Faculty Bibliography

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.

OBJECTIVES: : The purpose of this study was to compare the outcome after the operative treatment of patella fractures (PFs) as compared with those of quadriceps tendon and patella tendon (PT) ruptures. DESIGN: : This pertains to a retrospective case control. SETTING: : The setting was in academic teaching hospitals. PATIENTS: : Ninety-four patients with 99 extensor mechanism disruptions were treated operatively. Of these, 50 (50%) were PFs; 36 (37%) were quadriceps ruptures; and 13 (13%) were PT ruptures. MAIN OUTCOME MEASURES: : The patients were evaluated at 6 and 12 months and were tested for range of motion, quadriceps circumference and strength, SF36, Lysholm, and Tegner outcome scores by independent observers. Radiographs of the knee were obtained to assess bony healing, posttraumatic arthritis, and heterotopic ossification RESULTS: : A minimum of 12-month follow-up (range 12-81 months) was available for 76 patients (77%). PFs were seen more commonly in women (P < 0.001) and PT ruptures tended to occur in younger males (P < 0.001), with no difference in the body mass index. Thigh circumference was significantly smaller than normal in PFs at 1 year as compared with tendon injuries. At latest follow-up, there were no significant differences noted with respect to knee range of motion, radiographic arthritis, Tegner, Lysholm, or SF36 scores. CONCLUSIONS: : There were no significant differences with regard to outcome in patients sustaining these injuries. LEVEL OF EVIDENCE: : Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

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.

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.

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.

A mangled extremity is defined as a limb with injury to three of four systems in the extremity. The decision to salvage or amputate the injured limb has generated much controversy in the literature, with studies to support advantages of each approach. Various scoring systems have proved unreliable in predicting the need for amputation or salvage; however, a recurring theme in the literature is that the key to limb viability seems to be the severity of the soft-tissue injury. Factors such as associated injuries, patient age, and comorbidities (such as diabetes) also should be considered. Attempted limb salvage should be considered only if a patient is hemodynamically stable enough to tolerate the necessary surgical procedures and blood loss associated with limb salvage. For persistently hemodynamically unstable patients and those in extremis, life comes before limb. Recently, the Lower Extremity Assessment Project study attempted to answer the question of whether amputation or limb salvage achieves a better outcome. The study also evaluated other factors, including return-to-work status, impact of the level of and bilaterality of the amputation, and economic cost. There appears to be no significant difference in return to work, functional outcomes, or the cost of treatment (including the prosthesis) between the two groups. A team approach with different specialties, including orthopaedics, plastic surgery, vascular surgery and trauma general surgery, is recommended for treating patients with a mangled extremity.