Julius Bishop, MD

All Publications

• Orthopaedic Trauma Quality Measures for Value Based Healthcare Delivery: A Systematic Review. Journal of orthopaedic trauma DeBaun, M. R., Chen, M. J., Bishop, J. A., Gardner, M. J., Kamal, R. N. 2019

  Abstract

  OBJECTIVES: To assess the current portfolio of quality measures and candidate quality measures that address orthopaedic trauma surgery.DATA SOURCES: We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Quality Payment Program for quality measures relevant to fracture surgery. We also searched MEDLINE/PubMed, Embase/Scopus, and Cochrane libraries.DATA EXTRACTION: Clinical practice guidelines were included as candidate quality measures if their development was in accordance with the Institute of Medicine criteria for development of clinical practice guidelines, were based on consistent clinical evidence including at least one Level I study, and carried the strongest possible recommendation by the developing body. We categorized the measures as structure, process, or outcome domains according to the framework described by Donabedian.DATA SYNTHESIS: From the 3809 articles initially identified and screened, a total of 189 combined quality or candidate quality measures were extracted from our review. With regard to the Donabedian framework, there were a total of 7% (13/189) structure, 52% process (99/189), and 41% (77/189) outcome measures identified.CONCLUSIONS: As quality measures progressively inform reimbursement in value based healthcare models, quality measures evaluating the care of patients sustaining a fracture will become increasingly relevant to orthopaedic trauma surgeons.

  View details for PubMedID 30624346

• Distal Femur Locking Plates Fit Poorly Before and After Total Knee Arthroplasty. Journal of orthopaedic trauma Campbell, S. T., Bosch, L. C., Swinford, S., Amanatullah, D. F., Bishop, J. A., Gardner, M. J. 2019

  Abstract

  OBJECTIVE: To evaluate the fit of distal femur locking plates. Secondarily, we sought to compare plate fit among patients with and without a total knee arthroplasty (TKA).DESIGN: We retrospectively reviewed full-length femur radiographs of patients who underwent primary TKA.SETTING: All patients underwent TKA at a large university hospital.INTERVENTION: Standard length pre-contoured distal femur locking plates from four manufacturers were digitally templated onto each patient's pre- and post-TKA radiographs.MAIN OUTCOME MEASUREMENTS: The maximum distance from the plate to the lateral femoral cortex (plate-bone distance) was measured in the metaphyseal region. Mean plate-bone distances were compared between manufacturers and between pre and post-TKA radiographs.RESULTS: All implants tested were undercontoured in all patients. Plate-bone distances ranged from 6.6 ± 0.4 mm to 8.0 ± 0.4 mm (mean ± standard error) pre-TKA and 8.2 ± 0.3 mm to 8.6 ± 0.3 mm after TKA, indicating worse fit after arthroplasty (p < 0.001). There were also inter-manufacturer differences, with Synthes and Smith & Nephew implants demonstrating the lowest plate-bone distances in the pre- and post-TKA groups, respectively. Proportionally, plate-bone increase was greater in the female cohort (16%) compared to the male cohort (8%).CONCLUSIONS: There was a plate-bone mismatch for the distal femur locking plates tested in this study, due to undercontouring of the implants. After patients underwent TKA, poor implant fit was exacerbated. Surgeons must be aware of the potential for deformity if the proximal segment is brought into contact with the implant. These finding may help optimize implant design for the treatment of periprosthetic distal femur fractures.LEVEL OF EVIDENCE: V.

  View details for PubMedID 30614915

• Lower Complication Rate Following Ankle Fracture Fixation by Orthopaedic Surgeons Versus Podiatrists. The Journal of the American Academy of Orthopaedic Surgeons Chan, J. Y., Truntzer, J. N., Gardner, M. J., Bishop, J. A. 2018

  Abstract

  INTRODUCTION: Increased overlap in the scope of practice between orthopaedic surgeons and podiatrists has led to increased podiatric treatment of foot and ankle injuries. However, a paucity of studies exists in the literature comparing orthopaedic and podiatric outcomes following ankle fracture fixation.METHODS: Using an insurance claims database, 11,745 patients who underwent ankle fracture fixation between 2007 and 2015 were retrospectively evaluated. Patient data were analyzed based on the provider type. Complications were identified by the International Classification of Diseases, Ninth Revision, codes, and revision surgeries were identified by the Current Procedural Terminology codes. Complications analyzed included malunion/nonunion, infection, deep vein thrombosis, and rates of irrigation and debridement. Risk factors for complications were compared using the Charlson Comorbidity Index.RESULTS: Overall, 11,115 patients were treated by orthopaedic surgeons and 630 patients were treated by podiatrists. From 2007 to 2015, the percentage of ankle fractures surgically treated by podiatrists had increased, whereas that treated by orthopaedic surgeons had decreased. Surgical treatment by podiatrists was associated with higher malunion/nonunion rates among all types of ankle fractures. No differences in complications were observed in patients with unimalleolar fractures. In patients with bimalleolar or trimalleolar fractures, treatment by a podiatrist was associated with higher malunion/nonunion rates. Patients treated by orthopaedic surgeons versus podiatrists had similar comorbidity profiles.DISCUSSION: Surgical treatment of ankle fractures by orthopaedic surgeons was associated with lower rates of malunion/nonunion when compared with that by podiatrists. The reasons for these differences are likely multifactorial but warrants further investigation. Our findings have important implications in patients who must choose a surgeon to surgically manage their ankle fracture, as well as policymakers who determine the scope of practice.LEVEL OF EVIDENCE: Level III-retrospective cohort study.

  View details for DOI 10.5435/JAAOS-D-18-00630

  View details for PubMedID 30601371

• Prophylactic Fixation Can Be Cost-effective in Preventing a Contralateral Bisphosphonate-associated Femur Fracture. Clinical orthopaedics and related research Jiang, S. Y., Kaufman, D. J., Chien, B. Y., Longoria, M., Shachter, R., Bishop, J. A. 2018

  Abstract

  BACKGROUND: Bisphosphonates reduce the risk of fractures associated with osteoporosis but increase the risk of atypical subtrochanteric femur fractures. After unilateral atypical femur fracture, there is risk of contralateral fracture, but the indications for prophylactic fixation are controversial.QUESTIONS/PURPOSES: The purpose of this study is to use Markov modeling to determine whether contralateral prophylactic femur fracture fixation is cost-effective after a bisphosphonate-associated atypical femur fracture and, if so, what patient-related factors may influence that determination.METHODS: Markov modeling was used to determine the cost-effectiveness of contralateral prophylactic fixation after an initial atypical femur fracture. Simulated patients aged 60 to 90 years were included and separated into standard and high fracture risk cohorts. Patients with standard fracture risk were defined as those presenting with one atypical femur fracture but without symptoms or findings in the contralateral femur, whereas patients with high fracture risk were typified as those with more than one risk factor, including Asian ethnicity, prodromal pain, femoral geometry changes, or radiographic findings in the contralateral femur. Outcome probabilities and utilities were derived from studies matching to patient characteristics, and fragility fracture literature was used when atypical femur fracture data were not available. Associated costs were largely derived from Medicare 2015 reimbursement rates. Sensitivity analysis was performed on all model parameters within defined ranges.RESULTS: Prophylactic fixation for a 70-year-old patient with standard risk for fracture costs USD 131,300/quality-adjusted life-year (QALY) and for high-risk patients costs USD 22,400/QALY. Sensitivity analysis revealed that prophylaxis for high-risk patients is cost-effective at USD 100,000/QALY when the cost of prophylaxis was less than USD 29,400, the probability of prophylaxis complications was less than 21%, or if the patient was younger than 89 years old. The parameters to which the model was most sensitive were the cost of prophylaxis, patient age, and probability of prophylaxis-related complications.CONCLUSIONS: Prophylactic fixation of the contralateral side after unilateral atypical femur fracture is not cost-effective for standard-risk patients but is cost-effective among high-risk patients between 60 and 89 years of age with a high risk for an atypical femur fracture defined by patients with more than one risk factor such as Asian ethnicity, prodromal pain, varus proximal femur geometry, femoral bowing, or radiographic changes such as periosteal beaking and a transverse radiolucent line. However, our findings are based on several key assumptions for modeling such as the probability of fractures and complications, the costs associated for each health state, and the risks of surgical treatment. Future research should prospectively evaluate the degree of risk contributed by known radiographic and demographic parameters to guide management of the contralateral femur after a patient presents with an atypical femur fracture.LEVEL OF EVIDENCE: Level III, economic and decision analyses.

  View details for PubMedID 30394950

• A Preclinical Induced Membrane Model to Evaluate Synthetic Implants for Healing Critical Bone Defects Without Autograft. Journal of orthopaedic research : official publication of the Orthopaedic Research Society DeBaun, M. R., Stahl, A. M., Daoud, A. I., Pan, C., Bishop, J. A., Gardner, M. J., Yang, Y. P. 2018

  Abstract

  Critical bone defects pose a formidable orthopaedic problem in patients with bone loss. We developed a preclinical model based on the induced membrane technique using a synthetic graft to replace autograft for healing critical bone defects. Additionally, we used a novel osteoconductive scaffold coupled with a synthetic membrane to evaluate the potential for single-stage bone regeneration. Three experimental conditions were investigated in critical femoral defects in rats. Group A underwent a two-stage procedure with insertion of a polymethylmethacrylate (PMMA) spacer followed by replacement with a 3D printed polycaprolactone(PCL)/beta-tricalcium phosphate (beta-TCP) osteoconductive scaffold after 4 weeks. Group B received a single-stage PCL/beta-TCP scaffold wrapped in a PCL-based microporous polymer film creating a synthetic membrane. Group C received a single-stage bare PCL/beta-TCP scaffold. All groups were examined by serial radiographs for callus formation. After 12 weeks, the femurs were explanted and analyzed with micro-CT and histology. Mean callus scores tended to be higher in Group A. Group A showed statistically significant greater bone formation on micro-CT compared with other groups, although bone volume fraction was similar between groups. Histology results suggested extensive bone ingrowth and new bone formation within the macroporous scaffolds in all groups and cell infiltration into the microporous synthetic membrane. This study supports the use of a critical size femoral defect in rats as a suitable model for investigating modifications to the induced membrane technique without autograft harvest. Future investigations should focus on bioactive synthetic membranes coupled with growth factors for single-stage bone healing. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30273977

• Identification of the Human Skeletal Stem Cell. Cell Chan, C. K., Gulati, G. S., Sinha, R., Tompkins, J. V., Lopez, M., Carter, A. C., Ransom, R. C., Reinisch, A., Wearda, T., Murphy, M., Brewer, R. E., Koepke, L. S., Marecic, O., Manjunath, A., Seo, E. Y., Leavitt, T., Lu, W., Nguyen, A., Conley, S. D., Salhotra, A., Ambrosi, T. H., Borrelli, M. R., Siebel, T., Chan, K., Schallmoser, K., Seita, J., Sahoo, D., Goodnough, H., Bishop, J., Gardner, M., Majeti, R., Wan, D. C., Goodman, S., Weissman, I. L., Chang, H. Y., Longaker, M. T. 2018; 175 (1): 43

  Abstract

  Stem cell regulation and hierarchical organization ofhuman skeletal progenitors remain largely unexplored. Here, we report the isolation of a self-renewing and multipotent human skeletal stem cell (hSSC) that generates progenitors of bone, cartilage, and stroma, but not fat. Self-renewing and multipotent hSSCs are present in fetal and adult bones and can also be derived from BMP2-treated human adipose stroma (B-HAS) and induced pluripotent stem cells (iPSCs). Gene expression analysis of individual hSSCs reveals overall similarity between hSSCs obtained from different sources and partially explains skewed differentiation toward cartilage in fetal and iPSC-derived hSSCs. hSSCs undergo local expansion in response to acute skeletal injury. In addition, hSSC-derived stroma can maintain human hematopoietic stem cells (hHSCs) in serum-free culture conditions. Finally, we combine gene expression and epigenetic data of mouse skeletal stem cells (mSSCs) and hSSCs to identify evolutionarily conserved and divergent pathways driving SSC-mediated skeletogenesis. VIDEO ABSTRACT.

  View details for PubMedID 30241615

• Knee Pain After Intramedullary Nailing of Tibia Fractures: Prevalence, Etiology, and Treatment. The Journal of the American Academy of Orthopaedic Surgeons Bishop, J. A., Campbell, S. T., Eno, J. T., Gardner, M. J. 2018

  Abstract

  Intramedullary nailing is often the treatment of choice for fractures of the tibia, but postoperative knee pain is common after this procedure. Potential etiologies include implant prominence, injury to intra-articular structures, patellar tendon or fat pad injury, damage to the infrapatellar branch of the saphenous nerve, and altered biomechanics. Depending on the etiology, described treatment options include observation, implant removal, assessment and treatment of injured intra-articular structures, and selective denervation. Careful attention to appropriate starting point and implant selection combined with more recently described semiextended nailing techniques may aid in prevention of knee pain.

