The 3^rd Annual Harvard Orthopedic Trauma Research Day was held on Friday, June 3rd at the Leventhal Conference Room, hosted at the Beth Israel Deaconess Medical Center. On a day filled with research from residents, researchers, fellows and faculty, the staff was pleased and proud to present some of the clinical and basic science work from our HOT Research Group.

Four years ago, the orthopaedic trauma faculty of Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Children’s Hospital, and Massachusetts General Hospital began to collaborate formally on research endeavors across the Harvard system. While tremendously useful for purposes of publishing results involving large numbers of patient subjects, this collaboration has also proven to be of tremendous educational benefit for our fellows, residents and medical students.

Dr. Vrahas, along with all the faculty of the Harvard Orthopedic Trauma group constinues to encourage active participants in this forum and thanked all for attending.

Presentation #1: Catherine Logan, M.D., M.B.A., M.S.P.T. PGY-1, Harvard Combined Orthopaedic Residency Program

Distal Radius Fracture Management in the Emergency Department: Is a Mini C-Arm Beneficial?

Catherine Logan, M.D., Mitchel Harris, M.D.

This is a retrospective study analyzing the impact of a mini C-arm in a dedicated Orthopaedic procedure room on the management of distal radius fractures in the Emergency Department. Ninety patients from BWH and 242 patients from MGH were included and differences in ED throughput time and frequency of re-reduction were analyzed.

Presentation #2: Ida Leah Gitajn, M.D. PGY-3, Harvard Combined Orthopaedic Residency Program

Is the Sustentaculum truly "constant" in intra-articular calcaneus fractures? Implications for fracture management

Ida Leah Gitajn, M.D., Mostafa Abousayed, M.D., James Rull Toussaint, M.D., Beverly Ting, M.D., Jenny Jin, M.D., John Kwon, M.D.

While the idea of anatomic constancy of the sustentaculum in intra-articular calcaneus fractures is a long-standing belief, little has been published verifying this notion and the commonly used extensile lateral approach is based on this premise. The purpose of this study was to determine the incidence and magnitude of sustentacular fracture/displacement in intra-articular calcaneus fractures to determine whether this fragment can be accurately identified as constant and can be consistently relied upon to maintain anatomic alignment. We additionally aimed to evaluate whether there is an association with different patient and fracture-related variables and to determine whether management is affected by these observations.

Presentation #3: Michael Sridhar, M.D. Fellow, Partners Orthopaedic Trauma Service

The Role of Total Hip Arthroplasty in Acetabular Fractures

Michael Sridhar, M.D., Mark Vrahas, M.D.

The role of total hip arthroplasty in acetabular fractures continues to be defined, especially in the acute setting. This is a retrospective case series detailing our experience with these complex procedures. From 2004-2013 at Massachusetts General and Brigham and Women’s Hospital, there were 110 primary or revision total hip arthroplasties for acetabular fractures in patients from 24-90 years old. Indications included articular destruction warranting acute arthroplasty coupled with or without fixation, failed nonoperative management, posttraumatic arthrosis after nonoperative management or operative fixation, and periprosthetic acetabular fractures. Complications requiring reoperation were the focus of this study and included dislocation, a failed acetabular component, and infection. This work will serve as a springboard to further analysis of patient factors and fracture features to further optimize outcomes with arthroplasty in these injuries.

Presentation #4: Ryan Porter, Ph.D. Research Faculty, Center for Advanced Orthopaedic Studies, BIDMC

Towards improved cell-based strategies for articular cartilage repair: a rat model for the influence of pro-inflammatory signaling

Alfredo Maximilano Scheu, M.D., Elisabeth Ferreira, Ph.D., Lennart Brown, B.S., Mark Vrahas, M.D., Christopher Evans, Ph.D., Ryan Porter, Ph.D.

Present treatment options for articular cartilage injury attempt to harness the healing potential of autologous chondrocytes (ACI) or chondroprogenitor cells (microfracture). However, these cell-based strategies do not reliably restore the original tissue properties but, more often, provide just a stopgap to prolong joint function. To direct cartilage restoration and long term repair, it is apparent that we must first understand how the injured joint environment influences chondrogenic cells once introduced to the defect. Using a rat model of cartilage injury, we have focused on how pro-inflammatory signals following injury affect the regenerative activity of chondrogenic cells from bone marrow. Our ongoing studies suggest treatment regimens that control such pro-inflammatory signaling in order to improve the quality of defect repair.

