Faculty Bibliography

OBJECTIVE: To compare the strength and stiffness of standard double-plate fixation with that of a single-locking plate for comminuted extra-articular distal humeral fractures. MATERIALS: Eight matched pairs of humeri were used. One of each pair was fixed with two 3.5-mm standard reconstruction plates applied dorsally; the other was fixed with one precontoured locking plate applied to the posterior aspect of the lateral column. A 1-cm gap was created to simulate a distal fracture model with 100% metaphyseal comminution with no bony apposition. Stiffness testing of these constructs was performed in axial compression, anterior, posterior and lateral bending, and torsion. They were then cyclically loaded for 4000 cycles with 60 N in posterior bending and the stiffnesses retested. Finally, each construct was posteriorly loaded to failure to determine its ultimate strength. RESULTS: The double-plate construct was significantly stiffer than the one locking plate construct in anterior bending (39%; p = 0.02), posterior bending (23%; p = 0.04), and lateral bending (60%; p = 0.01). No significant stiffness differences were seen in axial compression and torsion (p = 0.64 and 0.25, respectively). After cyclic loading, all construct stiffnesses were relatively unchanged. Both construct types had similar failure strengths (p = 0.76) of approximately 400 N. CONCLUSIONS: Double-plating provides a more rigid fixation than a single-locked plate for fixation of extra-articular comminuted distal humeral fractures. This could be clinically relevant in situations with 100% comminution as seen in gun shot injuries

BACKGROUND: The saline solution load test helps to determine if a wound extends into the knee joint. Little is known about the volume of injected intra-articular saline solution that is needed to effectively rule in or rule out a traumatic arthrotomy of the knee. The purpose of the present study was to determine the appropriate volume and needle location for the diagnosis of a traumatic knee arthrotomy and to assess the effect of associated variables, including knee circumference, body mass index, and sex. METHODS: Fifty-six consecutive patients scheduled for knee arthroscopy were enrolled. A standard inferolateral arthroscopic portal was made with a single stab incision with use of a number-11 blade. Injection sites were randomized to either a superomedial or inferomedial location. The injection of normal saline solution at a rate of 5 mL/sec through an 18-gauge needle was continued while the knee was moved through a range of motion until fluid extravasated from the iatrogenic laceration. The volume of injected fluid was recorded. RESULTS: The study group included thirty-one female patients and twenty-five male patients with a combined average age of fifty years and an average body mass index of 30.9. In order to effectively diagnose 50% of the arthrotomies, 75 mL of injected fluid was needed; the volumes that were needed in order to effectively diagnose 75%, 90%, 95%, and 99% of the arthrotomies were 110, 145, 155, and 175 mL, respectively. The mean volumes of injected fluid needed for a positive result at the inferomedial and superomedial needle locations were 64.0 and 95.2 mL, respectively; this difference was significant (p = 0.01). There was no correlation between necessary injection volume and sex, body mass index, or knee circumference. CONCLUSIONS: In order to detect 95% of 1-cm inferolateral arthrotomies of the knee with use of the saline solution load test, 155 mL must be injected. An inferomedial injection location requires significantly less fluid than a superomedial injection location does for the diagnosis of inferolateral arthrotomies of the knee

Partial articular fractures of the distal humerus commonly involve the capitellum and may extend medially to involve the trochlea. As the complex nature of capitellar fractures has become better appreciated, treatment options have evolved from closed reduction and immobilization and fragment excision to a preference for open reduction and internal fixation. The latter is now recommended to achieve stable anatomic reduction, restore articular congruity, and initiate early motion. More complex fracture patterns require extensile surgical exposures. The fractures are characterized by metaphyseal comminution of the lateral column and have associated ipsilateral radial head fracture. With advanced instrumentation, elbow arthroscopy may be used in the management of these articular fractures. Though limited to level IV evidence, clinical series reporting outcomes following open reduction and internal fixation of fractures of the capitellum, with or without associated injuries, have demonstrated good to excellent functional results in most patients when the injury is limited to the radiocapitellar compartment. Clinically significant osteonecrosis and heterotopic ossification are rare, but mild to moderate posttraumatic osteoarthrosis may be anticipated at midterm follow-up