  View details for PubMedID 30095516

• A Structured Review Instrument Improves the Quality of Orthopaedic Journal Club. Journal of surgical education Campbell, S. T., Kleimeyer, J. P., Young, J. L., Gardner, M. J., Wood, K. B., Bishop, J. A. 2018

  Abstract

  OBJECTIVE: We asked the following questions: 1. Does the use of an structured review instrument (SRI) at journal club increase presentation quality, as measured objectively by a standardized evaluation rubric? 2. Does SRI use increase the time required to prepare for journal club? 3. Does SRI use positively impact presenter perceptions about confidence while presenting, satisfaction, and journal club effectiveness, as measured by postparticipation surveys?DESIGN: A prospective study was designed in which a grading rubric was developed to evaluate journal club presentations. The rubric was applied to 24 presentations at journal clubs prior to introduction of the SRI. An SRI was developed and distributed to journal club participants, who were instructed to use it to prepare for journal club. The grading rubric was then used to assess 25 post-SRI presentations and scores were compared between the pre- and post-SRI groups. Presentations occurred at either trauma, pediatrics, or spine subspecialty journal clubs. Participants were also surveyed regarding time requirements for preparation, perceptions of confidence while presenting, satisfaction, and perceptions of overall club effectiveness.SETTING: A single academic center with an orthopaedic surgery residency program.PARTICIPANTS: Resident physicians in the department of orthopaedic surgery.RESULTS: Mean presentation scores increased from 14.0 ± 5.9 (mean ± standard deviation) to 24.4 ± 5.2 after introduction of the SRI (p < 0.001). Preparation time decreased from a mean of 47 minutes to 40 minutes after SRI introduction (p = 0.22). Perceptions of confidence, satisfaction, and club effectiveness among trainees trended toward more positive responses after SRI introduction (confidence: 63% positive responses pre-SRI vs 72% post-SRI, p = 0.73; satisfaction: 64% vs 91%, p = 0.18; effectiveness: 64% vs 91%, p = 0.19).CONCLUSIONS: The use of a structured review instrument to guide presentations at orthopaedic journal club increased presentation quality, and there was no difference in preparation time. There were trends toward improved presenter confidence, satisfaction, and perception of journal club effectiveness. SRI utilization at orthopaedic journal club may be an effective method for increasing the quality of journal club presentations. Future work should examine the relationship between presentation quality and overall club effectiveness.

  View details for PubMedID 30093334

• Percutaneous versus Open Treatment of Posterior Pelvic Ring Injuries: Changes in Practice Patterns Over Time. Journal of orthopaedic trauma Gire, J. D., Jiang, S. Y., Gardner, M. J., Bishop, J. A. 2018

  Abstract

  OBJECTIVE: To determine how the utilization of open versus percutaneous treatment of posterior pelvic ring injuries in early career orthopaedic surgeons has changed over time.METHODS: Case log data from surgeons testing in the trauma subspecialty for Part II of the ABOS examination from 2003 to 2015 were evaluated. CPT codes for percutaneous fixation (27216) and open fixation (27218) of the posterior pelvic ring were evaluated using a regression analysis.RESULTS: A total of 377 candidates performed 2,095 posterior ring stabilization procedures (1,626 percutaneous, 469 open). Total case volume was stable over time (beta=-1.7 (1.1), p=.14). There was no significant change in the number of posterior pelvic ring fracture surgery cases performed per candidate per test year (beta= 0.1 (0.1), p=.50). The proportion of posterior pelvic ring cases performed percutaneously increased significantly from 49% in 2003 to 79% in 2015 (beta= 1.0 (0.4), p=.03). There was a significant decrease in the number of open cases reported per candidate (beta= -0.07 (0.03), p=.008).DISCUSSION AND CONCLUSION: Early career orthopaedic surgeons are performing more percutaneous fixation of the posterior pelvic ring and less open surgery. The impact of this change in volume on surgeon proficiency is unknown and warrants additional research.

  View details for PubMedID 29912737

• Which orthopaedic trauma patients need psychiatry consultation? A single institution pilot survey study CURRENT ORTHOPAEDIC PRACTICE Campbell, S. T., Schultz, B. J., Franciscus, A. M., Ravindranath, D., Bishop, J. A. 2018; 29 (3): 270–74

  View details for DOI 10.1097/BCO.0000000000000619

  View details for Web of Science ID 000435074900018

• What Makes Journal Club Effective?-A Survey of Orthopaedic Residents and Faculty. Journal of surgical education Campbell, S. T., Kang, J. R., Bishop, J. A. 2018; 75 (3): 722–29

  Abstract

  BACKGROUND: Journal clubs play an important role in the education of orthopaedic surgery residents; however, there are sparse data available on the characteristics that make journal clubs effective.OBJECTIVE: The primary goal of this study was to determine the characteristics of effective journal clubs as identified by orthopaedic residents and faculty. We sought to compare the opinions of residents and faculty in order to identify areas that may benefit from future research and discussion.DESIGN: Orthopaedic surgery residents and faculty at residency programs around the country were surveyed anonymously. The survey was designed to determine the contribution of various journal club characteristics on the effectiveness of journal club. Nonparametric statistics were used to test for goodness-of-fit, and to compare responses between faculty and residents.RESULTS: A total of 204 individuals participated. The most important goals of journal clubs were teaching the skillset of evaluating scientific papers (2.0 ± 1.2 [mean rank ± standard deviation, on a scale of 6, with 1 being most important]), encouraging participants to read current orthopaedic literature, (2.4 ± 1.1), and instilling career-long habits of reading the orthopaedic literature among residents (3.1 ± 1.3). Mandatory attendance (71.8%), monthly journal clubs (80.9%), resident presentation of articles (86.7%), and discussion of 3 to 5 papers (78.7%) were thought to lead to more effective clubs. The most clinically relevant articles published within the last year (63.8%), and classic articles that have influenced practice (68.1%) were preferred. Participation and attendance (2.4 ± 1.5) and paper selection (2.6 ± 1.5) were the most important characteristics overall.CONCLUSIONS: In orthopaedics, journal clubs fulfill the role of encouraging reading of the literature, as well as educating residents and faculty. There are many possible club formats, but some are clearly felt to be more effective. Particular attention should be paid to attendance, participation, and paper selection.

  View details for PubMedID 28822821

• Defining the width of the normal tibial plateau relative to the distal femur: Critical normative data for identifying pathologic widening in tibial plateau fractures. Clinical anatomy (New York, N.Y.) Johannsen, A. M., Cook, A. M., Gardner, M., Bishop, J. A. 2018

  Abstract

  INTRODUCTION: Tibial plateau widening in the setting of fracture is an indication for surgical treatment, and restoring width is an important goal of surgery. In order to identify and correct pathological widening, the width of the normal tibial plateau must first be defined. The aim of this study was to establish normative data for the width of the tibial plateau relative to the distal femur to enable surgeons to identify and correct pathological widening in the setting of tibial plateau fracture.MATERIALS AND METHODS: Fifty-one uninjured anteroposterior (AP) knee radiographs and 11 XR and CT scans of lateral tibial plateau fractures were retrospectively reviewed. The distances measured included maximal distal femoral width, femoral articular width, tibial articular width, and lateral plateau widening.RESULTS: On average, lateral plateau widening was +0.02±2.03 mm, indicating that the most lateral aspect of the tibial plateau is collinear with the most lateral aspect of the lateral epicondyle of the femur. In the fracture population, average widening was 7.13±3.59 mm on XR and 6.57±3.34 mm on CT, with an absolute difference between XR and CT of 1.19±0.66 mm.CONCLUSIONS: This study is the first to define the radiographic anatomy of the proximal tibia quantitatively. In the setting of tibial plateau fracture, residual widening of 2.1 mm could be within normal variation. However, the authors consider widening>2.1 mm pathological. These values can be used for assessing pathological widening of tibial plateau fractures. This article is protected by copyright. All rights reserved.

  View details for PubMedID 29700856

• Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation? Clinical orthopaedics and related research Lichstein, P. M., Kleimeyer, J. P., Githens, M., Vorhies, J. S., Gardner, M. J., Bellino, M., Bishop, J. 2018

  Abstract

  A well-reduced femoral neck fracture is more likely to heal than a poorly reduced one, and increasing the quality of the surgical exposure makes it easier to achieve anatomic fracture reduction. Two open approaches are in common use for femoral neck fractures, the modified Smith-Petersen and Watson-Jones; however, to our knowledge, the quality of exposure of the femoral neck exposure provided by each approach has not been investigated.(1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches?Ten fresh-frozen human pelvi underwent both modified Smith-Petersen (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approaches. Dissections were performed by three fellowship-trained orthopaedic traumatologists with extensive experience in both approaches. Exposure (in cm) was quantified with calibrated digital photographs and specialized software. Modified Smith-Petersen approaches were analyzed before and after rectus femoris tenotomy. The ability to visualize and palpate seven clinically relevant anatomic structures (the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater trochanter, lesser trochanter, and medial femoral neck) was also recorded. The quantified area of the exposed proximal femur was utilized to compare which approach afforded the largest field of view of the femoral neck and articular surface for assessment of femoral neck fracture and associated femoral head injury. The ability to visualize and palpate surrounding structures was assessed so that we could better understand which approach afforded the ability to assess structures that are relevant to femoral neck fracture reduction and fixation.After controlling for age, body mass index, height, and sex, we found the modified Smith-Petersen approach provided a mean of 2.36 cm (95% confidence interval [CI], 0.45-4.28 cm; p = 0.015) additional exposure without rectus femoris tenotomy (p = 0.015) and 3.33 cm (95% CI, 1.42-5.24 cm; p = 0.001) additional exposure with a tenotomy compared with the Watson-Jones approach. The labrum, femoral head, subcapital femoral neck, basicervical femoral neck, and greater trochanter were reliably visible and palpable in both approaches. The lesser trochanter was palpable in all of the modified Smith-Petersen and none of the Watson-Jones approaches (p < 0.001). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 Watson-Jones versus all 10 modified Smith-Petersen approaches (p = 0.470).In the hands of surgeons experienced with both surgical approaches to the femoral neck, the modified Smith-Petersen approach, with or without rectus femoris tenotomy, provides superior exposure of the femoral neck and articular surface as well as visualization and palpation of clinically relevant proximal femoral anatomic landmarks compared with the Watson-Jones approach.Open reduction and internal fixation of a femoral neck fracture is typically performed in a young patient (< 60 years old) with the objective of obtaining anatomic reduction that would not be possible by closed manipulation, thus enhancing healing potential. In the hands of surgeons experienced in both approaches, the modified Smith-Petersen approach offers improved direct access for reduction and fixation. Higher quality reductions and fixation are expected to translate to improved healing potential and outcomes. Although our experimental results are promising, further clinical studies are needed to verify if this larger exposure area imparts increased quality of reduction, healing, and improved outcomes compared with other approaches. The learning curve for the exposure is unclear, but the approach has broad applications and is frequently used in other subspecialties such as for direct anterior THA and pediatric septic hip drainage. Surgeons treating femoral neck fractures with open reduction and fixation should familiarize themselves with the modified Smith-Petersen approach.

  View details for PubMedID 29698292

• Pediatric Supracondylar Humerus Fractures: Does After-Hours Treatment Influence Outcomes? Journal of orthopaedic trauma Paci, G. M., Tileston, K. R., Vorhies, J. S., Bishop, J. A. 2018; 32 (6): e215–e220

  Abstract

  To compare the outcomes of pediatric supracondylar humerus fractures treated during daytime hours to those treated after-hours.Retrospective.Academic Level I trauma center.Two hundred ninety-eight pediatric patients treated with surgical reduction and fixation of closed supracondylar fractures were included.Seventy-seven patients underwent surgery during daytime hours (06:00-15:59 on weekdays). One hundred eighty-six patients underwent surgery after-hours (16:00-05:59 on weekdays and any surgery on weekends or holidays).Surgeon subspecialty, operative duration, and radiographic and clinical outcomes, including range of motion and carrying angle, were extracted from the patient medical records.There were no patient-related demographic differences between the daytime hours and after-hours groups. Daytime surgery was more likely to be performed by a pediatric orthopaedic surgeon than after-hours surgery. Fractures treated after-hours had more severe injury patterns. After-hours surgery was not independently associated with rate of open reduction, operative times, complications, achievement of functional range of motion, or radiographic alignment. A late-night surgery subgroup analysis demonstrated an increased rate of malunion in patients undergoing surgery between the hours of 23:00 and 05:59.There is no difference in the operative duration or outcomes after surgical treatment of pediatric supracondylar humerus fractures performed after-hours when compared with daytime surgery. However, late-night surgery performed between 23:00 and 05:59 may be associated with a higher rate of malunion. Surgeons can use these data to make better-informed decisions about the timing of surgery in this patient population.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for PubMedID 29432316

• Avoiding Neurovascular Risk During Percutaneous Clamp Reduction of Spiral Tibial Shaft Fractures: An Anatomic Correlation with Computed Tomography. Journal of orthopaedic trauma Horrigan, P. B., Coughlan, M. J., DeBaun, M., Schultz, B., Bishop, J. A., Gardner, M. J. 2018

  Abstract

  Use of percutaneous clamps are often helpful tools to aid reduction and intramedullary nailing of distal tibial spiral diaphyseal fractures. However, the anterior and posterior neurovascular bundles are at risk without careful clamp placement. We describe our preferred technique of percutaneous clamp reduction for distal spiral tibial fractures with a distal posterolateral fracture spike, with care to protect the adjacent neurovascular structures. We also investigated the relationship between these neurovascular structures and the site of common percutaneous clamp placement. Preoperative CT images of surgically managed patients who sustained this specific common fracture pattern (distal third spiral diaphyseal tibia fracture with a posterolateral fragment) were retrospectively reviewed. On CT, we extrapolated the ideal virtual clamp site on the posterolateral fracture fragment to facilitate reduction. The average distance of this clamp position from the anterior neurovascular bundle was 14 mm (SD= 7.6), with a range of 6 mm to 32 mm. The average distance of the clamp site from the posterior neurovascular bundle was 19 mm (SD= 6.1), with a range of 11 mm to 30 mm. In 31% of patients, the distal fragment's apex extended anterior to the interosseous membrane, and in 69% the apex was posterior to the interosseous membrane. We also describe our preferred surgical technique with percutaneous clamping and tibial nailing, which involves sliding the posterolateral tine of the percutaneous clamp along the lateral tibial cortex to prevent neurovascular bundle injury.

