Michael J Gardner

Washington University in St. Louis, San Luis, Missouri, United States

Are you Michael J Gardner?

Claim your profile

Publications (158)268.26 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: There is increasing evidence associating "atypical" femoral fractures with prolonged exposure to bisphosphonate therapy. The cause of these fractures is unknown and likely multifactorial. This study evaluated the hypothesis that patients with primary osteoporosis who sustain atypical femoral fracture(s) while on chronic bisphosphonate therapy have a more varus proximal femoral geometry than patients who use bisphosphonates for primary osteoporosis but do not sustain a femoral fracture. The femoral neck-shaft angle was measured on the radiographs of 111 patients with atypical femoral shaft fracture(s) and thirty-three asymptomatic patients; both groups were on chronic bisphosphonate therapy. Patients with characteristic lateral cortical thickening, stress lines, and thigh pain were included in the fracture group. The mean neck-shaft angle of the patients who sustained atypical femoral fracture(s) while taking bisphosphonates (case group) differed significantly from that of the patients on bisphosphonate therapy without a fracture (129.5° versus 133.8°; p < 0.001). Fifty-three (48%) of the patients in the case group had a neck-shaft angle that was lower than the lowest angle in the control group (128°). Side-to-side comparison in patients with a unilateral pathologic involvement and an asymptomatic contralateral lower limb did not demonstrate any significant difference between the neck-shaft angles in the two limbs. Patients on chronic bisphosphonate therapy who presented with atypical femoral fracture(s) had more varus proximal femoral geometry than those who took bisphosphonates without sustaining a fracture. Although no causative effect can be determined, a finding of varus geometry may help to better identify patients at risk for fracture after long-term bisphosphonate use. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.
    The Journal of bone and joint surgery. American volume. 11/2014; 96(22):1905-9.
  • [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this study was to determine factors, including day of week of hospital admission, associated with delay to surgery (DTS) and increased length of stay (LOS) in patients with hip fractures.
    Journal of orthopaedic trauma. 09/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: Total elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures.
    Injury 08/2014; · 2.46 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: 1) Determine if distal femoral traction pins result in knee dysfunction in femoral or pelvic fracture patients, and 2) to determine if skeletal traction relieves pain more effectively than splinting for femoral shaft fractures.
    Journal of orthopaedic trauma. 07/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: Upper sacral segment dysplasia increases the risk of cortical perforation during iliosacral screw insertion. Dysmorphic sacra have narrow and angled upper osseous corridors. However, there is no validated definition of this anatomic variation. We hypothesized that pelves could be quantitatively grouped by anatomic measurements.METHODS: One hundred and four computed tomography (CT) scans and virtual outlet views of uninjured pelves were analyzed for the presence of the five qualitative characteristics of upper sacral segment dysplasia. CT scans were reformatted to measure the cross-sectional area, angulation, and length of the osseous corridor. Principal components analysis was used to identify multivariable explanations of anatomic variability, and discriminant analysis was used to assess how well such combinations can classify dysmorphic pelves.RESULTS: The prevalences of the five radiographic qualitative characteristics of upper sacral segment dysplasia, as determined by two reviewers, ranged from 28% to 53% in the cohort. The rates of agreement between the two reviewers ranged from 70% to 81%, and kappa coefficients ranged from 0.26 to 0.59. Cluster analysis revealed three pelvic phenotypes based on the maximal length of the osseous corridor in the upper two sacral segments. Forty-one percent of the pelves fell into the dysmorphic cluster. The five radiographic qualitative characteristics of dysmorphism were significantly more frequent (p < 0.007) in this cluster. A combination of upper sacral coronal and axial angulation effectively explained the variance in the data, and an inverse linear relationship between these angles and a long upper sacral segment corridor was identified. A sacral dysmorphism score was derived with the equation: (first sacral coronal angle) + 2(first sacral axial angle). An increase in the sacral dysmorphism score correlated with a lower likelihood of a safe transsacral first sacral corridor. No subjects with a sacral dysmorphism score >70 had a safe transsacral first sacral corridor.CONCLUSIONS: Sacral dysmorphism was found in 41% of the pelves. The major determinants of sacral dysmorphism are upper sacral segment coronal and axial angulation. The sacral dysmorphism score quantifies dysmorphism and can be used in preoperative planning of iliosacral screw placement.
