Faculty Bibliography

OBJECTIVES: : To compare postoperative pain control in patients treated surgically for ankle fractures who receive popliteal blocks with those who received general anesthesia alone. DESIGN: : Institutional Review Board approved prospective randomized study. SETTING: : Metropolitan tertiary-care referral center. PATIENTS: : All patients being treated with open reduction internal fixation for ankle fractures who met inclusion criteria and consented to participate were enrolled. INTERVENTIONS: : Patients were randomized to receive either general anesthesia (GETA) or intravenous sedation and popliteal block. MAIN OUTCOME MEASURES: : Patients were assessed for duration of procedure, total time in the operating room, and postoperative pain at 2, 4, 8, 12, 24, and 48 hours after surgery using a visual analog scale. RESULTS: : Fifty-one patients agreed to participate in the study. Twenty-five patients received popliteal block, while 26 patients received GETA. There were no anesthesia-related complications. At 2, 4, and 8 hours postoperatively, patients who underwent GETA demonstrated significantly higher pain. At 12 hours, there was no significant difference between the 2 groups with regard to pain control. However, by 24 hours, those who had received popliteal blocks had significantly higher pain with no difference by 48 hours. CONCLUSIONS: : Popliteal block provides equivalent postoperative pain control to general anesthesia alone in patients undergoing operative fixation of ankle fractures. However, patients who receive popliteal blocks do experience a significant increase in pain between 12 and 24 hours. Recognition of this "rebound pain" with early narcotic administration may allow patients to have more effective postoperative pain control. LEVEL OF EVIDENCE: : Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Open distal humerus fractures present significant soft-tissue injury and bone devitalization that require prompt irrigation and debridement, temporization, and soft-tissue coverage. METHODS: This case-control comparison of open and closed AO type C fractures of the distal humerus tests the null hypothesis that there is no difference in the outcomes and prognosis of open versus closed distal humerus fractures treated operatively. Outcomes were determined clinically and radiographically and reported by the Short Musculoskeletal Function Assessment, the Short Form-36,and the Mayo Elbow Performance Index. RESULTS: Twenty-eight matched cohort patients treated by operative fixation were identified (14 open and 14 closed injuries), with average follow-up 98.9 weeks (range, 52-160 weeks). The average time to osseous healing after definitive treatment was 24.7 weeks for open fractures, when compared with 18.7 weeks for the closed group (p = 0.085). The average range of motion at final follow-up for open fractures was 82.5 degrees, versus 108.7 degrees for the closed group (p = 0.03). Short form-36 was significantly poorer(p = 0.002) in the open group (57.9) when compared with the closed group (79.0). CONCLUSIONS: When compared with closed fractures, open distal humerus fractures have worse functional outcome scores and decreased range of motion. Patients with open fractures also demonstrated a trend toward having higher complication rates, prolonged times to union, and higher rates of persistent nerve deficits requiring further surgery.

Management of traumatic soft-tissue injuries remains a challenging and ever evolving field within orthopedic surgery. The basic principle of addressing life before limb in the initial assessment of critically injured patients has not changed. Although arteriography remains the gold standard for vascular injury screening, computed tomography angiography is being used more often to determine limb viability, and its sensitivity and specificity for detecting vascular lesions are reported to be excellent. Thorough debridement and irrigation with early institution of antibiotics are crucial in preventing infection; debridement should be performed urgently once life-threatening conditions have been addressed. Increasing use of vacuum-assisted closure therapy has created a trend down the reconstructive ladder, with improvements in resulting wound closure. Although the orthoplastics approach and new microsurgical techniques have made limb salvage possible in even the most severely injured extremities, it is important to clearly identify the zone of injury and to inform patients and their families of the outcomes of limb salvage versus amputation. Results from the LEAP (Lower Extremity Assessment Project) trials and similar studies should guide orthopedic surgeons in the management of these complex injuries. Nevertheless, it is important to individualize management plans according to patient factors.

The recent increase in life expectancy is expected to bring about a concurrent rise in the number of proximal humerus fractures. Those presenting with significant displacement, osteoporosis, and comminution present distinct clinical challenges, and the optimal treatment of these injuries remains controversial. As implant technologies and treatment strategies continue to evolve, the role and appropriateness of certain operative and nonoperative treatment modalities are being debated. Prior concerns regarding humeral head viability forced many physicians to abandon operative management in favor of nonoperative modalities. However, with greater appreciation and understanding of the factors governing humeral head viability, operative intervention is increasingly used and investigated. Nevertheless, sub-optimal results with earlier implants continue to cloud the debate between nonoperative and operative treatment modalities. This paper will review historical considerations, biologic considerations, and implant considerations in the management of three-and four-part proximal humerus fractures.

