Roy I Davidovitch, M.D.

Infection after spanning external fixation for high-energy tibial plateau fractures: is pin site-plate overlap a problem?
Laible, Catherine; Earl-Royal, Emily; Davidovitch, Roy; Walsh, Mike; Egol, Kenneth A
2012 Feb;26(2):92-97, Journal of orthopaedic trauma
OBJECTIVES: : The purpose of this study was to determine whether overlap between temporary external fixator pins and definitive plate fixation correlates with infection in high-energy tibial plateau fractures. DESIGN: : Retrospective chart and radiographic review. SETTING: : Academic medical center. PATIENTS: : Seventy-nine patients with unilateral high-energy tibial plateau fractures formed the basis of this report. INTERVENTION: : Placement of knee-spanning external fixation followed by delayed internal fixation for high-energy tibial plateau fractures treated at our institution between 2000 and 2008. METHODS: : Demographic patient information was reviewed. Radiographs were reviewed to assess for the presence of overlap between the temporary external fixator pins and the definitive plate fixation. Fisher exact and t test analyses were performed to compare those patients who had overlap and those who did not and were used to determine whether this was a factor in the development of a postoperative infection. MAIN OUTCOME MEASUREMENTS: : Development of infection in those whose external fixation pin sites overlapped with the definitive internal fixation device compared with those whose pin sites did not overlap with definitive plate and screws. RESULTS: : Six knees in six patients developed deep infections requiring serial irrigation and debridement and intravenous antibiotics. Of these six infections, three were in patients with closed fractures and three in patients with open fractures. Two of these six infections followed definitive plate fixation that overlapped the external fixator pin sites with an average of 4.2 cm of overlap. In the four patients who developed an infection and had no overlap, the average distance between the tip of the plate to the first external fixator pin was 6.3 cm. There was no correlation seen between infection and distance from pin to plate, pin-plate overlap distance, time in the external fixator, open fracture, classification of fracture, sex of the patient, age of the patient, or healing status of the fracture. CONCLUSION: : Fears of definitive fracture fixation site contamination from external fixator pins do not appear to be clinically grounded. When needed, we recommend the use of a temporary external fixation construct with pin placement that provides for the best reduction and stability of the fracture, regardless of plans for future surgery
— id: 149948, year: 2012, vol: 26, page: 92, stat: Journal Article,

Contralateral deep venous thrombosis after hip arthroscopy
Alaia, Michael J; Zuskov, Andrey; Davidovitch, Roy I
2011 ;34(10):e674-e677, Orthopedics (Thorofare NJ)
Since the 1980s, hip arthroscopy has become an accepted treatment modality for a variety of hip conditions. It is generally considered a low-risk procedure with a low rate of complications. The risk of developing a deep venous thrombosis (DVT) or venous thromboembolism following these procedures is also thought to be low, and most patients undergoing these procedures receive no pharmacologic prophylaxis postoperatively.This article presents a case of a 33-year-old woman with a history of oral contraceptive use who presented 13 days after a routine hip arthroscopy with pain and swelling in the contralateral thigh. Ultrasonography revealed acute DVTs in the left common femoral, superficial femoral, and popliteal veins. She was admitted to the hospital and treated accordingly. A workup for thrombophilic disorders was negative. We believe that her history of oral contraceptive use, the use of axial traction, and asymmetric forces about the pelvis during the procedure contributed to this postoperative complication.Although this complication is rare and the use of pharmacologic prophylaxis is not common, physicians must be aware of this potential complication following hip arthroscopy
— id: 139921, year: 2011, vol: 34, page: e674, stat: Journal Article,

Implant choice for Weber C ankle fractures: Are one-third tubular plates adequate?
Bechtel C.P.; Walsh M.; Davidovitch R.I.; Egol K.A.
2011 ;22(1):64-70, Current Orthopaedic Practice
Background: Controversy exists regarding the use of one-third tubular plates for fixation of diaphyseal (Weber C) fibular fractures because of increased time to union and concerns about the plate's strength. No study has evaluated the efficacy of this type of plate for Weber C fractures. The purpose of this study was to evaluate one-third tubular plates in the fixation of diaphyseal fibular fractures regardless of whether or not the plate was locking or nonlocking. Methods: We prospectively followed 84 patients with displaced, unstable Weber C fractures. We excluded all OTA type 44-C3 fractures and those treated by any means other than a one-third tubular plate. Of the 50 patients who had sustained an OTA type 44-C1 or C2 fracture and were treated with one-third tubular plates, 39 patients (78%) had complete 1-year follow-up. Results: Union rates were 97% for Weber C fractures treated with onethird tubular plates. There was one wound infection and the overall complication rate was 10%. Two patients (5%) required revision open reduction and internal fixation. Finally, there was no evidence of wound necrosis, malunion, or post-traumatic osteoarthrosis in this cohort. Conclusions: One-third tubular plates provide adequate fixation for Weber C fractures. Theoretical concerns about fixation strength are clinically unfounded. Therefore, we recommend the use of one-third tubular plates for the treatment of Weber C fractures. 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
— id: 133420, year: 2011, vol: 22, page: 64, stat: Journal Article,