    The Journal of bone and joint surgery. American volume. 07/2014; 96(14):e120.
  • [Show abstract] [Hide abstract]
    ABSTRACT: The null hypothesis of the current study states that routine axial CT images are obtained at a consistent and reproducible orientation relative to the sacrum. The secondary null hypothesis states that there is no difference in the measurement of the safe zone for placement of iliosacral screws when using routine axial CT images and standardized reconstructions in defined planes perpendicular and parallel to the sacrum. Retrospective review. University Level-1 Trauma Center PATIENTS:: Sixty-eight consecutive trauma patients evaluated with routine pelvic computed tomography, without pelvic ring injury. Retrospective radiographic review and measurement. Sixty-eight consecutive adult patients with routine axial pelvic CT scans, without injury to the pelvic ring and obtained as part of a trauma evaluation were retrospectively identified. The orientation of the axial slices relative to the sacrum was measured for each patient and compared. The maximal cross-sectional distance at the smallest section of the sacral ala (safe zone) was measured using the routine axial CT images and these measurements compared to similar measurements taken on standardized images perpendicular (CT Inlet) and parallel (CT Outlet) to the body of the sacrum. Additional data referencing the orientation of multiple sacral radiographic landmarks were also collected. The orientation of routine axial CT image planes relative to the sacrum spanned a wide range. The angle between the routine axial CT plane and the sacrum varied from 43.5 degrees to 82.0 degrees (SD = 9 degrees). Significant differences were found in measured safe zones of routine axial CT images compared to standardized CT Inlet and CT Outlet images. Compared to CT Inlet images, routine axial CT images underestimated safe zones for transverse sacral screws at both S1 (p<0.01) and S2 (p<0.01). When compared to CT Outlet images, routine axial CT images overestimated safe zones for oblique sacro-iliac screws (p<0.01), and underestimated the safe zone for S2 transverse sacral style screws (p<0.01). No significant differences in measured variables were found between genders and sacral morphology. Our null hypotheses were rejected: routine axial CT images were found to be at widely ranging orientations relative to the sacrum, and standardized CT images (CT Inlet and CT Outlet) demonstrated statistically significant differences in measurements of safe zones compared to routine axial CT images. Furthermore, the CT Inlet and CT Outlet views provide additional information regarding sacral landmarks that could be useful for pre-operative planning.
    Journal of orthopaedic trauma 04/2014; · 1.78 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To determine if clavicle fracture displacement and shortening are different between upright and supine radiographic examinations. Combined retrospective and prospective comparative study. Level I Trauma Center PATIENTS:: Forty-six patients (mean age 49 years, range 24-89 years) with an acute clavicle fracture were evaluated. Standardized clavicle radiographs were obtained in both supine and upright positions for each patient. Displacement and shortening were measured and compared between the two positions. One resident and three traumatologists classified the fractures and measured displacement and shortening. Data was aggregated and compared to ensure reliability with a two-way mixed intraclass correlation (ICC). Fracture displacement was significantly greater when measured from upright radiographs (15.9±8.9mm) than from supine radiographs (8.4±6.6mm, p<0.001), representing an 89% increase in displacement with upright positioning. Forty-one percent of patients had greater than 100% displacement on upright, but not on supine radiographs. Compared to the uninjured side, 3.0±10.7mm of shortening was noted on upright radiographs and 1.3±9.5mm of lengthening on supine radiographs (p<0.001). The ICC was 0.82 (95% CI: 0.73-0.89) for OTA fracture classification, 0.81 (95% CI: 0.75-0.87) for vertical displacement, and 0.92 (95% CI: 0.88-0.95) for injured clavicle length, demonstrating very high agreement among evaluators. Increased fracture displacement and shortening was observed on upright compared to supine radiographs. This suggests that upright radiographs may better demonstrate clavicle displacement and predict the position at healing if nonoperative treatment is selected.