  View details for PubMedID 29905623

• Bilateral Sacral Ala Fractures Are Strongly Associated With Lumbopelvic Instability JOURNAL OF ORTHOPAEDIC TRAUMA Bishop, J. A., Dangelmajer, S., Corcoran-Schwartz, I., Gardner, M. J., Routt, M., Castillo, T. N. 2017; 31 (12): 636–39

  View details for DOI 10.1097/BOT.0000000000000972

  View details for Web of Science ID 000416625900013

• Are factor Xa inhibitors effective thromboprophylaxis following hip fracture surgery?: A large national database study. Injury Campbell, S. T., Bala, A., Jiang, S. Y., Gardner, M. J., Bishop, J. A. 2017

  Abstract

  INTRODUCTION: The purpose of this study was to evaluate the effectiveness of Factor Xa inhibitors (XaI) for thromboprophylaxis following hip fracture surgery in a large cohort of patients, and compare XaI against warfarin and enoxaparin.METHODS: Patients undergoing hip fracture surgery from 2007 to 2015 were identified in a large claims database. Patients prescribed warfarin, XaI, or enoxaparin within 2 weeks of surgery were identified and grouped into cohorts. Medical comorbidities and complication incidences, including deep venous thrombosis (DVT), pulmonary embolism (PE), and bleeding complications were calculated. Chi-square analysis was performed and adjusted residuals calculated to determine significant differences.RESULTS: DVT rates were significantly different between groups at thirty days only (5.03% warfarin, 2.91% XaI, 3.48% enoxaparin, p=0.047). PE rates were significantly different at all time points; enoxaparin had the lowest rates. There were no differences in the rates of other complications.DISCUSSION: XaI are an option for thromboprophylaxis in hip fracture patients, although their possible decreased effectiveness against PE compared to enoxaparin should be considered.CONCLUSIONS: This study compares the effectiveness of Factor Xa inhibitors to warfarin and enoxaparin for hip fracture patients, using a large national database. In this study, Factor Xa inhibitors had similar effectiveness for DVT prophylaxis compared to these agents.

  View details for PubMedID 29102371

• Disparities in Total Hip Arthroplasty Versus Hemiarthroplasty in the Management of Geriatric Femoral Neck Fractures GERIATRIC ORTHOPAEDIC SURGERY & REHABILITATION Dangelmajer, S., Yang, A., Githens, M., Harris, A. S., Bishop, J. A. 2017; 8 (3): 155–60

  Abstract

  Recent clinical evidence suggests that total hip arthroplasty (THA) provides improved clinical outcomes as compared to hemiarthroplasty (HA) for displaced femoral neck fractures in elderly individuals. However, THA is still utilized relatively infrequently. Few studies have evaluated the factors affecting utilization and the role socioeconomics plays in THA versus HA.In the United States, the National Inpatient Sample (NIS) database was used to identify patients treated surgically for femoral neck fracture, between 2009 and 2010. Patients were identified using International Classification of Diseases, Ninth Revision, codes for closed, transcervical femoral neck fractures and closed fractures at unspecified parts of the femoral neck. All candidate predictors of THA versus HA were entered into a multilevel mixed-effect regression model.Older patient age, being Asian or Pacific Islander, and having Medicaid payer status were all associated with lower odds of receiving THA. Patients with private insurance including Health Maintenance organization (HMO) had higher odds of THA as did patients with other insurance. Odds of THA were significantly lower among patients in teaching hospitals and higher at hospitals with greater THA volume.Ethnicity, payer status, hospital size, and institutional THA volume were all associated with the utilization of THA versus HA in the treatment of geriatric femoral neck fractures.Level III Retrospective Cohort study.

  View details for PubMedID 28835872

  View details for PubMedCentralID PMC5557198

• Continuous Femoral Nerve Catheters Decrease Opioid-Related Side Effects and Increase Home Disposition Rates Among Geriatric Hip Fracture Patients. Journal of orthopaedic trauma Arsoy, D., Gardner, M. J., Amanatullah, D. F., Huddleston, J. I., Goodman, S. B., Maloney, W. J., Bishop, J. A. 2017; 31 (6): e186-e189

  Abstract

  To evaluate the effect of continuous femoral nerve catheter (CFNC) for postoperative pain control in geriatric proximal femur fractures compared with standard analgesia (SA) treatment.Retrospective comparative study.Academic Level 1 trauma center.We retrospectively identified 265 consecutive geriatric hip fracture patients who underwent surgical treatment.One hundred forty-nine patients were treated with standard analgesia without nerve catheter whereas 116 patients received an indwelling CFNC.Daily average preoperative and postoperative pain scores, daily morphine equivalent consumption, opioid-related side effects and discharge disposition.Patients with CFNC patients reported lower average pain scores preoperatively (1.9 ± 1.7 for CFNC vs. 4.7 ± 2 for SA; P < 0.0001), on postoperative day 1 (1.5 ± 1.6 for CFNC vs. 3 ± 1.7 for SA; P < 0.0001) and postoperative day 2 (1.2 ± 1.5 for CFNC vs. 2.6 ± 2.1 for SA; P < 0.0001). CFNC group consumed 39% less morphine equivalents on postoperative day 1 (4.4 ± 5.8 mg for CFNC vs. 7.2 ± 10.8 mg for SA; P = 0.005) and 50% less morphine equivalent on postoperative day 2 (3.4 ± 4.4 mg for CFNC vs. 6.8 ± 13 mg for SA; P = 0.105). Patients with CFNC had a lower rate of opioid-related side effects compared with patients with SA (27.5% for CFNC vs. 47% for SA; P = 0.001). More patients with CFNC were discharged to home with or without health services than patients with SA (15% for CFNC vs. 6% for SA; P = 0.023).Continuous femoral nerve catheter decreased daily average patient-reported pain scores, narcotic consumption while decreasing the rate of opioid-related side effects. Patients with CFNC were discharged to home more frequently.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000000854

  View details for PubMedID 28538458

• Buttress Plating versus Anterior-to-Posterior Lag Screws for Fixation of the Posterior Malleolus: A Biomechanical Study. Journal of orthopaedic trauma Bennett, C., Behn, A., Daoud, A., Nork, S., Sangeorzan, B., Dikos, G., Bishop, J. 2016: -?

  Abstract

  The preferred method of fixation for posterior malleolus fractures remains controversial, and practices vary widely among surgeons. The purpose of this study was to compare anterior-to-posterior (AP) lag screws with posterior buttress plating for fixation of posterior malleolus fractures in a human cadaveric model.Posterior malleolus fractures involving 30% of the distal tibial articular surface were created in 7 pairs of fresh frozen cadaveric ankles. One specimen in each pair was randomly assigned to fixation with either 2 AP lag screws or a one-third tubular buttress plate without supplemental lag screws. Each specimen was then subjected to cyclic loading from 0% to 50% of body weight for 5000 cycles followed by loading to failure. Outcome measures included permanent axial displacement during each test cycle (axial displacement at no load), peak axial displacement during each test cycle (axial displacement at 50% body weight), load at 1-mm axial displacement, ultimate load, and axial displacement at ultimate load.The buttress plate group showed significantly less peak axial displacement at all time points during cyclic loading. Permanent axial displacement was significantly less in the buttress plate group beginning at cycle 200. There were no significant differences between the 2 groups during load-to-failure testing.Posterior malleolus fractures treated with posterior buttress plating showed significantly less displacement during cyclical loading compared with fractures fixed with AP lag screws. Surgeons should consider these findings when selecting a fixation strategy for these common fractures. Further research is warranted to investigate the clinical implications of these biomechanical findings.

  View details for PubMedID 27755282

• Are Early Career Orthopaedic Trauma Surgeons Performing Less Complex Trauma Surgery? JOURNAL OF ORTHOPAEDIC TRAUMA Gire, J. D., Gardner, M. J., Harris, A. H., Bishop, J. A. 2016; 30 (10): 525-529

  Abstract

  There has recently been an increase in the number of fellowship trained orthopaedic trauma surgeons, raising concerns that the surgical experience of early career surgeons may be diluted. We sought to evaluate the change in complex trauma case volume of orthopaedic trauma surgeons sitting for Part II of the American Board of Orthopaedic Surgeons certification examination.The case log data from all surgeons taking Part II of the American Board of Orthopaedic Surgeons examination over a 13-year period (2003-2015) was evaluated. Any surgeon who examined in the trauma subspecialty was included. We defined pelvis, acetabulum, and periarticular fracture surgeries as complex trauma procedures and evaluated changes in case volume over time.We included 468 candidates who examined as trauma subspecialists and performed 90,261 procedures. The number of candidates testing in trauma per year ranged from 15 to 65 and increased significantly over time [β = 4.05 (0.37), P < 0.0001]. Their case volume was stable over time [β = -1.7 (1.1), P = 0.16]. The number of acetabulum fracture surgeries performed decreased significantly over time from a mean of 10.1 cases in 2003 to 5.2 cases in 2015 [β = -0.34 (0.08), P = 0.0015]. There was no significant change in the number of pelvic fracture surgeries [β = -0.1 (0.1), P = 0.285]. There was a trend toward less periarticular fracture surgeries [β = -0.3 (0.1), P = 0.072].Although pelvic ring and periarticular fracture case volume have remained stable, early career surgeons have experienced a significant decrease in acetabular fracture case volume. The implications of this decreased surgical experience warrant careful consideration as the orthopaedic trauma workforce evolves.

  View details for DOI 10.1097/BOT.0000000000000653

  View details for Web of Science ID 000384467000009

• Admission Through the Emergency Department Is an Independent Risk Factor for Lower Satisfaction With Physician Performance Among Orthopaedic Surgery Patients: A Multicenter Study JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Vorhies, J. S., Weaver, M. J., Bishop, J. A. 2016; 24 (10): 735-742

  Abstract

  Patient experience data are increasingly used to guide performance improvement and to determine physician and hospital reimbursement. We studied the relationship between emergency department (ED) admission and patient satisfaction with physicians' performance, and identified other associated predictors.We evaluated 6,524 inpatient Press Ganey patient experience surveys from two academic level I trauma centers over 5 years. We stratified patients by ED admission or other admission and compared the proportions of patients in each group who were satisfied with physician performance. We used logistic regression to control for demographic differences and characteristics of hospitalizations.Among patients admitted through the ED, 85.18% were satisfied, compared with 89.44% of patients admitted through other pathways (P < 0.001). Admission through the ED predicted decreased satisfaction, with an odds ratio of 0.67 (P = 0.032) after controls were applied through logistic regression.Admission through the ED is an independent risk factor for lower satisfaction with physician performance. Understanding the determinants of patient satisfaction will help improve physician-patient interactions and guide quality improvement and value-based reimbursement initiatives.This retrospective survey-based analysis of satisfaction does not fall clearly under any of the Journal's established categories of level of evidence. The most closely aligned choice would be Level III Prognostic.

  View details for DOI 10.5435/JAAOS-D-16-00084

  View details for Web of Science ID 000385408400010

  View details for PubMedID 27579815

• The Effect of Transiliac-Transsacral Screw Fixation for Pelvic Ring Injuries on the Uninjured Sacroiliac Joint JOURNAL OF ORTHOPAEDIC TRAUMA Mardam-Bey, S. W., Beebe, M. J., Black, J. C., Chang, E. Y., Kubiak, E. N., Bishop, J. A., McAndrew, C. M., Ricci, W. M., Gardner, M. J. 2016; 30 (9): 463-468

  Abstract

  To evaluate the functional outcomes and pain in patients with unilateral posterior pelvic ring injuries treated with transiliac-transsacral screw fixation compared with unilateral iliosacral screw fixation.Retrospective comparative study.Three academic level 1 trauma centers.From a group of 866 patients with pelvic ring injuries treated surgically, 86 patients with unilateral pelvic ring injuries treated with transiliac-transsacral screws and 97 patients treated with unilateral iliosacral screws were identified. Thirty-six patients treated with transiliac-transsacral fixation and 26 patients treated with unilateral iliosacral screws met the inclusion criteria and participated.Patients were treated surgically for unstable pelvic ring injuries with either unilateral iliosacral screws or transiliac-transsacral screws at the discretion of the treating surgeon.Majeed Pelvic Score.There was no significant difference in Majeed Pelvic Scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws (72.8 ± 23.7 vs. 70.4 ± 19.0, P = 0.66). There was no difference in side-specific Numeric Rating Scale pain scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws on the injured side (2.5 ± 3.1 vs. 2.0 ± 2.4, P = 0.46) or the uninjured side (1.7 ± 2.8 vs. 0.8 ± 1.7, P = 0.12). Mean follow-up was greater than 3 years with no difference between the groups (mean 1270 vs. 1242 days, P = 0.84).Treatment of unilateral pelvic ring injuries with transiliac-transsacral screws does not adversely affect or improve patient outcomes or subjective pain scores when compared with those treated with unilateral iliosacral screws.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000000622

  View details for PubMedID 27144820

• Cancellous Screws Are Biomechanically Superior to Cortical Screws in Metaphyseal Bone ORTHOPEDICS Wang, T., Boone, C., Behn, A. W., Ledesma, J. B., Bishop, J. A. 2016; 39 (5): E828-E832

  Abstract

  Cancellous screws are designed to optimize fixation in metaphyseal bone environments; however, certain clinical situations may require the substitution of cortical screws for use in cancellous bone, such as anatomic constraints, fragment size, or available instrumentation. This study compares the biomechanical properties of commercially available cortical and cancellous screw designs in a synthetic model representing various bone densities. Commercially available, fully threaded, 4.0-mm outer-diameter cortical and cancellous screws were tested in terms of pullout strength and maximum insertion torque in standard-density and osteoporotic cancellous bone models. Pullout strength and maximum insertion torque were both found to be greater for cancellous screws than cortical screws in all synthetic densities tested. The magnitude of difference in pullout strength between cortical and cancellous screws increased with decreasing synthetic bone density. Screw displacement prior to failure and total energy absorbed during pullout strength testing were also significantly greater for cancellous screws in osteoporotic models. Stiffness was greater for cancellous screws in standard and osteoporotic models. Cancellous screws have biomechanical advantages over cortical screws when used in metaphyseal bone, implying the ability to both achieve greater compression and resist displacement at the screw-plate interface. Surgeons should preferentially use cancellous over cortical screws in metaphyseal environments where cortical bone is insufficient for fixation. [Orthopedics.2016; 39(5):e828-e832.].

