Faculty Bibliography

Treating intra-articular fractures about the osteoporotic distal humerus poses a significant challenge. The purpose of this retrospective study was to evaluate functional outcomes for distal humeral fractures treated with total elbow arthroplasty (TEA) or open reduction and internal fixation (ORIF) in a nonarthritic elderly population with osteoporosis. We reviewed the records of all women older than age 60 who had undergone surgical treatment for intraarticular distal humerus fractures (Orthopaedic Trauma Association types 13B and 13C) by 1 of 2 surgeons. Demographic and operative data were obtained, charts were reviewed, and patients were asked to have their outcomes evaluated with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Mayo Elbow Performance Index (MEPI). Twenty-two patients (23 elbows) were identified, and 2 of these (3 elbows) were excluded. Of the remaining 20 patients, 9 had undergone cemented, semiconstrained TEA as initial treatment, and 11 had undergone ORIF. These 2 groups were compared. Mean follow-up was 14.8 months (range, 6-38 months). There were no significant differences between the TEA and ORIF groups with respect to demographic factors. Final elbow range of motion was 92 degrees flexion-extension arc (arthroplasty group) and 98 degrees (fixation group). Two patients in the arthroplasty group and 2 in the fixation group died. For the remaining patients, mean DASH scores were 30.2 (arthroplasty) and 32.1 (fixation), and mean MEPI scores were 79 (arthroplasty) and 85 (fixation). These differences were not statistically significant. Four TEAs developed radiographic loosening by a mean of 15 months, and 1 of these underwent revision with good outcome. Ten of the 11 fractures in the fixation group healed radiographically; the 1 nonunion with collapse continued to be asymptomatic. Two patients in the fixation group underwent contracture release after union for limited elbow range of motion. Many factors come into play in the treatment of intra-articular distal humerus fractures in patients with osteoporosis. Implant selection must be based on bone quality, expected outcome, and surgeon experience. For these injuries, good outcomes may be obtained with either TEA or ORIF

Before proceeding with treatment, it is necessary to recognize that bony injuries are always associated with soft-tissue disruption and damage. A good soft-tissue envelope is essential to fracture healing and overall extremity function. Injury management begins by recognizing and classifying the injury. Wound debridement with irrigation fluid at low pressure and the administration of antibiotics are essential aspects of treatment. Wound treatment starts with applying dressing material using negative suction and can be guided by the tenets of an algorithm modeled on the reconstructive ladder

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.

INTRODUCTION: Wrong-site surgery is defined as an operation conducted at the wrong site, on the wrong person, or resulting in the wrong procedure. Since 1993, more than 2200 wrong-site surgeries have been reported by the National Practitioner Data Base. A 2005 survey reported, 5.6% of replying academy fellows encountered a wrong-site surgery incident. Multiple interventions have been since suggested for prevention of these occurrences by the American Academy of Orthopaedic Surgeons and Joint Commission on Accreditation of Healthcare Organizations. MATERIALS AND METHODS: This institutional review board-approved study was conducted to investigate patient compliance and reliability in marking the surgical site. Two hundred patients undergoing orthopedic surgery who agreed to participate were enrolled at the time of preoperative testing and clearance for surgery. The patients received instructions to mark the surgical site with a 'YES.' Patient data collected included age, sex, procedure type and location, history of previous orthopedic surgeries, workmen's compensation status or motor vehicle collision involvement, employment status, primary language, level of education, presence of depression or toxic habits, and the time between enrollment and day of surgery. RESULTS: We achieved an overall compliance rate of 68.2%. There was no difference with respect to sex, tobacco use or history of depression, level of education or occupation, workmen's compensation, or government insurance status. The mean age of compliant patients was 48.6 years versus 53.3 years for those who did not comply (P = 0.05). About 72% of those who spoke English as a primary language complied, as opposed to 49% in others (P = 0.009). The time between enrollment and surgery was 10.4 days in compliant patients versus 23.1 days in noncompliant patients (P = 0.05). No statistically significant difference was noted with all other variables recorded. In no instance did patients mark the wrong side or make any marks likely to contribute to the wrong operation. CONCLUSIONS: Patient's ability to be involved in this preventative measure is independent of most demographic variables previously thought to be significant. However, in view of the 68.2% compliance, patient involvement in surgical site marking is unreliable and may not help in decreasing the chances of wrong-site surgery