    Journal of orthopaedic trauma 04/2014; · 1.78 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this study was to compare the infection risk when internal fixation plates either overlap or did not overlap previous external fixator pin sites in patients with bicondylar tibial plateau fractures and pilon fractures treated with a two-staged protocol of acute spanning external fixation and later definitive internal fixation. Retrospective comparison study. Two level I trauma centers. A total of 85 OTA type 41C bicondylar tibial plateau fractures and 97 OTA type 43C pilon fractures treated between 2005 to 2010. Radiographs were evaluated to determine the positions of definitive plates in relation to external fixator pin sites and patients were grouped into an "overlapping" group and a "non-overlapping" group. Fifty patients had overlapping pin sites and 132 did not. Presence of a deep wound infection RESULTS:: Overall, 25 patients developed a deep wound infection. Of the 50 patients in the "overlapping" group, 12 (24%) developed a deep infection, compared to 13 (10%) of the 132 patients in the "non-overlapping" group (p = 0.033). Placement of definitive plate fixation overlapping previous external fixator pin sites significantly increases the risk of deep infection in the two-staged treatment of bicondylar tibial plateau and pilon fractures. Surgeons must make a conscious effort to place external fixator pins outside of future definitive fixation sites to reduce the overall incidence of deep wound infections. Additionally, consideration must be given to the relative benefit of a spanning external fixator in light of the potential for infection associated with their use.
    Journal of orthopaedic trauma 02/2014; · 1.78 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The evolution of locking plates and modern nail constructs provides the orthopaedic trauma surgeon with a myriad of options with regard to implant selection for common fractures. There is a significant amount of biomechanical literature comparing modern constructs with those conventionally used. A basic understanding of this literature is required in order to make informed decisions with regard to implant selection in the management of these injuries. This article reviews the most recent biomechanical literature regarding implant selection and application for a variety of commonly treated injuries including fractures of the clavicle, proximal humerus, distal humerus, intertrochanteric hip region, distal femur and bicondylar tibial plateau.
    Journal of orthopaedic trauma 01/2014; · 1.78 Impact Factor
  • Steven Cherney, Michael J Gardner
    [Show abstract] [Hide abstract]
    ABSTRACT: Successful treatment of bicondylar tibial plateau requires focused and specific assessment and treatment of the medial fragment. Many fragment variations exist that help guide treatment. This may include posteromedial or medial plating using a variety of reduction and fixation techniques, or indirect reduction and lateral locked plating. With appropriate assessment, good results can be achieved.
    The journal of knee surgery 12/2013;
  • Journal of orthopaedic trauma 11/2013; 27(11):605-6. · 1.78 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVES:: Locked plating has become a standard method to treat supracondylar femur fractures. Emerging evidence indicates this method of treatment is associated with modest failure rates. The goals of this study were to determine risk factors for complications and to provide technical recommendations for locked plating of supracondylar femur fractures. DESIGN:: Retrospective review SETTING:: Three Level I or II Trauma Centers PATIENTS/PARTICIPANTS:: Three-hundred twenty-six patients with 335 distal femur fractures (OTA 33A or C, 33% open) treated with lateral locked plates were studied. The average patient age was 57 years (range 17 - 97 years), 55% were female, 34% obese, 19% diabetic, and 24% smokers. INTERVENTION:: All patients were managed with open reduction internal fixation (ORIF) using a lateral distal femoral locked plate construct that included locked screws in the distal fragment and either non-locked, locked or a combination of locked and non-locked screws in the proximal fragment. MAIN OUTCOME MEASUREMENTS:: Risk factors for re-operation to promote union, deep infection, and implant failure. RESULTS:: After the index procedure, 64 fractures (19%) required re-operation to promote union, including 30 that had a planned staged bone grafting due to metaphyseal defect after debridement of an open fracture. Independent risk factors for re-operation to promote union and deep infection included diabetes and open fracture. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length. CONCLUSIONS:: The identified risk factors for re-operation to promote union and complications included open fracture, diabetes, smoking, increased body mass index, and shorter plate length. The majority of these factors are out of surgeon control, but are useful when considering prognosis. Use of relatively long plates is a technical factor that can reduce risk for fixation failure.