  View details for DOI 10.3928/01477447-20160509-01

  View details for Web of Science ID 000393107500003

  View details for PubMedID 27172369

• Evaluation of Contemporary Trends in Femoral Neck Fracture Management Reveals Discrepancies in Treatment. Geriatric orthopaedic surgery & rehabilitation Bishop, J., Yang, A., Githens, M., Sox, A. H. 2016; 7 (3): 135-141

  Abstract

  Recent evidence supports total hip arthroplasty (THA) as compared to hemiarthroplasty (HA) for the management of displaced femoral neck fractures in a significant subset of elderly patients. The purpose of this study was to examine trends in femoral neck fracture management over the last 12 years.Using the National Inpatient Sample database, we identified patients treated for femoral neck fractures between 1998 and 2010 with THA, HA, or internal fixation (IF). We examined treatment trends and demographic variables including patient age, gender, socioeconomic status, and payer and hospital characteristics.We identified 362 127 femoral neck fracture patients treated between 1998 and 2010. Overall, there were statistically significant increases in rates of THA and HA, whereas rates of IF decreased. Total hip arthroplasty varied based on patient age, with significant increases occurring in age-groups 0 to 49 years, 50 to 59 years, 60 to 69 years, and 70 to 79 years. Utilization of THA varied significantly based on socioeconomic status and race. Patient sex, urban versus rural hospital location, and teaching versus nonteaching hospital status were not related to rates of THA.Rates of THA for femoral neck fractures increased between 1998 and 2010 in patients younger than 80 years, suggesting that surgeons are responding to clinical evidence supporting THA for the treatment of elderly femoral neck fractures. This is the first study to demonstrate this change and expose disparities in practice patterns over time in response to this evidence in the United States. Further research is indicated to explore the effect of socioeconomic status and race on femoral neck fracture management.

  View details for DOI 10.1177/2151458516658328

  View details for PubMedID 27551571

  View details for PubMedCentralID PMC4976740

• The Effects of Limb Elevation on Muscle Oxygen Saturation: A Near-Infrared Spectroscopy Study in Humans PM&R Palanca, A. A., Yang, A., Bishop, J. A. 2016; 8 (3): 221-224

  Abstract

  Orthopaedic and rehabilitation physicians often instruct patients to elevate a traumatized or postoperative lower extremity. Elevation is thought to improve patient comfort, as well as decrease swelling, wound complications, and the risk of compartment syndrome. Elevating a limb with increased compartment pressures, however, has been shown to reduce perfusion pressure and contribute to tissue ischemia. This investigation aims to advance our understanding of the tissue effects of limb elevation using a healthy patient model.To quantify the effects of elevation, experimentally induced ischemia, and immobilization on muscle oxygen saturation in the human leg using near-infrared spectroscopy (NIRS).Experimental crossover study.Orthopaedic Surgery research laboratory, Stanford Hospitals & Clinics.Twenty-six healthy volunteers.Using transcutaneous sensors, we measured muscle oxygen saturation of the anterior compartment of the left (control) leg at 0, 15, and 30 cm of elevation relative to the heart using NIRS. A standardized short leg splint and a thigh tourniquet inflated to 50 mmHg were then applied to the right (experimental) leg to simulate a traumatized state. NIRS measurements were then repeated, again at 0, 15, and 30 cm of elevation. Muscle oxygen saturation values at various degrees of elevation of the control and experimental limb were then compared and analyzed by the use of a crossover study design and mixed-effects regression.Muscle oxygen saturation at varying levels of elevation in both the (1) control leg and (2) experimental leg in a simulated traumatic state.Male (18) males and female (8) patients between 22 and 62 years of age (mean 29.8 years) were enrolled. Mean regional muscle oxygen saturation (rSO2) of the control limbs at 0, 15 and, 30 cm of elevation were 74.2%, 72.5%, and 70.6%, respectively, whereas mean rSO2 of the experimental limbs were 66.3%, 65.0%, and 63.3%. A statistically significant decrease of rSO2 was observed (mean 7.65%) in the experimental limbs compared with the control limbs. As elevation increased, there was a statistically significant decrease in rSO2 of 0.12% per centimeter of elevation. Elevation did not decrease the rSO2 in the experimental limb to a greater degree than in the control limb.Increasing levels of elevation in a human limb results in progressively compromised muscle oxygen saturation as measured by NIR.

  View details for DOI 10.1016/j.pmrj.2015.07.015

  View details for Web of Science ID 000372434900004

• Intraoperative Distal Femoral Fine Wire Traction to Facilitate Intramedullary Nailing of the Femur ORTHOPEDICS Githens, M., Alton, T. B., Firoozabadi, R., Bishop, J. A. 2016; 39 (2): E380–E385

  Abstract

  Many techniques have been employed to facilitate intramedullary nailing of femur fractures. Maintaining limb length during the operation can be difficult. The authors describe the use of distal femoral fine wire skeletal traction as a technique to maintain reduction while allowing intramedullary nailing of femur fractures. This technique is safe, is effective, and negates the need for a fracture table or an assistant.

  View details for DOI 10.3928/01477447-20160201-07

  View details for Web of Science ID 000377511000034

  View details for PubMedID 26881460

• The Effects of Limb Elevation on Muscle Oxygen Saturation: A Near-Infrared Spectroscopy Study in Humans. PM & R : the journal of injury, function, and rehabilitation Palanca, A. A., Yang, A., Bishop, J. A. 2016; 8 (3): 221-224

  Abstract

  Orthopaedic and rehabilitation physicians often instruct patients to elevate a traumatized or postoperative lower extremity. Elevation is thought to improve patient comfort, as well as decrease swelling, wound complications, and the risk of compartment syndrome. Elevating a limb with increased compartment pressures, however, has been shown to reduce perfusion pressure and contribute to tissue ischemia. This investigation aims to advance our understanding of the tissue effects of limb elevation using a healthy patient model.To quantify the effects of elevation, experimentally induced ischemia, and immobilization on muscle oxygen saturation in the human leg using near-infrared spectroscopy (NIRS).Experimental crossover study.Orthopaedic Surgery research laboratory, Stanford Hospitals & Clinics.Twenty-six healthy volunteers.Using transcutaneous sensors, we measured muscle oxygen saturation of the anterior compartment of the left (control) leg at 0, 15, and 30 cm of elevation relative to the heart using NIRS. A standardized short leg splint and a thigh tourniquet inflated to 50 mmHg were then applied to the right (experimental) leg to simulate a traumatized state. NIRS measurements were then repeated, again at 0, 15, and 30 cm of elevation. Muscle oxygen saturation values at various degrees of elevation of the control and experimental limb were then compared and analyzed by the use of a crossover study design and mixed-effects regression.Muscle oxygen saturation at varying levels of elevation in both the (1) control leg and (2) experimental leg in a simulated traumatic state.Male (18) males and female (8) patients between 22 and 62 years of age (mean 29.8 years) were enrolled. Mean regional muscle oxygen saturation (rSO2) of the control limbs at 0, 15 and, 30 cm of elevation were 74.2%, 72.5%, and 70.6%, respectively, whereas mean rSO2 of the experimental limbs were 66.3%, 65.0%, and 63.3%. A statistically significant decrease of rSO2 was observed (mean 7.65%) in the experimental limbs compared with the control limbs. As elevation increased, there was a statistically significant decrease in rSO2 of 0.12% per centimeter of elevation. Elevation did not decrease the rSO2 in the experimental limb to a greater degree than in the control limb.Increasing levels of elevation in a human limb results in progressively compromised muscle oxygen saturation as measured by NIR.

  View details for DOI 10.1016/j.pmrj.2015.07.015

  View details for PubMedID 26261022

• Operative Versus Nonoperative Treatment of Jones Fractures: A Decision Analysis Model. American journal of orthopedics (Belle Mead, N.J.) Bishop, J. A., Braun, H. J., Hunt, K. J. 2016; 45 (3): E69-76

  Abstract

  Optimal management of metadiaphyseal fifth metatarsal fractures (Jones fractures) remains controversial. Decision analysis can optimize clinical decision-making based on available evidence and patient preferences. We conducted a study to establish the determinants of decision-making and to determine the optimal treatment strategy for Jones fractures using a decision analysis model. Probabilities for potential outcomes of operative and nonoperative treatment of Jones fractures were determined from a review of the literature. Patient preferences for outcomes were obtained by questionnaire completed by 32 healthy adults with no history of foot fracture. Derived values were used in the model as a measure of utility. A decision tree was constructed, and fold-back and sensitivity analyses were performed to determine optimal treatment. Nonoperative treatment was associated with a value of 7.74, and operative treatment with an intramedullary screw was associated with a value of 7.88 given the outcome probabilities and utilities studied, making operative treatment the optimal strategy. When parameters were varied, nonoperative treatment was favored when the likelihood of healing with nonoperative treatment rose above 82% and when the probability of healing after surgery fell below 92%. In this decision analysis model, operative fixation is the preferred management strategy for Jones fractures.

  View details for PubMedID 26991586

• Arthroscopic Reduction and Internal Fixation of an Inferior Glenoid Fracture With Scapular Extension (Ideberg V). Arthroscopy techniques Tuman, J. M., Bishop, J. A., Abrams, G. D. 2015; 4 (6): e869-72

  Abstract

  Arthroscopic reduction and internal fixation of glenoid fractures have been well described, especially for glenoid rim (Bankart) fractures, as well as for scapular body fractures with extensions into the articular surface. This approach has the advantage of decreasing comorbidities associated with a standard open approach, but it can be technically challenging and may not be amenable to all fracture patterns. Arthroscopic fixation of scapular fractures incorporating a transverse pattern along the inferior aspect of the glenoid is particularly challenging because of difficulty in accessing this space. We detail the use of a posteroinferior arthroscopic portal for fracture reduction and hardware placement in a scapular fracture with inferior glenoid involvement.

  View details for DOI 10.1016/j.eats.2015.08.012

  View details for PubMedID 27284526

  View details for PubMedCentralID PMC4886700

• Surgical Treatment of Posterior Tibial Plateau Fractures OPERATIVE TECHNIQUES IN ORTHOPAEDICS Bishop, J., Githens, M. 2015; 25 (4): 242–47

  View details for DOI 10.1053/j.oto.2015.08.004

  View details for Web of Science ID 000437584700004

• Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States? A Survey of Orthopaedic Surgeons. Clinical orthopaedics and related research Niu, E., Yang, A., Harris, A. H., Bishop, J. 2015; 473 (11): 3647-3655

  Abstract

  The best treatment for intertrochanteric hip fractures is controversial. The use of cephalomedullary nails has increased, whereas use of sliding hip screws has decreased despite the lack of evidence that cephalomedullary nails are more effective. As current orthopaedic trainees receive less exposure to sliding hip screws, this may continue to perpetuate the preferential use of cephalomedullary nails, with important implications for resident education, evidence-based best practices, and healthcare cost.We asked: (1) What are the current practice patterns in surgical treatment of intertrochanteric fractures among orthopaedic surgeons? (2) Do surgical practice patterns differ based on surgeon characteristics, practice setting, and other factors? (3) What is the rationale behind these surgical practice patterns? (4) What postoperative approaches do surgeons use for intertrochanteric fractures?A web-based survey containing 20 questions was distributed to active members of the American Academy of Orthopaedic Surgeons. Three thousand seven-hundred eighty-six of 10,321 invited surgeons participated in the survey (37%), with a 97% completion rate (3687 of 3784 responded to all questions in the survey). The survey elicited information regarding surgeon demographics, preferred management strategies, and decision-making rationale for intertrochanteric fractures.Surgeons use cephalomedullary nails most frequently for treatment of intertrochanteric hip fractures. Sixty-eight percent primarily use cephalomedullary nails, whereas only 19% primarily use sliding hip screws, and the remaining 13% use cephalomedullary nails and sliding hip screws with equal frequency. The cephalomedullary nail was the dominant approach regardless of experience level or practice setting. Surgeons who practiced in a nonacademic setting (71% versus 58%; p < 0.001), did not supervise residents (71% versus 61%; p < 0.001), or treated more than five intertrochanteric fractures a month (78% versus 67%; p < 0.001) were more likely to use primarily cephalomedullary nails. Of the surgeons who used only cephalomedullary nails, ease of surgical technique (58%) was cited as the primary reason, whereas surgeons who used only sliding hip screws cite familiarity (44%) and improved outcomes (37%) as their primary reasons. Of those who use only short cephalomedullary nails, ease of technique (59%) was most frequently cited. Postoperatively, 67% allow the patient to bear weight as tolerated. Nearly all respondents (99.5%) use postoperative chemical thromboprophylaxis.Despite that either sliding hip screw or cephalomedullary nail fixation are associated with equivalent outcomes for most intertrochanteric femur fractures, the cephalomedullary nail has emerged as the preferred construct, with the majority of surgeons believing that a cephalomedullary nail is easier to use, associated with improved outcomes, or is biomechanically superior to a sliding hip screw. The difference between what is evidence-based and what is done in clinical practice may be attributed to several factors, including financial considerations, educational experience, or inability of our current outcomes measures to reflect the experiences of surgeons. The educators, researchers, and policymakers among us must work harder to better define the roles of sliding hip screws and cephalomedullary nails and ensure that the increasing population with hip fractures receives high-quality and economically responsible care.Level V, therapeutic study.

