Faculty Bibliography

BACKGROUND: Persistent pain in the region of implanted hardware following fracture fixation commonly leads to implant removal. This prospective study evaluated patient outcomes and pain reduction following removal of orthopaedic hardware implanted for fracture fixation. METHODS: Sixty patients who had been treated previously for a fracture and complained of pain in the region of the fracture fixation hardware constituted the study cohort. Patients were carefully examined by the treating physician to rule out other causes of pain such as infection and nonunion. Baseline data were recorded preoperatively. Data obtained postoperatively at three, six, and twelve months included a visual analog pain scale score and results on the Short Musculoskeletal Function Assessment Questionnaire and the Medical Outcomes Study Short Form-36. At the one-year interval, a patient satisfaction questionnaire was completed and outcomes were analyzed. RESULTS: There were no complications associated with implant removal surgery. Three patients did not have complete follow-up, leaving a total of fifty-seven patients with complete follow-up. At one year, all patients indicated that they were satisfied, that they would have the procedure done again, and that their overall function had improved. The scores for pain on the visual analog scale decreased from a mean (and standard deviation) of 5.5 +/- 2.5 before hardware removal to 1.3 +/- 1.8 after hardware removal, with an overall improvement at one year of 76% (p = 0.00001). At one year, thirty (53%) of the fifty-seven patients had complete resolution of pain. In addition, the results on the Short Musculoskeletal Function Assessment Questionnaire showed a 43% improvement from baseline (p = 0.0001), and the results on the physical component of the Short Form-36 showed a similar improvement of 40% (p = 0.0001). CONCLUSIONS: Following fracture-healing, removal of hardware is safe with minimal risk. Improvement in pain relief and function can be expected

BACKGROUND: Recommendations for surgical treatment and expected outcomes differ for two unstable patterns of supination-external rotation ankle injuries. We compared the demographic characteristics and functional outcome following surgical stabilization between the two types of supination-external rotation type-4 fractures: distal fibular fracture with a deltoid ligament rupture and bimalleolar fracture. METHODS: Demographic data on 456 patients in whom an unstable fracture of the ankle was treated surgically were entered into a database and the patients were prospectively followed. Two hundred and sixty-six of these patients sustained either a bimalleolar fracture or a lateral malleolar fracture with insufficiency of the deltoid ligament and widening of the medial clear space. No medial fixation was used in the patients with a deltoid ligament injury. All patients followed a similar postoperative protocol. The patients were followed clinically and radiographically at three, six, and twelve months after the surgery. Function was assessed with the Short Musculoskeletal Function Assessment and the American Orthopaedic Foot and Ankle Society score. RESULTS: Bimalleolar fractures were more commonly seen in female patients, in those older than sixty years of age, and in patients with more comorbidities. There was no significant association between the fracture pattern and either diabetes or the length of the hospital stay. At a minimum of one year postoperatively, the patients with a bimalleolar fracture had significantly worse function, even after we controlled for all other variables. The overall complication rate, including elective hardware removal, was also higher in the group with a bimalleolar fracture (seventeen compared with nine patients). CONCLUSIONS: At one year after surgical stabilization of an unstable ankle fracture, most patients experience little or mild pain and have few restrictions in functional activities. However, the functional outcome for those with a bimalleolar fracture is worse than that for those with a lateral malleolar fracture and disruption of the deltoid ligament, possibly because of the injury pattern and the energy expended