    Journal of orthopaedic trauma 06/2013; · 1.78 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVES:: This study compared results of aggressive and nonaggressive debridement protocols for the treatment of high energy open supracondylar femur fractures after the primary procedure, with respect to the requirement for secondary bone grafting procedures, and deep infection. DESIGN:: Retrospective review SETTING:: Level I and Level II Trauma Centers PATIENTS/PARTICIPANTS:: Twenty-nine consecutive patients with high grade open (Gustilo Types II and III) supracondylar femur fractures (OTA/AO 33A and C) treated with debridement and locked plating. INTERVENTION:: Surgeons at two different Level I trauma centers had different debridement protocols for open supracondylar femur fractures. One center used a More Aggressive (MA)protocol in their patients (n=17) that included removal of all devitalized bone and placement of antibiotic cement spacers to fill large segmental defects. The other center used a Less Aggressive (LA) protocol in their patients (n=12) that included debridement of grossly contaminated bone with retention of other bone fragments and no use of antibiotic cement spacers. All other aspects of the treatment protocol at the two centers were similar: definitive fixation with locked plates in all cases; IV antibiotics were used until definitive wound closure; and weight bearing was advanced upon clinical and radiographic evidence of fracture healing. MAIN OUTCOME MEASUREMENTS:: Healing after the primary procedure, requirement for secondary bone grafting procedures, and the presence of deep infection. RESULTS:: Demographics were similar between included patients at each center with regard to: age; gender; rate of open fractures; open fracture classification; mechanism; and smoking (p>.05). Patients at the MA center were more often diabetic (p<.05). Cement spacers to fill segmental defects were used more often after MA debridement (35% vs 0%, p<0.006) and more patients had a plan for staged bone grafting after MA debridement (71% vs 8%, p<0.006). Healing after the index fixation procedure occurred more often after LA debridement (92% vs 35%, p<0.003). There was no difference in infection rate between the two protocols: 25% with the LA protocol; and 18% with the MA protocol, (p=0.63). All patients in both groups eventually healed and were without evidence of infection at an average of 1.8 years of follow-up. CONCLUSION:: The degree to which bone should be debrided after a high energy, high grade, open supracondylar femur fracture is a matter of surgeon judgment and falls along a continuous spectrum. Based on the results of the current study, the theoretic tradeoff between infection risk and osseous healing potential , seems to favor a less aggressive approach towards bone debridement in the initial treatment. LEVEL OF EVIDENCE:: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 06/2013; · 1.78 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: INTRODUCTION: The increasing frequency of orthopaedic trauma patient transfers is an issue at the centre of the current orthopaedic "call crisis" that has the potential to inundate resources at tertiary care centres. Appropriateness of transfer has been investigated only from the perspective of receiving surgeons. This study investigates the suitability and reasons for orthopaedic trauma patient transfer from the viewpoint of transferring surgeons. METHODS: A questionnaire was e-mailed to a random sampling of 500 active members of the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association. Surgeons were split into three groups: senders of trauma patients (senders); orthopaedic traumatologists who receive transfers (traumatologist receivers); and other trauma transfer receivers that are not traumatologists (non-traumatologist receivers). The perceived complexity and appropriateness for transfer of eight virtual case scenarios were determined, along with the specific reasons mitigating transfer. RESULTS: 51 Senders, 90 traumatologist receivers, and 98 non-traumatologist receivers completed 239 surveys. There was agreement between groups for case complexity and appropriateness for transfer in five of eight case scenarios (p<0.05). Fracture complexity was cited as the primary reason for transfer by 28% of senders. However, just as common was a lack of resources at the sending hospital; OR equipment (18%), critical care services (18%), and inability to handle the immediacy of the case (7%) were also cited. Likelihood of uninsured status was the least common reason for transfer (1%). CONCLUSIONS: In most cases, both senders and receivers of orthopaedic trauma have similar viewpoints regarding fracture complexity and appropriateness of transfer. Sending surgeons cite case complexity and a lack of hospital resources as the primary reasons for patient transfer. Mandating increased call for orthopaedic surgeons at non-trauma centres without a concomitant increase in hospital resources is unlikely to substantially reduce unnecessary patient transfers to higher level facilities.