  View details for DOI 10.1007/s11999-015-4469-5

  View details for PubMedID 26208608

  View details for PubMedCentralID PMC4586189

• Conventional versus virtual radiographs of the injured pelvis and acetabulum SKELETAL RADIOLOGY Bishop, J. A., Rao, A. J., Pouliot, M. A., Beaulieu, C., Bellino, M. 2015; 44 (9): 1303-1308

  Abstract

  Evaluation of the fractured pelvis or acetabulum requires both standard radiographic evaluation as well as computed tomography (CT) imaging. The standard anterior-posterior (AP), Judet, and inlet and outlet views can now be simulated using data acquired during CT, decreasing patient discomfort, radiation exposure, and cost to the healthcare system. The purpose of this study is to compare the image quality of conventional radiographic views of the traumatized pelvis to virtual radiographs created from pelvic CT scans.Five patients with acetabular fractures and ten patients with pelvic ring injuries were identified using the orthopedic trauma database at our institution. These fractures were evaluated with both conventional radiographs as well as virtual radiographs generated from a CT scan. A web-based survey was created to query overall image quality and visibility of relevant anatomic structures. This survey was then administered to members of the Orthopaedic Trauma Association (OTA).Ninety-seven surgeons completed the acetabular fracture survey and 87 completed the pelvic fracture survey. Overall image quality was judged to be statistically superior for the virtual as compared to conventional images for acetabular fractures (3.15 vs. 2.98, p = 0.02), as well as pelvic ring injuries (2.21 vs. 1.45, p = 0.0001). Visibility ratings for each anatomic landmark were statistically superior with virtual images as well.Virtual radiographs of pelvic and acetabular fractures offer superior image quality, improved comfort, decreased radiation exposure, and a more cost-effective alternative to conventional radiographs.

  View details for DOI 10.1007/s00256-015-2171-z

  View details for Web of Science ID 000358329600008

• The Inadequacy of Pediatric Fracture Care Information in Emergency Medicine and Pediatric Literature and Online Resources. Journal of pediatric orthopedics Tileston, K., Bishop, J. A. 2015; 35 (7): 769-773

  Abstract

  Emergency medicine and pediatric physicians often provide initial pediatric fracture care. Therefore, basic knowledge of the various treatment options is essential. The purpose of this study was to determine the accuracy of information commonly available to these physicians in textbooks and online regarding the management of pediatric supracondylar humerus and femoral shaft fractures.The American Academy of Orthopaedic Surgeons Clinical Practice Guidelines for pediatric supracondylar humerus and femoral shaft fractures were used to assess the content of top selling emergency medicine and pediatric textbooks as well as the top returned Web sites after a Google search. Only guidelines that addressed initial patient management were included. Information provided in the texts was graded as consistent, inconsistent, or omitted.Five emergency medicine textbooks, 4 pediatric textbooks, and 5 Web sites were assessed. Overall, these resources contained a mean 31.6% (SD=32.5) complete and correct information, whereas 3.6 % of the information was incorrect or inconsistent, and 64.8% was omitted. Emergency medicine textbooks had a mean of 34.3% (SD=28.3) correct and complete recommendations, 5.7% incorrect or incomplete recommendations, and 60% omissions. Pediatric textbooks were poor in addressing any of the American Academy of Orthopaedic Surgeons guidelines with an overall mean of 7.14% (SD=18.9) complete and correct recommendations, a single incorrect/incomplete recommendation, and 91.1% omissions. Online resources had a mean of 48.6% (SD=33.1) complete and correct recommendations, 5.72% incomplete or incorrect recommendations, and 45.7% omissions.This study highlights important deficiencies in resources available to pediatric and emergency medicine physicians seeking information on pediatric fracture management. Information in emergency medicine and pediatric textbooks as well as online is variable, with both inaccuracies and omissions being common. This lack of high-quality information could compromise patient care. Resources should be committed to ensuring accurate and complete information is readily available to all physicians providing pediatric fracture care. In addition, orthopaedic surgeons should take an active role to ensure that nonorthopaedic textbooks and online resources contain complete and accurate information.Level IV.

  View details for DOI 10.1097/BPO.0000000000000357

  View details for PubMedID 25393570

• Anterolateral Versus Medial Plating of Distal Extra-articular Tibia Fractures: A Biomechanical Model ORTHOPEDICS Pirolo, J. M., Behn, A. W., Abrams, G. D., Bishop, J. A. 2015; 38 (9): E760-E765

  Abstract

  Both medial and anterolateral plate applications have been described for the treatment of distal tibia fractures, each with distinct advantages and disadvantages. The objective of this study was to compare the biomechanical properties of medial and anterolateral plating constructs used to stabilize simulated varus and valgus fracture patterns of the distal tibia. In 16 synthetic tibia models, a 45° oblique cut was made to model an Orthopedic Trauma Association type 43-A1.2 distal tibia fracture in either a varus or valgus injury pattern. Each fracture was then reduced and plated with a precontoured medial or anterolateral distal tibia plate. The specimens were biomechanically tested in axial and torsional loading, cyclic axial loading, and load to failure. For the varus fracture pattern, medial plating showed less fracture site displacement and rotation and was stiffer in both axial and torsional loading (P<.05). For the valgus fracture pattern, there was no statistically significant difference between medial and anterolateral plating. There were no significant differences between the 2 constructs for either fracture pattern with respect to ultimate load, displacement, or energy absorption in load to failure testing. When used to stabilize varus fracture patterns, medial plates showed superior biomechanical performance compared with anterolateral plates. In this application, the medial plates functioned in anti-glide mode. For valgus fracture patterns, no biomechanical differences between anterolateral and medial plating were observed. In clinical practice, surgeons should take this biomechanical evidence into account when devising a treatment strategy for fixation of distal tibia fractures.

  View details for DOI 10.3928/01477447-20150902-52

  View details for Web of Science ID 000365393600003

  View details for PubMedID 26375532

• Surgical wound closure in orthopaedic surgery: operative techniques and adjunctive treatment modalities CURRENT ORTHOPAEDIC PRACTICE Kang, J. R., Friedrich, J. B., Hanel, D. P., Barei, D. P., Bishop, J. A. 2015; 26 (4): 403–10

  View details for DOI 10.1097/BCO.0000000000000257

  View details for Web of Science ID 000217846000015

• The prevalence of sacroiliac joint degeneration in asymptomatic adults. journal of bone and joint surgery. American volume Eno, J. T., Boone, C. R., Bellino, M. J., Bishop, J. A. 2015; 97 (11): 932-936

  Abstract

  Degenerative changes of the sacroiliac joint have been implicated as a cause of lower back pain in adults. The purpose of this study was to determine the prevalence of sacroiliac joint degeneration in asymptomatic patients.Five hundred consecutive pelvic computed tomography (CT) scans, made at a tertiary-care medical center, of patients with no history of pain in the lower back or pelvic girdle were retrospectively reviewed and analyzed for degenerative changes of the sacroiliac joint. After exclusion criteria were applied, 373 CT scans (746 sacroiliac joints) were evaluated for degenerative changes. Regression analysis was used to determine the association between age and the degree of sacroiliac joint degeneration.The prevalence of sacroiliac joint degeneration was 65.1%, with substantial degeneration occurring in 30.5% of asymptomatic subjects. The prevalence steadily increased with age, with 91% of subjects in the ninth decade of life displaying degenerative changes.Radiographic evidence of sacroiliac joint degeneration is highly prevalent in the asymptomatic population and is associated with age. Caution must be exercised when attributing lower back or pelvic girdle pain to sacroiliac joint degeneration seen on imaging.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.N.01101

  View details for PubMedID 26041855

• The Prevalence of Sacroiliac Joint Degeneration in Asymptomatic Adults JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Eno, J. T., Boone, C. R., Bellino, M. J., Bishop, J. A. 2015; 97A (11): 932-936

  Abstract

  Degenerative changes of the sacroiliac joint have been implicated as a cause of lower back pain in adults. The purpose of this study was to determine the prevalence of sacroiliac joint degeneration in asymptomatic patients.Five hundred consecutive pelvic computed tomography (CT) scans, made at a tertiary-care medical center, of patients with no history of pain in the lower back or pelvic girdle were retrospectively reviewed and analyzed for degenerative changes of the sacroiliac joint. After exclusion criteria were applied, 373 CT scans (746 sacroiliac joints) were evaluated for degenerative changes. Regression analysis was used to determine the association between age and the degree of sacroiliac joint degeneration.The prevalence of sacroiliac joint degeneration was 65.1%, with substantial degeneration occurring in 30.5% of asymptomatic subjects. The prevalence steadily increased with age, with 91% of subjects in the ninth decade of life displaying degenerative changes.Radiographic evidence of sacroiliac joint degeneration is highly prevalent in the asymptomatic population and is associated with age. Caution must be exercised when attributing lower back or pelvic girdle pain to sacroiliac joint degeneration seen on imaging.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.N.01101

  View details for Web of Science ID 000363418100010

• CORR Insights ®: A dedicated research program increases the quantity and quality of orthopaedic resident publications. Clinical orthopaedics and related research Bishop, J. A. 2015; 473 (4): 1522-1523

  View details for DOI 10.1007/s11999-014-4111-y

  View details for PubMedID 25516003

  View details for PubMedCentralID PMC4353522

• Terrible Triad Elbow Fracture-Dislocation With Triceps and Flexor-Pronator Mass Avulsion ORTHOPEDICS Gajendran, V. K., Bishop, J. A. 2015; 38 (2): E143-E146

  Abstract

  Terrible triad elbow injuries, consisting of fractures of the radial head and coronoid with ulnohumeral dislocation, are challenging to treat. They require a comprehensive understanding of the complex anatomy of the elbow to effectively treat all of the pathology and create a stable, congruent joint. The authors present a case of a terrible triad injury with avulsion of the triceps and flexor-pronator mass after a low-energy fall in a young patient. Although most terrible triad fracture-dislocations can be successfully treated with coronoid fixation, radial head fixation or replacement, and repair of the lateral collateral ligament complex, this case involved a completely circumferential injury to the elbow. The coronoid and anterior capsule were disrupted anteriorly, the radial head and lateral collateral ligament complex were disrupted laterally, the triceps was disrupted posteriorly, and the flexor-pronator mass was disrupted medially. Although the authors prefer to address most terrible triad injuries through a lateral approach, they suspected a circumferential injury preoperatively and elected to use a single posterior incision to address all of the pathology conveniently. This injury required treatment of all disrupted structures, because the elbow remained unstable until the triceps and flexor-pronator mass avulsions were ultimately repaired. With any elbow fracture-dislocation, surgeons should look for evidence of additional injuries that do not fit the commonly described patterns, because they may necessitate modifications to the treatment plan. Given the relatively common complications of stiffness and instability despite modern surgical techniques, additional injuries may further compromise functional outcomes unless they are addressed properly.

  View details for DOI 10.3928/01477447-20150204-91

  View details for Web of Science ID 000352076100012

  View details for PubMedID 25665121

• Optimizing stabilization in osteoporotic ankle fractures CURRENT ORTHOPAEDIC PRACTICE Chan, J. Y., Bishop, J. A. 2015; 26 (6): 605-609

  View details for DOI 10.1097/BCO.0000000000000303

• Open Reduction and Internal Fixation Versus Total Elbow Arthroplasty for the Treatment of Geriatric Distal Humerus Fractures: A Systematic Review and Meta-Analysis JOURNAL OF ORTHOPAEDIC TRAUMA Githens, M., Yao, J., Sox, A. H., Bishop, J. 2014; 28 (8): 481-488

  Abstract

  The purpose of this systematic review and meta-analysis was to pool and analyze outcomes and complication rates in elderly patients with intraarticular distal humerus fractures being treated with either total elbow arthroplasty (TEA) or open reduction and internal fixation (ORIF) with locking plates.PubMed, Embase, and the Cochrane databases were used. The search included publications up to June 2013. Article selection was independently performed by 2 authors and disagreements were resolved by consensus.Studies meeting criteria for inclusion were observational cohort studies or randomized controlled trials evaluating functional and radiographic outcomes and complications in elderly patients treated for distal humerus fractures with either primary TEA or ORIF with locking plates. Studies with mean age <60 years, indications for TEA other than acute fracture, and those including nonlocked plates were excluded.Standardized data extraction was performed. A quality assessment tool was used to evaluate individual study methodology.Descriptive statistics for functional outcomes were reported. Meta-analysis and regression analysis were performed for complication rates.A systematic review and meta-analysis revealed that TEA and ORIF for the treatment of geriatric distal humerus fractures produced similar functional outcome scores and range of motion. Although there was a trend toward a higher rate of major complications and reoperation after ORIF, this was not statistically significant. The quality of study methodology was generally weak. Ongoing research including prospective trials and cost analysis is indicated to better define the roles of ORIF versus TEA in the management of these injuries.