Presentation #5: Lauren Barber, A.B. M.D. Candidate, HMS

Patient Satisfaction with Involvement in Research

Lauren Barber, A.B., Michiel Hageman, M.D., Stijn Bekker, B.Sc., Arjan Bot, M.D., David Ring, M.D., Ph.D.

We conducted a cross-sectional and observational study evaluating whether participation in clinical research influences patients’ satisfaction. In this study, there are two randomized cohorts each with 64 patients. Cohort I is comprised of patients who completed questionnaires about disability, self-efficacy, and anxiety, while Cohort II was not subject to research questionnaires. Both cohorts completed 11-point ordinal satisfaction scales about their visit and their physician. We found no significant difference in average satisfaction between those who participated in research and those who did not.

Presentation #6: Michiel Hageman, M.D. Research Fellow, Orthopaedic Hand and Upper Extremity Service, MGH

Predictors of Readmission in Orthopaedic Surgery

Michiel Hageman, M.D., Jeroen Bossen, M.D., R. Malcolm Smith, M.D., David Ring, M.D., Ph.D.

This retrospective study addresses the association between readmission within 30 days of discharge after operative treatment of skeletal trauma with comorbidities, and the differences between all-cause readmissions and those due to an adverse event. Three thousand four hundred and fifty-two operations for skeletal trauma between 2008 and 2012 were reviewed. There was a significant association between readmission within 30 days of surgery and higher CCI (p<0.001), older age (p<0.001), and marital status (widowed) (p<0.001). The factors associated with readmission related to an adverse event were identical. Older patients and patients with greater comorbidity are more likely to be readmitted within 30 days of surgery for musculoskeletal trauma. We found no difference between readmissions related and unrelated to adverse events related directly to surgery.

Presentation #7: Michael Weaver, M.D. & Houman Javedan, M.D. Faculty, Orthopedic Trauma Service, BWH; Faculty, Division of Aging, BWH

Early Results of the BWH Orthopedic-Geriatric Collaboration

Houman Javedan, M.D., Michael Weaver, M.D., Mark Vrahas, M.D., Mitchel Harris, M.D.

Geriatric patients who suffer hip fractures have poor 1 year outcomes (20-30% mortality) and can have complicated and prolonged hospital admissions. Geriatricians specialize in the care of elderly patients. Geriatricians and orthopedic surgeons have started to collaborate to see if they can improve outcomes in these patients. The Brigham and Women’s Trauma Orthopedic Service and Division of Aging started such collaboration over a year ago. This study looks at outcomes in patients 70 and older with hip fractures compared to a historical control group. Outcomes analyzed: Length of stay; Emergency Room to Operating Room time; Operating Room to Discharge time; Discharging service; 30-day readmission; 30 day mortality; Goals of care discussions; and Survey results from nursing and allied services.

Presentation #8: Marilyn Heng, M.D. Fellow, Partners Orthopaedic Trauma Service

Mini-Cog Testing as a Predictor of Outcome in Elderly Fracture Patients

Marilyn Heng, M.D., Houman Javedan, M.D., Mitchel Harris, M.D.

This is a retrospective study investigating the relationship of Mini-Cog Testing as a predictor for mortality in geriatric fracture patients. We will quantify the proportion of our study population with baseline dementia and correlate its incidence with American Society of Anesthesiologists score, functional status, perioperative delirium, length of stay in hospital, re-admission, and mortality.

Presentation #9: Collin May, M.D. PGY-5, Harvard Combined Orthopaedic Residency Program

Blood Loss in Geriatric Hip Fracture – Natural History and Outcomes of Transfusion.

Collin May, M.D., Lauren Ehrlichman, M.D., Paul Appleton, M.D., Edward K. Rodriguez, M.D., Ph.D.

This is a retrospective study of 280 consecutive geriatric patients treated for hip fracture with a short cephalomedullary device at a single institution. Our aim was to describe the "natural history" of blood loss following this injury and fixation, and evaluate outcomes related to autologous blood transfusion during admission. Primary endpoints included: length of stay, 30-day readmission, cardiac complications, and mortality. Secondary analyses of risk factors associated with transfusion were also performed.