Open reduction with internal fixation versus limited internal fixation and external fixation for high grade pilon fractures (OTA type 43C)
Davidovitch, Roy I; Elkataran, Rami; Romo, Santiago; Walsh, Michael; Egol, Kenneth A
2011 Oct;32(10):955-961, Foot & ankle international
BACKGROUND: The optimal treatment for high energy pilon fractures is controversial. Good clinical and functional results have been reported with traditional open reduction techniques and minimally invasive techniques utilizing external fixation (EF). The purpose of this study was to critically evaluate clinical, radiographic and functional outcomes following high-energy fractures of the tibial plafond. METHODS: Between 2000 and 2006, 62 patients who were diagnosed with 63 Type 43C pilon fractures were treated surgically by a single surgeon and retrospectively reviewed. Twenty-seven patients were treated with a hinged bridging external fixator (EF) with supplemental limited internal fixation and 35 were treated with open reduction and internal fixation (ORIF) utilizing traditional small fragment plates and screws. Out of the 62 patients, a total of 46 patients were available for review. Charts and radiographs were reviewed and a Short Musculoskeletal Function Assessment (SMFA) questionnaire was administered by a trained interviewer. Seventy-four percent of both the ex-fix patients and ORIF patients were available for followup with a mean of 18 and 22 months, respectively. Results were compared using student's T-tests. RESULTS: There were no differences between the cohorts with respect to mechanism of injury, presence of an open wound and age. Functional outcomes were similar between the two groups based on the American Orthopaedic Foot and Ankle Society (AOFAS) score and the 'function' index of the SMFA. The overall complication and union rates were similar between the two groups. CONCLUSION: Both ORIF and EF appear to be comparable for treatment of OTA type 43C (pilon) fractures with regard to final range of ankle motion, development of arthritis and hindfoot scores
— id: 149809, year: 2011, vol: 32, page: 955, stat: Journal Article,

A novel technique for reduction and immobilization of tibial shaft fractures: the hammock
Konda, Sanjit R; Jordan, Charles J; Davidovitch, Roy I; Egol, Kenneth A
2011 Jun;25(6):385-390, Journal of orthopaedic trauma
Standard techniques for immobilization of a tibia shaft fracture in the emergency department in a long-leg splint can be cumbersome, technically difficult, and often requires the use of an assistant. We have developed a novel technique for the reduction and splinting of tibial shaft fractures, which uses a 'hammock' constructed of stockinette, which allows a single consulting orthopaedic physician to rapidly reduce and place a long-leg plaster splint or cast on a patient. This technique was performed on 12 consecutive patients with a total of 12 tibial shaft fractures. Translation, angulation, and shortening of the fracture were documented in anteroposterior and lateral views of the injured tibia and these parameters were compared against values measured after the hammock technique was used to reduce and splint the fracture. Pre-'hammock' average values for fracture displacement in the anteroposterior plane for translation, angulation, and shortening were 10.5 mm (53.1%), 12.0 degrees , and 9.4 mm, respectively. Post-'hammock' average values for fracture displacement in the anteroposterior plane for the same parameters were 8.7 mm (44.4%), 4.2 degrees , and 7.9 mm, respectively. Pre-'hammock' average values for fracture displacement in the lateral plane for translation and angulation were 4.9 mm and 8.7 degrees . Post-'hammock' average values for fracture displacement in the lateral plane for the same parameters were 4.9 mm and 2.0 degrees , respectively. These results show that this technique is able to achieve the goals of fracture reduction and immobilization in a rapid fashion when help is not available
— id: 132594, year: 2011, vol: 25, page: 385, stat: Journal Article,