  View details for Web of Science ID 000340149400019

• Fabrication, vascularization and osteogenic properties of a novel synthetic biomimetic induced membrane for the treatment of large bone defects. Bone Ren, L., Kang, Y., Browne, C., Bishop, J., Yang, Y. 2014; 64: 173-182

  Abstract

  The induced membrane has been widely used in the treatment of large bone defects but continues to be limited by a relatively lengthy healing process and a requisite two stage surgical procedure. Here we report the development and characterization of a synthetic biomimetic induced membrane (BIM) consisting of an inner highly pre-vascularized cell sheet and an outer osteogenic layer using cell sheet engineering. The pre-vascularized inner layer was formed by seeding human umbilical vein endothelial cells (HUVECs) on a cell sheet comprised of a layer of undifferentiated human bone marrow-derived mesenchymal stem cells (hMSCs). The outer osteogenic layer was formed by inducing osteogenic differentiation of hMSCs. In vitro results indicated that the undifferentiated hMSC cell sheet facilitated the alignment of HUVECs and significantly promoted the formation of vascular-like networks. Furthermore, seeded HUVECs rearranged the extracellular matrix produced by hMSC sheet. After subcutaneous implantation, the composite constructs showed rapid vascularization and anastomosis with the host vascular system, forming functional blood vessels in vivo. Osteogenic potential of the BIM was evidenced by immunohistochemistry staining of osteocalcin, tartrate-resistant acid phosphatase (TRAP) staining, and alizarin red staining. In summary, the synthetic BIM showed rapid vascularization, significant anastomoses, and osteogenic potential in vivo. This synthetic BIM has the potential for treatment of large bone defects in the absence of infection.

  View details for DOI 10.1016/j.bone.2014.04.011

  View details for PubMedID 24747351

• Fabrication, vascularization and osteogenic properties of a novel synthetic biomimetic induced membrane for the treatment of large bone defects. Bone Ren, L., Kang, Y., Browne, C., Bishop, J., Yang, Y. 2014; 64: 173-182

  View details for DOI 10.1016/j.bone.2014.04.011

  View details for PubMedID 24747351

• Delayed union and nonunions: Epidemiology, clinical issues, and financial aspects INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED Hak, D. J., Fitzpatrick, D., Bishop, J. A., Marsh, J. L., Tilp, S., Schnettler, R., Simpson, H., Alt, V. 2014; 45: S3-S7

  Abstract

  Fracture healing is a critically important clinical event for fracture patients and for clinicians who take care of them. The clinical evaluation of fracture healing is based on both radiographic findings and clinical findings. Risk factors for delayed union and nonunion include patient dependent factors such as advanced age, medical comorbidities, smoking, non-steroidal anti-inflammatory use, various genetic disorders, metabolic disease and nutritional deficiency. Patient independent factors include fracture pattern, location, and displacement, severity of soft tissue injury, degree of bone loss, quality of surgical treatment and presence of infection. Established nonunions can be characterised in terms of biologic capacity, deformity, presence or absence of infection, and host status. Hypertrophic, oligotrophic and atrophic radiographic appearances allow the clinician to make inferences about the degree of fracture stability and the biologic viability of the fracture fragments while developing a treatment plan. Non-unions are difficult to treat and have a high financial impact. Indirect costs, such as productivity losses, are the key driver for the overall costs in fracture and non-union patients. Therefore, all strategies that help to reduce healing time with faster resumption of work and activities not only improve medical outcome for the patient, they also help reduce the financial burden in fracture and non-union patients.

  View details for DOI 10.1016/j.injury.2014.04.002

  View details for Web of Science ID 000343236400002

  View details for PubMedID 24857025

• Lack of Proficiency in Musculoskeletal Medicine Among Emergency Medicine Physicians JOURNAL OF ORTHOPAEDIC TRAUMA Comer, G. C., Liang, E., Bishop, J. A. 2014; 28 (4): E85-E87

  Abstract

  Emergency medicine (EM) physicians are frequently responsible for evaluating and treating patients with urgent or emergent musculoskeletal conditions, so it is critical that they achieve a basic level of proficiency in musculoskeletal medicine. However, inadequacies in musculoskeletal education have previously been documented among medical students, residents, and attending physicians in a number of specialties. The goal of this study was to assess the proficiency with musculoskeletal medicine among EM physicians in particular.A validated musculoskeletal medicine competency examination was administered to the EM residents and faculty at a university-affiliated level 1 trauma center. Demographic data and satisfaction with musculoskeletal education were also surveyed.Twenty-three EM residents and 21 attending physicians completed the survey. Thirty-five percent of residents and 43% of attending physicians failed to demonstrate proficiency on the examination. Pass rates were not significantly different among junior residents, senior residents, or attending physicians. Twenty-three percent of respondents indicated that they were dissatisfied with their musculoskeletal education.Significant deficiencies in musculoskeletal education exist among EM physicians in training and attending staff. Given the frequency with which these physicians evaluate and treat acute musculoskeletal conditions, additional resources should be committed to their training.

  View details for DOI 10.1097/BOT.0b013e3182a66829

  View details for Web of Science ID 000333153200004

  View details for PubMedID 23899765

• The Biomechanical Significance of Washer Use With Screw Fixation JOURNAL OF ORTHOPAEDIC TRAUMA Bishop, J. A., Behn, A. W., Castillo, T. N. 2014; 28 (2): 114-117

  Abstract

  OBJECTIVES:: Washers can be used with lag screws during fracture fixation to optimize compression and minimize the risk of unintentional intrusion of the screw head through cortical bone during screw insertion. The concept of using washers to optimize screw fixation is particularly applicable to iliosacral screw fixation as well as screw fixation of the femoral neck, distal femur, proximal and distal tibia. However, there is a paucity of literature on this topic. The purpose of this study was to detail the biomechanical consequences of washer use and screw intrusion. METHODS:: Partially threaded 7.0 mm cannulated screws with and without washers were placed through synthetic bone blocks fabricated to simulate cortical and cancellous bone. A load cell was used to measure the compressive force before and after screw intrusion. Screws were tested with a washer (N=8), without a washer (N=8), and with a washer after initially being intruded (N=8). RESULTS:: Screws inserted with washers generated significantly more compressive force than screws inserted without washers before screw intrusion. After intrusion, compressive force decreased significantly under all conditions, but screws inserted with washers maintained greater compressive force than screws inserted without washers. Screws with washers reinserted after intrusion without a washer, produced almost as much compressive force as screws inserted with washers primarily. CONCLUSIONS:: Screw intrusion during fracture fixation results in a loss of compressive force that may compromise fixation quality. Washers are advantageous in that they allow for more compression to be generated before intrusion occurs and can be used to salvage compressive force of intruded screws.

  View details for Web of Science ID 000331197000014

  View details for PubMedID 23782961

• Survey Finds Few Orthopedic Surgeons Know The Costs Of The Devices They Implant HEALTH AFFAIRS Okike, K., O'Toole, R. V., Pollak, A. N., Bishop, J. A., McAndrew, C. M., Mehta, S., Cross, W. W., Garrigues, G. E., Harris, M. B., Lebrun, C. T. 2014; 33 (1): 103-109

  Abstract

  Orthopedic procedures represent a large expense to the Medicare program, and costs of implantable medical devices account for a large proportion of those procedures' costs. Physicians have been encouraged to consider cost in the selection of devices, but several factors make acquiring cost information difficult. To assess physicians' levels of knowledge about costs, we asked orthopedic attending physicians and residents at seven academic medical centers to estimate the costs of thirteen commonly used orthopedic devices between December 2012 and March 2013. The actual cost of each device was determined at each institution; estimates within 20 percent of the actual cost were considered correct. Among the 503 physicians who completed our survey, attending physicians correctly estimated the cost of the device 21 percent of the time, and residents did so 17 percent of the time. Thirty-six percent of physicians and 75 percent of residents rated their knowledge of device costs "below average" or "poor." However, more than 80 percent of all respondents indicated that cost should be "moderately," "very," or "extremely" important in the device selection process. Surgeons need increased access to information on the relative prices of devices and should be incentivized to participate in cost containment efforts.

  View details for DOI 10.1377/hlthaff.2013.0453

  View details for Web of Science ID 000330289300014

  View details for PubMedID 24395941

• The posterior approach to pelvic ring injuries: A technique for minimizing soft tissue complications INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED Fowler, T. T., Bishop, J. A., Bellino, M. J. 2013; 44 (12): 1780-1786

  Abstract

  Surgical techniques and fixation strategies for the treatment of unstable posterior pelvic ring injuries continue to evolve. The safety of the posterior surgical approach in particular has been questioned due to historically high rates of wound related complications. More contemporary studies have shown lower infection rates, however concern still persists. These concerns for infection and wound necrosis have led, in part, to increased interest in closed reduction and percutaneous fixation for treatment of these injuries but an open posterior approach remains the optimal strategy in some injury patterns. We describe herein a modified posterior approach to the pelvis designed to minimize wound related complications and present our clinical results demonstrating wound complication rates consistent with contemporary publications.

  View details for DOI 10.1016/j.injury.2013.08.005

  View details for Web of Science ID 000326376500016

  View details for PubMedID 24011422

• Surgical versus nonsurgical treatment of femur fractures in people with spinal cord injury: an administrative analysis of risks. Archives of physical medicine and rehabilitation Bishop, J. A., Suarez, P., DiPonio, L., Ota, D., Curtin, C. M. 2013; 94 (12): 2357-2364

  Abstract

  To assess the risks associated with surgical and nonsurgical care of femur fractures in people with spinal cord injury (SCI).Retrospective cohort study; an analysis of Veterans Affairs (VA) data from the National Patient Care Database.Administrative data from database.The cohort was identified by searching the administrative data from fiscal years 2001 to 2006 for veterans with a femur fracture diagnosis using the International Classification of Diseases, 9th Revision, Clinical Modification codes. This group was subdivided into those with (n=396) and without (n=13,350) SCI and those treated with and without surgical intervention.Not applicable.Rates of mortality and adverse events.The SCI group was younger with more distal fractures than the non-SCI group. In the non-SCI population, 78% of patients had associated surgical codes compared with 37% in the SCI population. There was higher mortality in the non-SCI group treated nonoperatively. In the SCI population, there was no difference in mortality between patients treated nonoperatively and operatively. Overall adverse events were similar between groups except for pressure sores in the SCI population, of which the nonoperative group had 20% and the operative had 7%. Rates of surgical interventions for those with SCI varied greatly among VA institutions.We found lower rates of surgical intervention in the SCI population. Those with SCI who had surgery did not have increased mortality or adverse events. Surgical treatment minimizes the risks of immobilization and should be considered in appropriate SCI patients.

  View details for DOI 10.1016/j.apmr.2013.07.024

  View details for PubMedID 23948614

• Synthesis and characterization of novel elastomeric poly(D,L-lactide urethane) maleate composites for bone tissue engineering EUROPEAN POLYMER JOURNAL Mercado-Pagan, A. E., Kang, Y., Ker, D. F., Park, S., Yao, J., Bishop, J., Yang, Y. P. 2013; 49 (10): 3337-3349

  Abstract

  Here, we report the synthesis and characterization of a novel 4-arm poly(lactic acid urethane)-maleate (4PLAUMA) elastomer and its composites with nano-hydroxyapatite (nHA) as potential weight-bearing composite. The 4PLAUMA/nHA ratios of the composites were 1:3, 2:5, 1:2 and 1:1. FTIR and NMR characterization showed urethane and maleate units integrated into the PLA matrix. Energy dispersion and Auger electron spectroscopy confirmed homogeneous distribution of nHA in the polymer matrix. Maximum moduli and strength of the composites of 4PLAUMA/nHA, respectively, are 1973.31 ± 298.53 MPa and 78.10 ± 3.82 MPa for compression, 3630.46 ± 528.32 MPa and 6.23 ± 1.44 MPa for tension, 1810.42 ± 86.10 MPa and 13.00 ± 0.72 for bending, and 282.46 ± 24.91 MPa and 5.20 ± 0.85 MPa for torsion. The maximum tensile strains of the polymer and composites are in the range of 5% to 93%, and their maximum torsional strains vary from 0.26 to 0.90. The composites exhibited very slow degradation rates in aqueous solution, from approximately 50% mass remaining for the pure polymer to 75% mass remaining for composites with high nHA contents, after a period of 8 weeks. Increase in ceramic content increased mechanical properties, but decreased maximum strain, degradation rate, and swelling of the composites. Human bone marrow stem cells and human endothelial cells adhered and proliferated on 4PLAUMA films and degradation products of the composites showed little-to-no toxicity. These results demonstrate that novel 4-arm poly(lactic acid urethane)-maleate (4PLAUMA) elastomer and its nHA composites may have potential applications in regenerative medicine.