    Injury 05/2013; · 2.46 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The incidence of osteoporotic fractures has been steadily rising along with the aging of the population. Surgical management of these fractures can be a challenge to orthopedic surgeons. Diminished bone mass and frequent comminution make fixation difficult. Advancements in implant design and fixation techniques have served to address these challenges and when properly applied, can improve overall outcome. The purpose of this review is to describe fixation challenges of common osteoporotic fractures and provide options for successful treatment.
    Orthopedic Clinics of North America 04/2013; 44(2):183-200. · 1.25 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVES:: The purpose of this study was to determine if surgeons could reliably predict if patients with tibia fractures treated with intramedullary nails will proceed to nonunion based on their clinical scenario and radiographs at three months. DESIGN:: Blinded randomized questionnaire based on a retrospective cohort SETTING:: University level one trauma center. PATIENTS/PARTICIPANTS:: Fifty-six patients who underwent intramedullary fixation for tibia fractures with incomplete healing at three months. METHODS:: A questionnaire was applied to 56 consecutive patients treated between 2005-2009 with intramedullary fixation for tibia fractures who had incomplete healing at three months. Each case was developed into a vignette that included the three-month radiographs and detailed clinical histories. The questionnaire was distributed to three fellowship-trained trauma surgeons, who were asked to predict if the fracture would go onto nonunion. MAIN OUTCOME MEASUREMENT:: Diagnostic accuracy of predicting nonunion in patients with incomplete healing of their tibia fracture at 3 months. RESULTS:: The combined overall diagnostic accuracy of all three surgeons was 74%. Sensitivity and specificity were 62% and 77% respectively. Radiographic features and injury mechanism were the most commonly cited clinical information used to predict fracture healing. The average positive predictive value was 73%. In 9 patients with diabetes, the diagnostic accuracy was 88%. CONCLUSION:: Clinical judgment at three months allows for correct prediction of eventual nonunion development in a majority of patients. We suggest that analysis of the entire clinical picture be used to predict fracture healing at 3 months. A protocol of waiting for six months before reoperation in all patients treated with intramedullary nailing for tibia fractures may subject patients to prolonged disability and discomfort. LEVEL OF EVIDENCE:: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 03/2013; · 1.78 Impact Factor
  • Foot & Ankle International 02/2013; 34(2):290-4. · 1.47 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVES:: To evaluate the impact of Computerized Tomography (CT) scan on both fracture classification and surgical planning of patellar fractures. DESIGN:: Prospective study SETTING:: Academic level I trauma center PATIENTS AND METHODS:: Four fellowship-trained orthopaedic trauma surgeons analyzed radiographs of 41 patellar fractures. Each fracture was classified (OTA/AO classification) and a treatment plan was developed using plain radiographs alone. The process was repeated (4-6 weeks later) with addition of CT scan. After 12 months, the 2-step analysis was repeated, and inter-observer reliability and intra-observer reproducibility were assessed. RESULTS:: Suboptimal intra- and inter- observer reliability was found for the surgical plan as well as classification using the OTA/AO system, despite the addition of a CT scan. After addition of CT, reviewers modified the classification in 66% of cases and treatment plan in 49%. CT frequently demonstrated a distinctive and severely comminuted distal pole fracture; this fracture pattern was present in 88% of cases and was unappreciated on plain radiographs in 44% of those cases. This pattern is unaccounted for by the current OTA/AO classification. CONCLUSIONS:: CT facilitates improved delineation of patella fracture patterns. Understanding the distal pole fracture pattern is fundamental in choosing a fixation construct. A fracture-specific classification system, based on CT scans should be developed.
