral nailing at our academic medical center. Clinical notes and radiographs were reviewed retrospectively. Data points such as demographics, fracture location on femur, time to union after surgery, presence or absence of comminution, associated injuries, and complications were assessed. Average time to union was 4.69 months with no statistically significant relationship found between time to union and age, sex, comminution, or location of fracture. Knee pain was present in 23 % of patients, and distal screw removal was necessary in 19.4 % of patients. Retrograde femoral nailing is an effective method of femoral shaft fracture fixation in polytrauma patients. The healing rate of femoral shaft fractures fixed with a retrograde nail is the same regardless of location of fracture, age, sex, or comminution. Prevention of tip of nail lying into the knee and early physical therapy are important to prevent arthrofibrosis knee.
While the gold standard of treatment of nonunion is open autologous bone grafting, studies have s... more While the gold standard of treatment of nonunion is open autologous bone grafting, studies have shown that injecting bone marrow aspirate concentrates (BMAC) is effective in treating tibial nonunions with fracture gaps less than 5 mm. We aim to demonstrate that combining BMAC with osteoinductive agents can effectively treat delayed or nonunion regardless of fracture gap size, nonunion site, or osteoinductive agent used. In this non-randomized retrospective-prospective cohort study, 49 patients with tibial nonunion met the inclusion criteria and underwent BMAC injection with demineralized bone matrix (DBM) and/or recombinant human bone morphogenic protein-2 (rhBMP-2). Radiologic healing of the fracture was the primary outcome. Patients were followed until radiographic union was achieved or another procedure was performed. Radiographic healing was defined as bridging of three out of four cortices on anteroposterior and lateral films. There was no difference in the healing rate (p = 0.81) between patients with fracture gaps less than and greater than 5 mm. On multivariate analysis, the use of rhBMP-2 was associated with a lower healing rate compared to DBM (p = 0.036). Patients who underwent early intervention (within 6 months of fixation) had higher union rates (p = 0.04). This study shows that percutaneous BMAC injection combined with either DBM and/or rhBMP-2 is a safe and effective treatment for delayed or nonunion regardless of the fracture gap size or fracture site. DBM may be superior to rhBMP-2 in this procedure.
European Journal of Orthopaedic Surgery & Traumatology, 2013
Bicondylar Hoffa fractures are rare. We report a patient who sustained an open bicondylar Hoffa f... more Bicondylar Hoffa fractures are rare. We report a patient who sustained an open bicondylar Hoffa fracture with an ipsilateral transverse fracture of the patella after a high-energy motor vehicle accident.
Bisphosphonates are the most commonly used drugs worldwide for treating osteoporosis. Atypical fe... more Bisphosphonates are the most commonly used drugs worldwide for treating osteoporosis. Atypical femoral fractures most commonly are associated with prolonged bisphosphonate use. They also may occur with denosumab use or in patients without a history of using these drugs. In this article, we provide a comprehensive review of the mechanism of action of bisphosphonate and the definition, incidence, epidemiology, pathogenesis, diagnosis, management, and prevention of atypical femoral fractures.
A 14-year-old right-hand dominant female lacrosse player presented with a complaint of right shou... more A 14-year-old right-hand dominant female lacrosse player presented with a complaint of right shoulder and upper posterior thorax pain of 8 days’ duration. She had been playing lacrosse at the attack wing and midfielder positions and experienced insidious pain after a game. She had no history of trauma to that shoulder during that game and had not experienced an injury in the past. Six days after the pain developed, she woke up one night with a sudden increase in the pain, which brought her to tears and caused slight difficulty with breathing. The pain was located anteriorly just lateral to the right sternoclavicular joint and posteriorly in the paraspinal muscles in the upper thoracic region. Physical examination suggested a first-rib stress fracture, which was subsequently confirmed by chest and shoulder radiographs.
European Journal of Orthopaedic Surgery & Traumatology, 2012
Fracture of the tibia in the area of a pre-existing implant is not common. We report two cases of... more Fracture of the tibia in the area of a pre-existing implant is not common. We report two cases of a fracture of the distal tibia at the distal interlocking screw site. We are not aware of any similar reports in the literature.
Chinese journal of traumatology = Zhonghua chuang shang za zhi / Chinese Medical Association, 2012
Breakage of surgical instruments and implants during operative procedures is not uncommon in any ... more Breakage of surgical instruments and implants during operative procedures is not uncommon in any surgical discipline. The need for removal and the outcome of leaving the broken instruments and implants in the surgical area have not been described in detail. Few studies have suggested removal if they are lying loosely in the tissues or joint, close to neurovascular structures. Challenges and the amount of time spent in the retrieval of broken instruments and implants are well known among surgeons, so most choose to leave them in situ. We reported a novel method of retrieval of a broken drill bit in the femoral medullary canal during internal fixation of a type C distal femoral fracture.
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