  View details for DOI 10.1016/j.eurpolymj.2013.07.004

  View details for Web of Science ID 000325233800049

  View details for PubMedCentralID PMC4012890

• Provisional mini-fragment plate fixation in clavicle shaft fractures. American journal of orthopedics (Belle Mead, N.J.) Bishop, J. A., Castillo, T. N. 2013; 42 (10): 470-472

  Abstract

  Plate fixation has an increasingly prominent role in the management of select clavicle fractures. However, many fracture patterns are not easily reduced and provisionally stabilized with conventional clamp application and lag-screw placement, and maintaining an appropriate reduction can be a challenge. In this article, we present a technique in which a mini-fragment plate is used to provisionally maintain fracture reduction while the definitive plate is applied.

  View details for PubMedID 24278907

• Antegrade Femoral Nailing in Acetabular Fractures Requiring a Kocher-Langenbeck Approach ORTHOPEDICS Bishop, J. A., Cross, W. W., Krieg, J. C., Routt, M. L. 2013; 36 (9): E1159-E1164

  Abstract

  Ipsilateral displaced acetabular and femoral shaft fractures represent a dilemma for orthopedic surgeons because antegrade femoral nailing may complicate a Kocher-Langenbeck acetabular exposure. The goals of this study were to review the results of ipsilateral femoral and acetabular fractures treated with antegrade femoral nailing and a Kocher-Langenbeck approach and to evaluate the assertion that this treatment strategy is associated with increased morbidity. This was a retrospective cohort study at a regional Level I trauma center. Sixteen patients with a femoral fracture treated with antegrade nailing and an ipsilateral acetabular fracture treated with a Kocher-Langenbeck approach were identified. One patient died as a result of his injuries, and 2 were not available for long-term follow-up. One had a deep infection requiring irrigation, debridement, and intraveonous antibiotics. One patient developed a hematoma requiring irrigation and debridement. At final follow-up, 2 patients had no heterotopic ossification about the hip, 4 had Brooker class I heterotopic ossification, 3 had Brooker class II heterotopic ossification, 2 had Brooker class III heterotopic ossification, and 2 patients had Brooker class IV heterotopic ossification requiring excision. Ipsilateral femoral and acetabular fractures represent a rare and severe injury constellation. Antegrade nailing of the femur with ipsilateral Kocher-Langenbeck exposure for fixation of the acetabulum was not associated with excessive rates of wound-healing complications, but the incidence of heterotopic ossification was increased.

  View details for DOI 10.3928/01477447-20130821-18

  View details for Web of Science ID 000325553500009

• The effect of rhBMP-2 and PRP delivery by biodegradable beta-tricalcium phosphate scaffolds on new bone formation in a non-through rabbit cranial defect model JOURNAL OF MATERIALS SCIENCE-MATERIALS IN MEDICINE Lim, H., Mercado-Pagan, A. E., Yun, K., Kang, S., Choi, T., Bishop, J., Koh, J., Maloney, W., Lee, K., Yang, Y. P., Park, S. 2013; 24 (8): 1895-1903

  Abstract

  This study evaluated whether the combination of biodegradable β-tricalcium phosphate (β-TCP) scaffolds with recombinant human bone morphogenetic protein-2 (rhBMP-2) or platelet-rich plasma (PRP) could accelerate bone formation and increase bone height using a rabbit non-through cranial bone defect model. Four non-through cylindrical bone defects with a diameter of 8-mm were surgically created on the cranium of rabbits. β-TCP scaffolds in the presence and absence of impregnated rhBMP-2 or PRP were placed into the defects. At 8 and 16 weeks after implantation, samples were dissected and fixed for analysis by microcomputed tomography and histology. Only defects with rhBMP-2 impregnated β-TCP scaffolds showed significantly enhanced bone formation compared to non-impregnated β-TCP scaffolds (P < 0.05). Although new bone was higher than adjacent bone at 8 weeks after implantation, vertical bone augmentation was not observed at 16 weeks after implantation, probably due to scaffold resorption occurring concurrently with new bone formation.

  View details for DOI 10.1007/s10856-013-4939-9

  View details for Web of Science ID 000321915300008

  View details for PubMedID 23779152

• Cost-Effectiveness Analysis of Primary Arthroscopic Stabilization Versus Nonoperative Treatment for First-Time Anterior Glenohumeral Dislocations ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Crall, T. S., Bishop, J. A., Guttman, D., Kocher, M., Bozic, K., Lubowitz, J. H. 2012; 28 (12): 1755-1765

  Abstract

  The purpose of this study was to compare the cost-effectiveness of initial observation versus surgery for first-time anterior shoulder dislocation.The clinical scenario of first-time anterior glenohumeral dislocation was simulated using a Markov model (where variables change over time depending on previous states). Nonoperative outcomes include success (no recurrence) and recurrence; surgical outcomes include success, recurrence, and complications of infection or stiffness. Probabilities for outcomes were determined from published literature. Costs were tabulated from Medicare Current Procedural Terminology data, as well as hospital and office billing records. We performed microsimulation and probabilistic sensitivity analysis running 6 models for 1,000 patients over a period of 15 years. The 6 models tested were male versus female patients aged 15 years versus 25 years versus 35 years.Primary surgery was less costly and more effective for 15-year-old boys, 15-year-old girls, and 25-year-old men. For the remaining scenarios (25-year-old women and 35-year-old men and women), primary surgery was also more effective but was more costly. However, for these scenarios, primary surgery was still very cost-effective (cost per quality-adjusted life-year, <$25,000). After 1 recurrence, surgery was less costly and more effective for all scenarios.Primary arthroscopic stabilization is a clinically effective and cost-effective treatment for first-time anterior shoulder dislocations in the cohorts studied. By use of a willingness-to-pay threshold of $25,000 per quality-adjusted life-year, surgery was more cost-effective than nonoperative treatment for the majority of patients studied in the model.Level II, economic and decision analysis.

  View details for DOI 10.1016/j.arthro.2012.05.885

  View details for Web of Science ID 000311751500008

  View details for PubMedID 23040837

• Open Reduction and Intramedullary Nail Fixation of Closed Tibial Fractures ORTHOPEDICS Bishop, J. A., Dikos, G. D., Mickelson, D., Barei, D. P. 2012; 35 (11): E1631-E1634

  Abstract

  Some tibial shaft fractures cannot be accurately reduced using closed or percutaneous techniques during an intramedullary nailing procedure. Under these circumstances, a formal open reduction can be performed. Direct exposure of the fracture facilitates accurate reduction but does violate the soft tissue envelope. The purpose of this study was to evaluate the safety and efficacy of open reduction prior to intramedullary nailing. Using the trauma database at a Level I trauma center, 11 uncomplicated closed displaced tibia fractures treated with formal open reduction prior to intramedullary nailing were identified and matched with a cohort of 21 fractures treated with closed reduction and nailing. The authors attempted to match 2 controls to each patient to improve the power of the study. Clinical and radiographic outcomes were compared. All fractures ultimately healed within 5° of anatomic alignment. No infections or non-unions occurred in the open reduction group, and 1 deep infection and 1 nonunion occurred in the closed reduction group. No significant differences existed between the study groups. Although closed reduction and intramedullary nailing remains the treatment of choice for most significantly displaced tibial shaft fractures, open reduction with respectful handling of the soft tissue envelope can be safe and effective and should be considered when less invasive techniques are unsuccessful.

  View details for DOI 10.3928/01477447-20121023-21

  View details for Web of Science ID 000311031900010

  View details for PubMedID 23127455

• Predictive factors for knee stiffness after periarticular fracture: a case-control study. journal of bone and joint surgery. American volume Bishop, J., Agel, J., Dunbar, R. 2012; 94 (20): 1833-1838

  Abstract

  Knee stiffness is an important complication after periarticular fracture, but a systematic evaluation of risk factors for this complication and outcomes of treatment has not been undertaken, to our knowledge. The aims of this study were to evaluate risk factors for knee stiffness requiring manipulation after periarticular fracture and to document the clinical outcomes of the manipulation.This study was designed as a case-control study in which patients requiring manipulation under anesthesia after periarticular fracture were compared with those who did not require manipulation. Using billing data from a regional level-I trauma center, we identified twenty-four knees requiring manipulation for refractory stiffness over a six-year period. These were matched, on the basis of the AO/OTA classification, with forty-three control knees that did not develop stiffness requiring manipulation. Descriptive statistics were used for frequency and mean analysis.Univariate analysis revealed that extensor mechanism disruption (chi square = 0.05), fasciotomy (chi square = 0.020), wounds requiring ongoing management and precluding knee motion (p = 0.001), and the need for more than two surgical procedures to achieve definitive fracture fixation and soft-tissue coverage (p = 0.003) all placed patients at increased risk for knee stiffness requiring manipulation. The mean improvement in knee motion following all procedures targeting knee stiffness was 62°. Mean final flexion was significantly less in the case group (107°) compared with the control group (124°; p=0.01).To our knowledge, this is the first study to systematically evaluate the risk factors for knee stiffness after periarticular fracture and document the outcomes of manipulation under anesthesia. It demonstrates that injury characteristics that delay or prevent postoperative knee motion place patients at increased risk for refractory knee stiffness. Although knee motion remains compromised, late surgery aimed at improving knee motion leads to improvements in flexion

  View details for PubMedID 23243676

• Predictive Factors for Knee Stiffness After Periarticular Fracture A Case-Control Study JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Bishop, J., Agel, J., Dunbar, R. 2012; 94A (20): 1833-1838

  Abstract

  Knee stiffness is an important complication after periarticular fracture, but a systematic evaluation of risk factors for this complication and outcomes of treatment has not been undertaken, to our knowledge. The aims of this study were to evaluate risk factors for knee stiffness requiring manipulation after periarticular fracture and to document the clinical outcomes of the manipulation.This study was designed as a case-control study in which patients requiring manipulation under anesthesia after periarticular fracture were compared with those who did not require manipulation. Using billing data from a regional level-I trauma center, we identified twenty-four knees requiring manipulation for refractory stiffness over a six-year period. These were matched, on the basis of the AO/OTA classification, with forty-three control knees that did not develop stiffness requiring manipulation. Descriptive statistics were used for frequency and mean analysis.Univariate analysis revealed that extensor mechanism disruption (chi square = 0.05), fasciotomy (chi square = 0.020), wounds requiring ongoing management and precluding knee motion (p = 0.001), and the need for more than two surgical procedures to achieve definitive fracture fixation and soft-tissue coverage (p = 0.003) all placed patients at increased risk for knee stiffness requiring manipulation. The mean improvement in knee motion following all procedures targeting knee stiffness was 62°. Mean final flexion was significantly less in the case group (107°) compared with the control group (124°; p=0.01).To our knowledge, this is the first study to systematically evaluate the risk factors for knee stiffness after periarticular fracture and document the outcomes of manipulation under anesthesia. It demonstrates that injury characteristics that delay or prevent postoperative knee motion place patients at increased risk for refractory knee stiffness. Although knee motion remains compromised, late surgery aimed at improving knee motion leads to improvements in flexion

  View details for DOI 10.2106/JBJS.K.00659

  View details for Web of Science ID 000310416700002

• The osteogenic differentiation of human bone marrow MSCs on HUVEC-derived ECM and beta-TCP scaffold BIOMATERIALS Kang, Y., Kim, S., Bishop, J., Khademhosseini, A., Yang, Y. 2012; 33 (29): 6998-7007

  Abstract

  Extracellular matrix (ECM) serves a key role in cell migration, attachment, and cell development. Here we report that ECM derived from human umbilical vein endothelial cells (HUVEC) promoted osteogenic differentiation of human bone marrow mesenchymal stem cells (hMSC). We first produced an HUVEC-derived ECM on a three-dimensional (3D) beta-tricalcium phosphate (β-TCP) scaffold by HUVEC seeding, incubation, and decellularization. The HUVEC-derived ECM was then characterized by SEM, FTIR, XPS, and immunofluorescence staining. The effect of HUVEC-derived ECM-containing β-TCP scaffold on hMSC osteogenic differentiation was subsequently examined. SEM images indicate a dense matrix layer deposited on the surface of struts and pore walls. FTIR and XPS measurements show the presence of new functional groups (amide and hydroxyl groups) and elements (C and N) in the ECM/β-TCP scaffold when compared to the β-TCP scaffold alone. Immunofluorescence images indicate that high levels of fibronectin and collagen IV and low level of laminin were present on the scaffold. ECM-containing β-TCP scaffolds significantly increased alkaline phosphatase (ALP) specific activity and up-regulated expression of osteogenesis-related genes such as runx2, alkaline phosphatase, osteopontin and osteocalcin in hMSC, compared to β-TCP scaffolds alone. This increased effect was due to the activation of MAPK/ERK signaling pathway since disruption of this pathway using an ERK inhibitor PD98059 results in down-regulation of these osteogenic genes. Cell-derived ECM-containing calcium phosphate scaffolds is a promising osteogenic-promoting bone void filler in bone tissue regeneration.

