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Second Session
Moderator:   Mark C. Gebhardt, MD

Thesis Presenter: Charles J. Petit, MD
Topic: Management of Proximal Humerus Fractures: Surgeons Don’t Agree
Discusser: Lawrence Higgins, MD
Advisor: Jon J.P. Warner, MD

Dr. Charles J. Petit commented on the wide spectrum of treatment options available for the treatment proximal humerus fractures and the seemingly high variability of surgical decision-making. Dr. Petit believed that both interobserver and intraobserver agreement for surgical management would be poor and independent of fellowship training. He enrolled 8 fellowship-trained orthopaedic surgeons (3 shoulder, 5 trauma), who viewed preoperative plain radiographs of patients with proximal humerus fractures. All surgeons viewed the same pool of 38 cases and their own cases from 2000- 2005 in a blinded fashion. Surgeons chose from one of 6 management options: (1) non-operative, (2) closed manipulation under anesthesia, (3) closed (or open) reduction and percutaneous pinning, (4) open reduction internal fixation with a fixed angle device, (5) open reduction internal fixation with an alternative fixation device (e.g., as suture fixation), or (6) hemiarthroplasty. Interobserver variability was calculated using the weighted kappa coefficient and intraobserver variability was calculated comparing each surgeon’s survey results with the operation they originally performed. Dr. Petit found that overall interobserver agreement on management was moderate (weighted kappa 0.4116) and did not differ significantly between trauma surgeons and shoulder surgeons. He discovered that reducing the number of management choices increased agreement between all surgeons. Testing for intraobserver agreement showed that surgeons picked the same operation in the survey as in the actual clinical setting only 56% of the time. Dr. Petit concluded that interobserver agreement was moderate overall and that intraobserver agreement was poor, thus raising the question about inconsistent decision-making by a given surgeon. Dr. Petit looked ahead to the future charging the audience to generate outcomes research to establish if treatment choice actually influences the clinical outcome. Dr. Pellegrini was curious to learn how allowing the surgeons to review CT scans might influence management.

Thesis Presenter: Robert D. Golden, MD
Topic: Increased Fracture Severity in Workers’ Compensation Patients: An Etiology for Poorer Outcomes
Discusser: E. Kenneth Rodriguez, MD
Advisor: Timothy Bhattacharyya, MD

Dr. Robert D. Golden made the observation that outcomes for patients with work-related injuries are poorer than for patients with non-work related injuries. Dr. Golden set out to determine whether patients with workrelated fractures have more severe injuries thereby contributing to inferior outcomes. He carried out a retrospective review of patients collected from a prospectively created database at two Level I trauma centers. All patients from April 2002 through March 2008 with distal radius, elbow, tibial plateau or tibial shaft fractures were analyzed. Severity was classified by the AO/ OTA classification of fracture type. Cases were then age and sex matched, and three fellowship-trained orthopedic traumatologists performed a further severity analysis using the rank order methodology. Dr. Golden found that Workers’ Compensation patients tended to be younger (p <0.011) and more frequently male (p < 0.0001) than non-Workers’ Compensation patients. He also noted that they had a higher rate of C-type fractures, especially in the upper extremity (p < 0.001), and were roughly 2 times more likely to have a Type C distal radius (cumulative odds ratio, 1.92, 95% confidence interval, 1.41 to 2.62) or elbow (cumulative odds ratio, 2.83; 95% confidence interval, 1.58 to 5.06) fracture than patients with non-work related injuries. When matched for age and sex, Dr. Golden found that Workers’ Compensation patients were rated as having more severe fractures of the upper extremity than non-Workers’ Compensation controls (p < 0.017). He concluded that although the etiology of the inferior outcomes seen in Workers’ Compensation patients is likely multifactorial, increased fracture severity appears to play a role, at least for fractures of the upper extremity. Dr. Rodriguez praised Dr. Golden for his efforts in helping to simplify the complex milieu of factors that can make the treatment of Workers’-Compensation patients challenging. Dr. Golden won the Best Basic Research Paper award for his efforts.

Thesis Presenter: Catherine A. Petty, MD
Topic: Minimizing peri-operative complications associated with open repair of acute Achilles tendon rupture: a prospective protocol
Discusser: Navin Duggal, MD
Advisor: Christopher P. Chiodo, MD

In an attempt to detach the stigma of high wound complication rates from open repair of acute Achilles tendon rupture, Dr. Catherine A. Petty took on the task of cataloging complications in the hope of better understanding their causes and future prevention. The goals of her study were to assess peri-operative complications using a specific, standardized protocol for Achilles tendon repair in a large prospective series. Ninety-one consecutive patients underwent primary repair of an acute Achilles tendon rupture at 3 different institutions. The surgical technique, developed by Dr. Chris Chiodo, was standardized to include five measures believed to be important in minimizing post-operative infections and wound complications: (1) posteromedial incision, (2) a posterior compartment release, (3) a layered closure, (4) 5 days of post-operative oral antibiotics, and (5) no tourniquet. Out of 91 patients, none had post-operative wound complications, including deep or superficial infection, sural nerve injury, or re-rupture. However, two patients developed a symptomatic, ipsilateral deep venous thrombosis (DVT). Additionally, 2 patients developed pulmonary emboli (PE), one requiring thoracotomy. These patients were treated with chemical anticoagulation. These results suggest that wound complications may be reduced with this standardized technique, but that other complications including DVT and PE may occur regularly. Areas of further research might include standardized screening and prevention protocols for venous thromboembolic disease. Dr. Chiodo commented that he has now made 5 days of post-operative antibiotics routine in his foot and ankle practice.