Operative fixation of distal radius fractures is one of the most commonly performed orthopedic procedures. However, there remains little consensus on the indications for operative versus nonoperative treatment of these injuries. The American Academy of Orthopaedic Surgeons has recently published clinical practice guidelines to help guide management of these injuries. The purpose of this paper is to review the biomechanical and clinical retrospective and prospective data pertinent to the indications for operative management of distal radius fractures. Conflicting data exists as to the optimal management of these injuries, especially in patients over the age of 55. Although there is some evidence to support operative fixation of distal radius fractures, better longterm, prospective, randomized studies with validated patient outcome measures are needed to definitively establish the optimal method of treatment for these injuries.

In managing complex proximal tibia fractures, several options are available to the treating surgeon. Closed management with or without external fixation, formal open reduction and internal fixation, and intramedullary nail fixation have been described in the literature. There is a lack of consensus regarding the optimal treatment method for complex bicondylar patterns or proximal metadiaphyseal fractures with or without involvement of the articular surface. It is helpful to review the standard and alternative surgical approaches to bicondylar tibial plateau fractures and to be aware of the intramedullary nail as an alternative approach for complex proximal metadiaphyseal patterns.

OBJECTIVE: The objective of our study was to evaluate the diagnostic utility of conventional radiography for diagnosing bisphosphonate-related atypical subtrochanteric femoral fractures. MATERIALS AND METHODS: Retrospective interpretation of 38 radiographs of complete subtrochanteric and diaphyseal femoral fractures in two patient groups-one group being treated with bisphosphonates (19 fractures in 17 patients) and a second group not being treated with bisphosphonates (19 fractures in 19 patients)-was performed by three radiologists. The readers assessed four imaging criteria: focal lateral cortical thickening, transverse fracture, medial femoral spike, and fracture comminution. The odds ratios and the sensitivity, specificity, and accuracy of each imaging criterion as a predictor of bisphosphonate-related fractures were calculated. Similarly, the interobserver agreement and the sensitivity, specificity, and accuracy of diagnosing bisphosphonate-related fractures (i.e., atypical femoral fractures) were determined for the three readers. RESULTS: Among the candidate predictors of bisphosphonate-related fractures, focal lateral cortical thickening and transverse fracture had the highest odds ratios (76.4 and 10.1, respectively). Medial spike and comminution had odd ratios of 3.8 and 0.63, respectively. Focal lateral cortical thickening and transverse fracture were also the most accurate factors for detecting bisphosphonate-related fractures for all readers. The sensitivity, specificity, and overall accuracy for diagnosing bisphosphonate-related fractures were 94.7%, 100%, and 97.4% for reader 1; 94.7%, 68.4%, and 81.6% for reader 2; and 89.5%, 89.5%, and 89.5% for reader 3, respectively. The interobserver agreement was substantial (kappa > 0.61). CONCLUSION: Radiographs are reliable for distinguishing between complete femoral fractures related to bisphosphonate use and those not related to bisphosphonate use. Focal lateral cortical thickening and transverse fracture are the most dependable signs, showing high odds ratios and the highest accuracy for diagnosing these fractures

BACKGROUND: : Open distal humerus fractures are associated with soft tissue and bony injury. This study compares the results of a staged protocol using initial joint spanning external fixation and delayed definitive fixation to acute definitive fixation. METHODS: : Treated open distal humerus fractures were retrospectively reviewed, with patients examined at 2 weeks, 6 weeks, 12 weeks, 26 weeks, and 52 weeks after definitive surgery. Outcomes were determined radiographically by union rate and clinically by range of motion, Short Musculoskeletal Function Assessment, Short Form-36, and Mayo Elbow Performance Index. RESULTS: : Fourteen treated patients with open AO/OTA type 13-C3 distal humerus fractures, with average patient age 52.7 years and average follow-up 98.6 weeks, were identified. All fractures were treated with initial irrigation and debridement emergently and either spanning external fixation in eight patients or primary definitive internal fixation in six patients. All fractures healed, with average time to osseous healing, in 25.7 weeks versus 23.4 weeks (p = 0.7) in staged versus primary definitive treatment, respectively. Elbow range of motion on final follow-up was 73.75 degrees versus 94.17 degrees (p = 0.22). Complications included nonunions, heterotopic ossification, infection, and persistent ulnar nerve deficit. Average functional outcomes scores for staged management versus primary internal fixation were Short Form-36, 50.2 versus 68.2 (p = 0.065); Short Musculoskeletal Function Assessment, 33.5 versus 12.5 (p = 0.078); and Mayo Elbow Performance Index, 55.6 versus 84.2 (p = 0.011), respectively. CONCLUSIONS: : Open distal humerus fractures had poor outcomes relative to normative functional scores; however, this is possibly due to more severe soft tissue injuries that were felt better managed with staged management at the time of presentation