BACKGROUND:: The purpose of this article was to compare clinical and functional outcomes of surgically treated trimalleolar fractures with bimalleolar and unimalleolar ankle fractures. METHODS:: A prospective database was established to enroll all unstable ankle fractures treated operatively at our institution from October 2000 to July 2005. Demographic data on 456 patients, who sustained an unstable fracture of the ankle and were treated surgically, were entered into a database, and the patients were prospectively followed up. Of these 309 patients who had at least 1-year follow-up, 54 patients sustained an ankle fracture with involvement of the posterior malleolus. Two hundred fifty-five patients had an ankle fracture without involvement of the posterior malleolus. Of the 54 posterior malleolus fracture, 20 underwent fixation of the posterior malleolus. All patients were followed up at 3 months, 6 months, and 12 months after surgery and assessed functionally with Short Musculoskeletal Function Assessment and American Orthopaedic Foot and Ankle Society Scores. RESULTS:: There was no difference in age, sex distribution, or American society of anesthesiologists classification or incidence of diabetes between the two groups. At 1-year follow-up, all patients improved their function and pain status. Using the American Orthopaedic Foot and Ankle Society, patients with posterior malleolus fracture were significantly worse both for total score (p = 0.004) and pain function (p = 0.002). At 2-year follow-up, there was no significant difference in a smaller group of patients (41 patients). Using the Short Form-36, there was a significant difference seen with vitality and social function subgroups at 1 year. Using the Short Musculoskeletal Function Assessment, there was a significant difference at 1 year for dysfunction index (p = 0.04) for the trimalleolar group. CONCLUSION:: Most patients after unstable ankle fractures treated surgically do well; however, some patients continue to have some pain and dysfunction at 1 year. There was a significant difference in outcomes comparing patients with unstable ankle fractures associated with and without posterior malleolus fractures. The presence of a posterior malleolus fracture may indicate higher energy of injury, and it does seem to result in worse outcomes at 1 year, but this seems to even out over time as was seen at 2-year follow-up in a smaller group of patients

The goals of this study were to find associations between anterior and posterior ring injuries, provide a descriptive comparison of pelvic ring disruptions as assessed by plain radiography, and compare the value of computed tomography (CT) over plain radiography in evaluating anterior and posterior structures. A retrospective review of radiographic reports and records identified 142 patients with pubic ramus fractures as observed by plain radiography. A statistical analysis was performed to test the associations between anterior ring injury as assessed by plain radiography and posterior ring injury as assessed by CT. Forty-five point five percent of patients with bilateral ramus fractures and 42.0% of patients with dual-ramus fractures had concomitant sacral fractures not observed on plain radiographs. These occult sacral fractures were found in only 11.1% of patients with inferior ramus fractures. The type of pubic injury on plain radiographs may be predictive of posterior ring injury, and therefore may help determine injury energy and severity, determine the need for further imaging studies, and help guide clinical management. Although CT is highly sensitive in identifying both anterior and posterior pubic ring injuries, elderly patients with simple fractures of a single pubic ramus are less likely to suffer from pelvic instability and thus may not benefit from CT

Distal radius fractures are the most common upper extremity fracture, representing one-sixth of all fractures treated in emergency departments nationwide. Beyond the initial reduction and immobilization of these fractures, providing proper followup to ensure maintenance of the reduction and identify complications is necessary for optimal recovery of forearm and wrist functions. We sought to identify the clinical and demographic factors that characterize patients with distal radius fractures who do not return for followup and to assess the underlying causes for their poor followup rates. Compared with patients who were compliant with followup, those lost to followup had lower Physical and Mental Health scores on the SF-36 forms, more often were treated nonoperatively, and more likely had not surpassed secondary education. However, we found no difference between these two groups based on age, gender, mechanism of injury, marital status, or hand dominance. Early identification of patients who potentially are noncompliant can result in additional measures being taken to ensure the patient's return to the treating hospital and physicians. This in turn will prevent complications attributable to lack of followup and allow more accurate assessment of results, thereby improving patient outcomes

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