  View details for DOI 10.1016/j.biomaterials.2012.06.061

  View details for Web of Science ID 000308269600010

  View details for PubMedID 22795852

  View details for PubMedCentralID PMC3427692

• Use of an Inflatable Pressure Bag Bump for Medial and Lateral Operative Approaches to the Lower Leg FOOT & ANKLE INTERNATIONAL Abrams, G. D., Bishop, J. A. 2012; 33 (9): 795-797

  View details for DOI 10.3113/FAI.2012.0795

  View details for Web of Science ID 000308273000019

  View details for PubMedID 22995270

• Osseous fixation pathways in pelvic and acetabular fracture surgery: Osteology, radiology, and clinical applications JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Bishop, J. A., Routt, M. L. 2012; 72 (6): 1502-1509

  View details for DOI 10.1097/TA.0b013e318246efe5

  View details for Web of Science ID 000305422900012

  View details for PubMedID 22695413

• Assessment of Compromised Fracture Healing JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Bishop, J. A., Palanca, A. A., Bellino, M. J., Lowenberg, D. W. 2012; 20 (5): 273-282

  Abstract

  No standard criteria exist for diagnosing fracture nonunion, and studies suggest that assessment of fracture healing varies among orthopaedic surgeons. This variability can be problematic in both clinical and orthopaedic trauma research settings. An understanding of risk factors for nonunion and of diagnostic tests used to assess fracture healing can facilitate a systematic approach to evaluation and management. Risk factors for nonunion include medical comorbidities, age, and the characteristics of the injury. The method of fracture management also influences healing. Comprehensive evaluation includes an assessment of the patient's symptoms, signs, and immune and endocrine status as well as the biologic capacity of the fracture, presence of infection, and quality of reduction and fixation. Diagnostic tests include plain radiography, CT, ultrasonography, fluoroscopy, bone scan, MRI, and several laboratory tests, including assays for bone turnover markers in the peripheral circulation. A systematic approach to evaluating fracture union can help surgeons determine the timing and nature of interventions.

  View details for DOI 10.5435/JAAOS-20-05-273

  View details for PubMedID 22553099

• Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis JOURNAL OF SHOULDER AND ELBOW SURGERY Bishop, J. A., Crall, T. S., Kocher, M. S. 2011; 20 (7): 1087-1094

  Abstract

  The optimal management strategy for primary traumatic anterior glenohumeral dislocation remains controversial. Patients have traditionally been managed nonoperatively, but high recurrence rates in certain populations have led to increased interest in early operative stabilization. The purpose of this study was to use expected-value decision analysis to determine the optimal management strategy--nonoperative treatment or arthroscopic stabilization--for a first-time traumatic anterior shoulder dislocation.Probabilities for the occurrences of the potential outcomes after nonoperative and arthroscopic treatment of a first-time traumatic anterior glenohumeral dislocation were determined from a systematic review of the literature. Utilities for these outcomes were obtained from a questionnaire on patient preferences completed by 42 subjects without a history of shoulder injury. A decision tree was constructed, fold-back analysis was performed to determine optimal management, and sensitivity analyses were used to determine the effect on decision making of varying outcome probabilities and utilities.Nonoperative treatment was associated with a utility value of 5.9 and early arthroscopic surgery with a value of 7.6. On sensitivity analysis, it was found that when the rate of recurrence after nonoperative treatment falls below 32% or when the utility value for successful arthroscopic stabilization falls below 6.6, nonoperative treatment is the preferred management strategy.Arthroscopic stabilization was the preferred strategy after a primary anterior glenohumeral dislocation. In clinical settings where the likelihood of recurrent instability is low after nonoperative care or when an informed patient has an aversion to surgery, nonoperative treatment may be the preferred treatment strategy.

  View details for DOI 10.1016/j.jse.2011.01.031

  View details for Web of Science ID 000296386600015

  View details for PubMedID 21530321

• Closed Intramedullary Nailing of the Femur in the Lateral Decubitus Position JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Bishop, J. A., Rodriguez, E. K. 2010; 68 (1): 231-235

  Abstract

  Closed intramedullary nailing is the standard of care for femoral shaft fractures and the technique now has broader applications with the proliferation of cephalomedullary instrumentation for the treatment of intertrochanteric and subtrochanteric femur fractures. Nailing in the lateral decubitus position has several advantages, but we are unaware of a detailed, contemporary description of the surgical technique published in the English language literature.A retrospective review of 158 patients treated with intramedullary nailing in the lateral position by a single surgeon over a 3-year period was performed. Clinical and radiographic outcomes were evaluated. In a group of 58 diaphyseal femur fractures, there were three rotational malreductions and one limb length discrepancy that required operative intervention. All but one were recognized and corrected intraoperatively on placing the patient supine. In a group of 100 primarily geriatric intertrochanteric, subtrochanteric, or peritrochatneric fractures managed with a cephalomedullary device, there were two lag screw cutouts, one nonunion, and one hardware failure. All of these required revision surgery. There were no rotational or length malreductions that required correction. There were no injuries to the perineum or contralateral leg, nerve palsies, or traction-related complications. Lateral positioning obviates the need for a fracture table, makes it easier to establish a starting point for an intramedullary device, and facilitates conversion to an open procedure without repositioning should this become necessary. This study demonstrates that the technique is safe and effective with an incidence of complications comparable with fracture table and supine positioning.

  View details for DOI 10.1097/TA.0b013e3181c488d8

  View details for Web of Science ID 000273585800045

  View details for PubMedID 20065779

• Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model. journal of hand surgery Bishop, J., Ring, D. 2009; 34 (6): 991-6 e1

  Abstract

  When managing radial nerve palsy associated with a humerus fracture, both surgeon and patient must balance the risks and benefits of performing an invasive surgical procedure to address a functional deficit that is likely, but not certain, to recover with nonsurgical management. The purpose of this study was to better understand the determinants of optimal management strategy using expected-value decision analysis.Probabilities for the occurrences of the potential outcomes after initial observation or early surgery were determined from a systematic review of the literature. Scores for these outcomes were obtained from a questionnaire on patient preferences completed by 82 subjects without a history of humerus fracture and radial nerve palsy and used in the model as a measure of utility. A decision tree was constructed, fold-back analysis was performed to determine optimal treatment, and sensitivity analyses were used to determine the effect on decision making of varying outcome probabilities and utilities.Observation was associated with a value of 8.4 and early surgery a value of 6.7 given the outcome probabilities and utilities studied in this model, making observation the optimal management strategy. When parameters were varied in sensitivity analysis, it was noted that when the rate of recovery after initial observation falls below 40% or when the utility value for successful early surgery rises above 9.4, early surgery is the preferred management strategy.Initial observation was the preferred strategy. In clinical settings in which the likelihood of spontaneous recovery of nerve function is low or when an informed patient has a strong preference for surgery, early surgery may optimize outcome.Economic and Decision Analysis II.

  View details for DOI 10.1016/j.jhsa.2008.12.029

  View details for PubMedID 19361935

• Locking plate fixation for pediatric femur fractures JOURNAL OF PEDIATRIC ORTHOPAEDICS Hedequist, D., Bishop, J., Hresko, T. 2008; 28 (1): 6-9

  Abstract

  The use of locking plates for pediatric femur fractures has not been studied. Locking plate applications for fractures associated with comminution, osteopenia, or minimal bone available for purchase have been well studied in the adult trauma population.We conducted a retrospective review of children at our institution treated with a locking plate for a femur fracture. We identified 32 patients treated at an average age of 11 years (6-15 years of age). Locking plates were chosen for comminution in 13 patients, nonmalignant pathologic fracture in 9 patients, fracture location in 7 patients, and osteopenia in 3 patients. All patients were treated with a locking plate and followed up until definitive radiologic union.There were no intraoperative complications related to this technology. All patients were healed with near-anatomic alignment with the exception of 1 patient who had valgus malalignment of 12 degrees, which was of no clinical concern and required no intervention. Seven patients had the plates removed with no noted complications.Locking plates are a safe and effective treatment for children and adolescents with femur fractures that may not be amenable to other current means of stabilization.

  View details for Web of Science ID 000255766600002

  View details for PubMedID 18157038

• Prophylactic pinning of the contralateral hip after unilateral slipped capital femoral epiphysis JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Kocher, M. S., Bishop, J. A., Hresko, M. T., Millis, M. B., Kim, Y. J., Kasser, J. R. 2004; 86A (12): 2658-2665

  Abstract

  The management of the contralateral hip after unilateral slipped capital femoral epiphysis is controversial. The purpose of this study was to determine, with use of expected-value decision analysis, the optimal management strategy-prophylactic in situ pinning versus observation-for the contralateral hip.Outcome probabilities were determined from a systematic review of the literature. Utility values were obtained from a questionnaire on patient preferences completed with use of a visual analog scale by twenty-five adolescent male patients without slipped capital femoral epiphysis. A decision tree was constructed, fold-back analysis was performed to determine the optimal treatment, and one and two-way sensitivity analyses were performed to determine the effect on decision-making of varying outcome probabilities and utilities.Observation was the optimal management strategy for the contralateral hip given the outcome probabilities and utilities that we studied (the expected value was 9.5 for observation and 9.2 for prophylactic in situ pinning, with a marginal value of 0.3). Increased rates of a late second slip favored prophylactic in situ pinning (the threshold probability was 27%). Risk-taking patients with a high utility for uncomplicated prophylactic in situ pinning favored prophylaxis (the threshold utility was 9.8).The iatrogenic risks of treating a healthy patient or an uninvolved body part rarely outweigh the potential benefits unless the probability of the adverse event is likely and the consequences of the adverse event are very severe. In this decision analysis, the optimal decision was observation. In cases where the probability of contralateral slipped capital femoral epiphysis exceeds 27% or in cases where reliable follow-up is not feasible, pinning of the contralateral hip is favored. For a given individual patient, the optimal strategy depends not only on probabilities of the various outcomes but also on personal preference. Thus, we advocate a model of doctor-patient shared decision-making in which both the outcome probabilities and the patient preferences are considered in order to optimize the decision-making process.Economic and decision analysis, Level III-1 (limited alternatives and costs; poor estimates). See Instructions to Authors for a complete description of levels of evidence.

  View details for Web of Science ID 000225719700011

• Delay in diagnosis of slipped capital femoral epiphysis PEDIATRICS Kocher, M. S., Bishop, J. A., Weed, B., Hresko, M. T., Millis, M. B., Kim, Y. J., Kasser, J. R. 2004; 113 (4): E322-E325

  Abstract

  Delay in diagnosis of slipped capital femoral epiphysis (SCFE) has important implications in terms of slip severity and long-term hip outcome. The purpose of this study was to identify predictors of delay in the diagnosis of SCFE.A review of 196 patients with SCFE was performed. The primary outcome measure was delay from onset of symptoms to diagnosis. Covariates included age, gender, side, weight, pain location, insurance status, family income, slip severity, and slip stability. Delay in diagnosis was not normal in distribution; therefore, nonparametric univariate and multivariate analyses were performed.The median delay in diagnosis was 8.0 weeks. There was a significant relationship between delay in diagnosis and slip severity (<30 degrees : 10.0 weeks; 30 degrees to 50 degrees : 14.4 weeks; >50 degrees : 20.6 weeks). There were no significant associations between delay in diagnosis and covariates of age, gender, side, and weight. There were significant associations between longer delay in diagnosis and covariates of knee/distal-thigh pain versus hip/proximal-thigh pain (6.0 vs 15.0 weeks), Medicaid coverage versus private insurance (12.0 vs 7.5 weeks), lower family income, and stable slips versus unstable slips (8.0 vs 6.5 weeks). Controlling for the other covariates, knee/distal-thigh pain, Medicaid insurance, and stable slips remained significant independent multivariate predictors of delay in diagnosis.Patients who present with primarily knee or distal-thigh pain, patients with Medicaid coverage, and patients with stable slips have longer delays in diagnosis of SCFE. Focused intervention programs to reduce the delay in diagnosis of SCFE should emphasize patients with knee/thigh pain and patients with Medicaid coverage.

  View details for Web of Science ID 000220585100048

  View details for PubMedID 15060261

• Images in clinical medicine. Something fishy going on in the heart. New England journal of medicine de la Torre, J., Bishop, J. 2002; 347 (22): 1769-?

  View details for PubMedID 12456853

• Operative versus nonoperative management of acute Achilles tendon rupture - Expected-value decision analysis 68th Annual Meeting of the American-Academy-of-Orthopaedic-Surgeons Kocher, M. S., Bishop, J., Marshall, R., Briggs, K. K., Hawkins, R. J. SAGE PUBLICATIONS INC. 2002: 783–90

  Abstract

  The optimal management strategy for acute Achilles tendon rupture is controversial.To determine the optimal management by using expected-value decision analysis.Cross-sectional study.Outcome probabilities were determined from a systematic literature review, and patient-derived utility values were obtained from a visual analog scale questionnaire. A decision tree was constructed, and fold-back analysis was used to determine optimal treatment. Sensitivity analyses were used to determine the effect of varying outcome probabilities and utilities on decision-making.Outcome probabilities (expressed as operative; nonoperative) were as follows: well (0.762; 0.846), rerupture (0.022; 0.121), major complication (0.030; 0.025), moderate complication (0.075; 0.003), and mild complication (0.111; 0.005). Outcome utility values were well operative (7.9), well nonoperative (7.0), rerupture (2.6), major complication (1.0), moderate complication (3.5), and mild complication (4.7). Fold-back analysis revealed operative treatment as the optimal management strategy (6.89 versus 6.30). Threshold values were determined for the probability of a moderate complication from operative treatment (0.21) and the utility of rerupture (6.8).Operative management was the optimal strategy, given the outcome probabilities and patient utilities we studied. Nonoperative management was favored by increasing rates of operative complications; operative, by decreasing utility of rerupture. We advocate a model of doctor-patient shared decision-making in which both outcome probabilities and patient preferences are considered.

  View details for Web of Science ID 000179364300004

  View details for PubMedID 12435641