    Journal of orthopaedic trauma 09/2012; · 1.78 Impact Factor
  • Mark J Jo, Michael J Gardner
    [Show abstract] [Hide abstract]
    ABSTRACT: Proximal humeral fractures are extremely common injuries, and are one of the true osteoporotic fractures. Most fractures can be effectively treated nonoperatively, as the rich vascularity and broad cancellous surfaces impart a high propensity for healing. Additionally, many fracture patterns result in adequate bone contact and minimal displacement with acceptable alignment. Open reduction and internal fixation of displaced fractures can improve outcomes, depending on the pre-injury functional status of the patient. If operative treatment is selected, unique treatment challenges must be overcome, including obtaining and maintaining reduction of small bone fragments with strong muscle forces, often in osteoporotic bone. Many options are feasible, including plates, nails, sutures, and other novel devices. Locking plates are the most common device used, but technical detail is critical to minimize the risk of implant failure, loss of reduction, and reoperation.
    Current Reviews in Musculoskeletal Medicine 05/2012; 5(3):192-8.
  • James R Ross, Michael J Gardner
    [Show abstract] [Hide abstract]
    ABSTRACT: Femoral head fractures may present in various patterns with or without associated fractures around the hip. As a result, the treating orthopaedic surgeon must understand not only the fracture pattern, but also patient-related fractures and the relevant operative exposures and reconstructive options to achieve the best functional outcome while minimizing complications. Treatment options range from non-operative treatment to fracture fragment excision or fracture fixation using various surgical exposures and implants. This article reviews the current literature on the treatment options for femoral head fractures and presents modern operative techniques that have improved exposure of the fracture while minimizing associated risks such as avascular necrosis, heterotopic ossification, and neurovascular compromise. A sound understanding of the anatomy and these newer techniques can enable the surgeon to provide improved expectations and clinical outcomes.
    Current Reviews in Musculoskeletal Medicine 05/2012; 5(3):199-205.

Publication Stats

2k Citations
268.26 Total Impact Points


  • 2009–2014
    • Washington University in St. Louis
      • Department of Orthopaedic Surgery
      San Luis, Missouri, United States
  • 2013
    • United States Navy
      • Department of Orthopaedic Surgery
      Monterey, California, United States
  • 2009–2012
    • University of Washington Seattle
      • Department of Orthopaedics and Sports Medicine
      Seattle, WA, United States
  • 2006–2012
    • Weill Cornell Medical College
      • Department of Orthopaedic Surgery
      New York City, New York, United States
  • 2011
    • Barnes Jewish Hospital
      San Luis, Missouri, United States
    • University of Pennsylvania
      • Department of Orthopaedic Surgery
      Philadelphia, PA, United States
  • 2008–2009
    • Swedish Medical Center Seattle
      Seattle, Washington, United States
    • Washington Hospital Center
      Washington, Washington, D.C., United States
  • 2007–2009
    • Hannover Medical School
      • Trauma Department
      Hannover, Lower Saxony, Germany
    • University of Zurich
      • Department of Pediatric Orthopaedics
      Zürich, ZH, Switzerland
    • State University of New York Upstate Medical University
      Syracuse, New York, United States
  • 2004–2009
    • Hospital for Special Surgery
      • Department of Orthopaedic Surgery
      New York City, NY, United States
  • 2002
    • New York Presbyterian Hospital
      New York City, New York, United States