Faculty Bibliography

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

OBJECTIVE: This study was performed to evaluate the results of operative treatment of ankle fractures in patients who required syndesmotic stabilization in addition to malleolar fracture fixation compared with patients who required malleolar fixation alone. DESIGN: The authors conducted a retrospective review of prospectively collected data. SETTING: Academic medical center. PATIENTS: Between October 2000 and November 2006, 347 patients who underwent surgical repair of an unstable ankle fracture were enrolled in a prospective database. INTERVENTION: Patients who had an associated syndesmotic disruption requiring surgical stabilization in association with either an ankle fracture or a fracture-dislocation were identified and compared with a cohort treated during the same time period who had sustained an ankle fracture or fracture-dislocation without syndesmotic disruption. MAIN OUTCOME MEASUREMENTS: All patients were followed and evaluated at 3, 6, and 12 months with clinical and radiographic examination as well as functional status (Short Musculoskeletal Functional Assessment, American Orthopaedic Foot and Ankle Society). Patient-reported pain and postoperative complications were recorded as well. RESULTS: Three hundred forty-seven patients met the inclusion criteria and had 1-year minimum follow up. Seventy-nine patients (23%) who had syndesmotic stabilization were identified and compared with 268 patients (77%) who did not. No differences were found between the two groups with respect to age or American Society of Anesthesiologists status; however, there was a greater percentage of men in the syndesmotic injury group (P = 0.04). There was a greater percentage of Type C fractures requiring syndesmosis stabilization, whereas Type B fractures were less likely to require syndesmosis stabilization (P = 0.001) At 6- and 12-month follow up, there was a clear difference in outcome based on American Orthopaedic Foot and Ankle Society and Short Musculoskeletal Functional Assessment scores; patients who underwent syndesmotic stabilization had worse American Orthopaedic Foot and Ankle Society scores with lower function ratings (P = 0.04) and worse pain ratings (P = 0.02). Short Musculoskeletal Functional Assessment scores were also worse at 12 months in patients who had syndesmotic stabilization because the dysfunction index was higher in the syndesmotic injury group (P = 0.009). Radiographically, 18 of 144 (13%) syndesmotic screws were noted to be broken on follow-up radiographs, eight of which were subsequently removed. There were no other differences in complication rates. CONCLUSION: Patients who required syndesmotic stabilization in addition to malleolar fracture fixation had poorer outcomes at 12 months compared with patients who required malleolar fracture fixation alone. This information is important for patient counseling to manage expectations regarding outcomes after injury

Hip dislocations are uncommon injuries that result from high-energy mechanisms. These patients require careful trauma evaluation to rule out concomitant injuries. Early closed or open reduction that is performed within 6 hours and close radiological follow-up is recommended to obtain the best possible results. It is also essential to educate the patient regarding the potential sequelae and follow them for evidence of osteonecrosis and posttraumatic arthritis

Fractures of the distal humerus can be difficult to treat due to the periarticular nature of these injuries and the complexity of the elbow joint. Although anatomic and timely repair of the distal humerus with meticulous handling of soft tissues and appropriate postoperative therapy all help to optimize results, an open fracture presents other challenges that may limit successful outcomes in spite of these measures. Open fractures have been found to affect younger males involved in high-energy injuries, as well as older, osteoporotic females involved in lower energy situations. Successful management of these injuries requires urgent and aggressive soft tissue management, skeletal stabilization, and treatment of neurovascular insult (if applicable). This article presents a review of the current literature available concerning the epidemiology, assessment and examination, treatment options, complications, and outcomes of patients with open distal humerus fractures

The diagnostic and therapeutic modalities utilized in the management of pelvic ring fractures depend on patient characteristics, mechanism of injury, and hemodynamic status at the time of presentation. Knowledge of the complex anatomy and biomechanics of pelvic stability may guide appropriate initial management strategies. Even with the development of specific treatment algorithms and advances in both diagnostic and operative techniques, fractures of the pelvis continue to cause significant morbidity and mortality. The current paper reviews the diagnosis and management of pelvic ring fractures, focusing on current concepts with respect to initial assessment and treatment protocols, including the identification of associated injuries and emergency methods of provisional pelvic stabilization

Various treatment options exist for distal radius fractures, and the complications associated with operative and nonoperative management are well documented in the literature. While surgical management with the use of various buttress and locked plating constructs has gained popularity, the long-term outcomes of these plating techniques have not yet significantly demonstrated improved outcomes, as compared to adequately reduced nonoperative measures. Furthermore, this operative technique can be associated with failures and complications. We present a case report of one volar-plate construct requiring revision, secondary to loss of fracture reduction, with no evidence of implant loosening or failure. A literature review on the complications associated with these plate constructs is also presented

There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12-36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence

BACKGROUND: While alendronate therapy has been shown to decrease the risk of vertebral and femoral neck fractures in postmenopausal osteoporotic patients, recent reports have associated long-term alendronate therapy with unilateral low-energy subtrochanteric and diaphyseal femoral fractures in a small number of patients. To our knowledge, there has been only one report of sequential bilateral femoral fractures in patients on long-term bisphosphonate therapy. METHODS: We retrospectively reviewed the case log of the senior author over the last four years to identify patients who presented with a subtrochanteric or diaphyseal femoral fracture after a low-energy mechanism of injury (a fall from standing height or less) and who had been taking alendronate for more than five years. Radiographs were reviewed, and the fracture patterns were recorded. Serum calcium levels were recorded when available. RESULTS: Seven patients who sustained low-energy bilateral subtrochanteric or diaphyseal femoral fractures while on long-term alendronate therapy were identified. One patient presented with simultaneous bilateral diaphyseal fractures, two patients had sequential subtrochanteric fractures, and four patients had impending contralateral subtrochanteric stress fractures noted at the time of the initial fracture. Of the latter four, one patient had a fracture through the stress site and the other three patients had prophylactic stabilization of the site with internal fixation. No patient had discontinued alendronate therapy prior to the second fracture. All patients were women with an average age of sixty-one years, and they had been on alendronate therapy for an average of 8.6 years. All fractures were treated with reamed intramedullary nailing and went on to union at an average of four months. CONCLUSIONS: In patients on long-term alendronate therapy who present with a subtrochanteric or diaphyseal femoral fracture, we recommend radiographs of the contralateral femur and consideration of discontinuing alendronate in consultation with an endocrinologist. If a contralateral stress fracture is found, prophylactic fixation should be considered