Presentation #10: Ara Nazarian, Ph.D. Assistant Professor of Orthopaedic Surgery, HMS, BIDMC

CT-based Rigidity Analysis: From Pathologic Fractures to Fracture Nonunion

Edward K. Rodriguez, M.D., Ph.D., Juan Villa, M.D., Ara Nazarian, Ph.D.

We have developed algorithms to calculate the minimal rigidity of a bone containing an osteolytic lesion using serial, trans-axial, computed tomography (CT) images through the affected bone to measure both the bone tissue mineral density and cross-sectional geometry. The accuracy of this approach has been validated in a series of ex-vivo and in-vivo studies. We would like to extend the use of this technique to help provide a better means to identify fracture nonunions apriori.

Presentation #11: Sjoerd Nota, M.D. Research Fellow, Orthopaedic Hand and Upper Extremity Service, MGH

The Correspondence Between the Use Of Pain Medication And Patient Satisfaction After Orthopaedic Surgery.

Sjoerd Nota, M.D., Silke Spit, B.Sc., Timothy Voskuyl, M.D., Arjan Bot, M.D., David Ring, M.D., Ph.D.

This is a prospective study analyzing the correspondence between the type and quantity of pain medication and patients’ satisfaction after orthopaedic surgery. Two hundred and thirty-two patients who underwent elective orthopaedic surgery were enrolled and study participants were asked to fill out questionnaires at post-operative day 1,2,3 and 14. Patients’ pain medications use was gathered with the use of the electronic medication registration system eMAR. The correspondence between pain medication and patients’ satisfaction was analyzed.

Presentation #12: Jordan Morgan, B.S. Senior Research Coordinator, Partners Orthopaedic Trauma Service

Correlation of PROMIS Physical Function Computer Adapted Test To Other Upper Extremity Outcome Measures

Jordan Morgan, B.S., Kanu Okike, M.D., Michael Kallen, Ph.D., M.P.H., Mark Vrahas, M.D.

The purpose of this study was to compare the PROMIS Physical Function Computer Adaptive Test (PROMIS PF CAT) to commonly used, traditional measures for the evaluation of patients with proximal humeral fractures. Forty seven patients over the age of 60 with displaced proximal humerus fractures treated between 2006 and 2009 completed four outcome measure to evaluate their level of physical function: the Short Musculoskeletal Functional Assessment (SMFA), the Disabilities of the Arm, Shoulder, and Hand score (DASH), the Constant Shoulder Score, and the PROMIS PF CAT. Pearson correlation analyses were then used to determine the observed correlations amongst the administered outcome measures.

Presentation #13: Elisabeth Ferreira, Ph.D. Research Faculty, Center for Advanced Orthopaedic Studies, BIDMC

Development of expedited bone healing technologies using genetically modified RIA cells

Elisabeth Ferreira, Ph.D.; Ryan Porter, Ph.D.; Jordan Morgan, B.S.; Mark Vrahas M.D.; Christopher Evans, Ph.D.

This study aims at developing methods for delivering BMP-2 cDNA using adenovirus to freshly harvested bone marrow cells in such a manner that they will heal large osseous defects. More specifically the study describes methods for genetically modifying minimally processed marrow cells in order to avoid the use of ex vivo culture of osteoprogenitor cells, and provide a clinically expeditious method for bone repair applications. Nucleated bone marrow cells were isolated from intramedullary reamings collected from 5 patients for various orthopaedic indications (Massachusetts General Hospital). Conditions for optimal modification of unfractionated human marrow cells with adenovirus were established, and levels and kinetics of BMP-2 expression by Ad.BMP-2 transduced marrow cells were determined.

Presentation #14: Mitchel Harris, M.D. Chief, BWH Orthopaedic Trauma Service

Mass Health Care Reform: Its Effect on the Level One Orthopedic Trauma Services of Boston

James Toussaint, M.D., Stephane Bergeron, M.D., Michael Weaver, M.D., Mark Vrahas, M.D., Paul Tornetta, M.D., Mitchel Harris, M.D.

This study combines retrospective and prospective data collection to analyze the financials and work efforts performed by three of the four ACS Level 1 Trauma Centers in Boston, pre- and post onset of Mass Health Care reform. It directly compares the published data referencing the rate of uninsured in Massachusetts to the clinical population treated at these three trauma centers spanning the time period 2003-2010.