Challenges in the treatment of femoral neck fractures in the nonelderly adult
Davidovitch, Roy I; Jordan, Charles J; Egol, Kenneth A; Vrahas, Mark S
2010 Jan;68(1):236-242, Journal of trauma
Femoral neck fractures in young patients are a relatively rare event and are often the consequence of a high-energy injury. Concomitant injuries are present more than 50% of the time. Previous reports have found the rate of nonunion and avascular necrosis in this population to be as high as 35% and 45%, respectively. The salvage options, which tend to yield more acceptable results in elderly patients with femoral neck fractures, yield disproportionately poor results in young, active patients who are often productive members of the labor force. Many reports exist in the literature evaluating the various treatment options of these injuries. This review will address the epidemiology and diagnosis of the injury. In addition, the various treatment options in the acute presentation, as well as options available for treating the sequelae of femoral neck fractures in the young, will be discussed. Although longer life expectancy and the sustained activity level of many people previously considered elderly has blurred the definition of 'young,' this review will use the available literature dealing with skeletally mature patients up to the age of 60 years
— id: 106205, year: 2010, vol: 68, page: 236, stat: Journal Article,

Utility of pathologic evaluation following removal of explanted orthopaedic internal fixation hardware
Davidovitch, Roy I; Temkin, Steven; Weinstein, Barton S; Singh, Jaspal R; Egol, Kenneth A
2010 ;68(1):18-21, Bulletin of the NYU Hospital for Joint Diseases
This report questions the cost and effectiveness of routinely sending explanted hardware to pathology for evaluation. Forty-six consecutive patients who had symptomatic hardware removed were enrolled in this study. Pathology reports following hardware removal were obtained, and charts were reviewed for these patients. The pathology department was contacted for related departmental procedure codes, and hospital billing records were obtained regarding the cost of the procedure. In all cases, the pathology reports gave the gross diagnosis of 'hardware' and the gross description included the measurements of the internal fixation hardware removed. In no case did the report alter the plan of the attending physician. The healthcare system may benefit by subspecialty review of the current practice of sending internal fixation devices to pathology for evaluation. We recommend a single radiographic view along with proper documentation in the postoperative report to confirm the removal of internal fixation hardware in lieu of pathologic evaluation
— id: 108929, year: 2010, vol: 68, page: 18, stat: Journal Article,

Outcome after unstable ankle fracture: effect of syndesmotic stabilization
Egol, Kenneth A; Pahk, Brian; Walsh, Michael; Tejwani, Nirmal C; Davidovitch, Roy I; Koval, Kenneth J
2010 Jan;24(1):7-11, Journal of orthopaedic trauma
OBJECTIVE: This study was performed to evaluate the results of operative treatment of ankle fractures in patients who required syndesmotic stabilization in addition to malleolar fracture fixation compared with patients who required malleolar fixation alone. DESIGN: The authors conducted a retrospective review of prospectively collected data. SETTING: Academic medical center. PATIENTS: Between October 2000 and November 2006, 347 patients who underwent surgical repair of an unstable ankle fracture were enrolled in a prospective database. INTERVENTION: Patients who had an associated syndesmotic disruption requiring surgical stabilization in association with either an ankle fracture or a fracture-dislocation were identified and compared with a cohort treated during the same time period who had sustained an ankle fracture or fracture-dislocation without syndesmotic disruption. MAIN OUTCOME MEASUREMENTS: All patients were followed and evaluated at 3, 6, and 12 months with clinical and radiographic examination as well as functional status (Short Musculoskeletal Functional Assessment, American Orthopaedic Foot and Ankle Society). Patient-reported pain and postoperative complications were recorded as well. RESULTS: Three hundred forty-seven patients met the inclusion criteria and had 1-year minimum follow up. Seventy-nine patients (23%) who had syndesmotic stabilization were identified and compared with 268 patients (77%) who did not. No differences were found between the two groups with respect to age or American Society of Anesthesiologists status; however, there was a greater percentage of men in the syndesmotic injury group (P = 0.04). There was a greater percentage of Type C fractures requiring syndesmosis stabilization, whereas Type B fractures were less likely to require syndesmosis stabilization (P = 0.001) At 6- and 12-month follow up, there was a clear difference in outcome based on American Orthopaedic Foot and Ankle Society and Short Musculoskeletal Functional Assessment scores; patients who underwent syndesmotic stabilization had worse American Orthopaedic Foot and Ankle Society scores with lower function ratings (P = 0.04) and worse pain ratings (P = 0.02). Short Musculoskeletal Functional Assessment scores were also worse at 12 months in patients who had syndesmotic stabilization because the dysfunction index was higher in the syndesmotic injury group (P = 0.009). Radiographically, 18 of 144 (13%) syndesmotic screws were noted to be broken on follow-up radiographs, eight of which were subsequently removed. There were no other differences in complication rates. CONCLUSION: Patients who required syndesmotic stabilization in addition to malleolar fracture fixation had poorer outcomes at 12 months compared with patients who required malleolar fracture fixation alone. This information is important for patient counseling to manage expectations regarding outcomes after injury
— id: 106097, year: 2010, vol: 24, page: 7, stat: Journal Article,

Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle fractures
Jordan, Charles; Davidovitch, Roy I; Walsh, Michael; Tejwani, Nirmal; Rosenberg, Andrew; Egol, Kenneth A
2010 Feb;92(2):368-374, Journal of bone & joint surgery (American volume)
BACKGROUND: To our knowledge, no study to date has compared the use of spinal and general anesthesia in patients undergoing operative fixation of an unstable ankle fracture. The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients. METHODS: Between October 2000 and November 2006, 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively. Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia. All patients were evaluated at three, six, and twelve months postoperatively with use of standardized, validated general and limb-specific outcome instruments. Standard and multivariable analyses comparing outcomes at these intervals were performed. RESULTS: Four hundred and sixty-six patients (93%) who had been followed for a minimum of one year met the inclusion criteria. Compared with the general anesthesia group, the spinal anesthesia group had a greater mean age (p = 0.005), higher classification on the American Society of Anesthesiologists system (p = 0.03), and a greater number of patients with diabetes (p = 0.02). There was no difference in sex distribution between the groups. At three months, patients who received spinal anesthesia had significantly better pain scores (p = 0.03) and total scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 0.02). At six months, patients in the spinal anesthesia group continued to have better pain scores (p = 0.04), but there was no longer a difference in total scores (p = 0.06). At twelve months, no difference was detected between the groups in terms of functional or pain scores. There was no difference in complication rates between the groups. CONCLUSIONS: Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period. We recommend that, unless there is a specific contraindication, patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence
— id: 106512, year: 2010, vol: 92, page: 368, stat: Journal Article,

Ethnic disparities in recovery following distal radial fracture
Walsh, Michael; Davidovitch, Roy I; Egol, Kenneth A
2010 May;92(5):1082-1087, Journal of bone & joint surgery (American volume)
BACKGROUND: Ethnic disparities have been demonstrated in the treatment of chronic diseases, such as diabetes and heart disease. It is unclear if similar ethnic disparities appear with respect to recovery following fracture care. METHODS: We retrospectively reviewed 496 individuals (253 whites, 100 blacks, and 143 Latinos) with a fracture of the distal part of the radius. Assessment of physical function and pain was conducted at three, six, and twelve months following treatment. The Disabilities of the Arm, Shoulder and Hand (DASH) score was used to assess physical function, and a visual analog scale was used to assess pain. Multiple linear regression was used to model physical function and pain across ethnicity while controlling for age, sex, mechanism of injury, level of education, type of fracture, type of treatment (operative or nonoperative), and Workers' Compensation status. RESULTS: Both blacks and Latinos exhibited poorer physical function and greater pain than whites did at most follow-up points. Latinos reported more pain at each follow-up point in comparison with blacks and whites (p < 0.001 at three, six, and twelve months). These significant differences remained after controlling for Workers' Compensation status, which was also strongly associated with both pain and function. CONCLUSIONS: These findings suggest that recovery is different between ethnic groups following a fracture of the distal part of the radius. These ethnic disparities may result from multifactorial sociodemographic factors that are present both before and after fracture treatment
— id: 109571, year: 2010, vol: 92, page: 1082, stat: Journal Article,

The medial malleolus osteoligamentous complex and its role in ankle fractures
Davidovitch, Roy I; Egol, Kenneth A
2009 ;67(4):318-324, Bulletin of the NYU Hospital for Joint Diseases
Ankle stability in ankle fractures is dependent on multiple factors. The medial malleolus and the associated deltoid ligament provide for ankle stability on the medial side. Over the years, the relative importance of this medial malleolar osteoligamentous complex (MMOLC) has been debated. This review will describe the evolution of ankle fracture surgery from the perspective of the contribution of the MMOLC to re-establishing ankle stability. Also discussed are the surgical and nonsurgical treatment options, various presentations of medial sided injuries in ankle fractures, and, finally, current recommendations for fixation
— id: 105970, year: 2009, vol: 67, page: 318, stat: Journal Article,

Functional outcome after operatively treated ankle fractures in the elderly
Davidovitch, Roy I; Walsh, Michael; Spitzer, Allison; Egol, Kenneth A
2009 Aug;30(8):728-733, Foot & ankle international
BACKGROUND: The goal of this review was to compare the functional outcomes of patients less than 60 and greater than or equal to 60 years old following operative stabilization of unstable ankle fractures. The review was conducted as a retrospective analysis of prospectively collected data at two level one trauma centers and a tertiary referral academic center. MATERIALS AND METHODS: All patients operatively treated for an unstable ankle fracture were entered into a database and prospectively followed. The postoperative protocol was standardized for all patients. Baseline characteristics, complications, additional surgery, functional status and the American Orthopaedic Foot and Ankle Society score (AOFAS) were assessed. The intervention chosen was open reduction and internal fixation of unstable ankle fractures. AOFAS hindfoot score and Short Musculoskeletal Functional Assessment (SMFA) questionnaire were used as the main outcome measures in the study. A p < 0.05 was considered significant. RESULTS: Three hundred sixty-nine (369) patients were entered into the database, 313 (84.8%) were less than 60 years old. At 3 months, 57% (32/56) of patients greater than or equal to 60 years old reported limitation of activities versus 33% (103/313) of patients less than 60 years old (p = 0.005). At 6 and 12 months, these percentages improved to 41% versus 10% (p = 0.001), and 29% versus 7.4% (p = 0.001) for older and younger individuals respectively. However, when compared to their baseline scores, both groups achieved a return to pre-injury status. Total AOFAS scores were not significantly different at 3, 6, or 12 months (p = 0.431). CONCLUSION: Operative fixation of unstable ankle fractures in patients greater than or equal to 60 years old can provide a reasonable functional result at the 1-year followup with a return to preoperative baseline even though they report more limitation of activities than younger patients
— id: 102161, year: 2009, vol: 30, page: 728, stat: Journal Article,

Use of a "hybrid" locking plate for complex metaphyseal fractures and nonunions about the humerus
Spitzer, Allison B; Davidovitch, Roy I; Egol, Kenneth A
2009 Mar;40(3):240-244, Injury
PURPOSE: To review one surgeon's experience with a novel type of 'hybrid' locking plate (which has both 3.5mm and 4.5mm locking holes) for difficult fractures of the meta-diaphyseal humeral shaft. METHODS: Over a 2-year period, 24 patients who presented with a metaphyseal humeral fracture or nonunion (proximal or distal) were treated surgically by a single surgeon. A 'hybrid' locking plate containing 3.5mm locking holes on one end and 4.5mm locking holes on the other end (Metaphyseal plate, Synthes, Paoli, Pa) was used in all patients. The selection of this implant was based on fracture location and bone quality. Fractures were operated on through an anterolateral or direct posterior approach. All fractures were secured with a minimum of three 4.5mm screws on one side of the fracture and three 3.5mm screws on the other side. All patients were treated with a similar post-operative protocol for early range of shoulder and elbow motion. RESULTS: Three patients were lost to follow-up. The cohort consisted of 15 women and 6 men with a mean age of 49 years (range 18-78). There were 14 acute fractures and 7 nonunions. Twelve fractures involved the distal metaphyseal segment and 9 involved the proximal metaphyseal segment. Twenty-two patients completed a minimum 6-month clinical and radiographic follow-up and form the basis for this report. All 21 patients healed their fractures or nonunions at a mean of 4.5 months. There were no infections or hardware failures. In every case the 'hybrid' nature of the plate design was felt to be advantageous. CONCLUSION: This 'second generation' metaphyseal locking plate, which affords the surgeon the ability to place a greater number of smaller calibre screws within a short bone segment, while using traditional large fragment screw fixation in the longer segment, is clearly an improvement in plate design. Meta-diaphyseal upper extremity long bones may serve as the most ideal location for this implant
— id: 93740, year: 2009, vol: 40, page: 240, stat: Journal Article,