Over years of practice, many beliefs and practices become entrenched as tried and tested, and we subconsciously believe they are based on scientific evidence. We identified nine such beliefs by interviewing orthopaedic surgeons in which studies (or lack thereof) apparently do not support such practices. These are: changing the scalpel blade after the skin incision to limit contamination; bending the patient's knee when applying a thigh tourniquet; bed rest for treatment of deep vein thrombosis; antibiotics in irrigation solution; routine use of hip precautions; routine use of antibiotics for the duration of wound drains; routine removal of hardware in children; correlation between operative time and infection; and not changing dressings on the floor before scrubbing. A survey of 186 practicing orthopaedic surgeons in academic and community settings was performed to assess their routine practice patterns. We present the results of the survey along with an in-depth literature review of these topics. Most surgeon practices are based on a combination of knowledge gained during training, reading the literature, and personal experience. The results of this survey hopefully will raise the awareness of the selected literature for common practices

OBJECTIVES: External fixation is frequently used for provisional and/or definitive stabilization of open and closed fractures and dislocations involving the lower extremity. There is some concern, however, that application of an external fixator with subsequent reduction of the fractures with distraction may precipitate the development of compartment syndrome. The hypothesis of this study was that application of external fixation and restoration of limb length would have no effect on the compartment pressures. DESIGN: Prospective cohort study. SETTING: Academic medical center, 2 level 1 trauma centers. PATIENTS: Between October 2003 and May 2006, 25 patients who met inclusion criteria and underwent immediate knee-spanning external fixation. INTERVENTION: All 4 compartments of the injured leg were measured with a Solid-State Transducer Intra Compartment device or an arterial line set-up during the temporizing procedure at 4 different time points. In addition, at the time each pressure reading was taken, the patient's diastolic pressure was recorded from the anesthesia monitor. MAIN OUTCOME MEASUREMENT: Elevation of compartment pressure at any of 4 distinct time points during the procedure. Each of the compartments was measured and recorded 4 times: (1) after the patient had been draped but before any fixation or reduction of the fracture, (2) immediately after the insertion of the fixator pins, (3) immediately after reduction of the fracture, and (4) 5 minutes after the reduction. A threshold of less than 30 mm Hg differential from diastolic pressure in conjunction with clinical examination was set as an indication for 4-compartment fasciotomy. RESULTS:: Twenty-five patients with a mean age of 52 years (range, 21-69 years) were enrolled in the study. Injuries included proximal tibial fractures (Orthopaedic Trauma Association types, 41) in 21 patients; knee fracture-dislocation (Moore type II) in 2 patients, and knee (femoro-tibial) dislocations in 2 patients. Two fractures were open, and all other injuries were closed. Fasciotomy was required in 3 cases at initial compartment measurement. In the remaining 22, there were no significant trends toward increased compartment pressures as a result of external fixation placement and knee reduction. There were 9 patients (41%) who had a transient DeltaP < 30 mm Hg at some point during surgery. No patient had a DeltaP < 30 mm Hg sustained through the conclusion of the procedure, and no compartments were released in any of these patients. None of the patients in the study developed compartment syndrome after surgery, and no sequelae of compartment syndrome were noted at minimum 6-month follow-up. CONCLUSIONS: Application of knee-spanning external fixation as a temporary measure for stabilization of high-energy proximal tibial fractures and dislocations may result in transient elevation of intracompartmental pressure of the leg. Although DeltaP may fall below the threshold of 30 mm Hg, this does not appear to lead to compartment syndrome

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group

BACKGROUND: The outcome of operatively treated capitellar fractures has not been reported frequently. The purpose of the present study was to evaluate the clinical, radiographic, and functional outcomes following open reduction and internal fixation of capitellar fractures that were treated with a uniform surgical approach in order to further define the impact on the outcome of fracture type and concomitant lateral column osseous and/or ligamentous injuries. METHODS: A retrospective evaluation of the upper extremity database at our institution identified sixteen skeletally mature patients (mean age, 40 +/- 17 years) with a closed capitellar fracture. In all cases, an extensile lateral exposure and articular fixation with buried cannulated variable-pitch headless compression screws was performed at a mean of ten days after the injury. Clinical, radiographic, and elbow-specific outcomes, including the Mayo Elbow Performance Index, were evaluated at a mean of 27 +/- 19 months postoperatively. RESULTS: Six Type-I, two Type-III, and eight Type-IV fractures were identified with use of the Bryan and Morrey classification system. Four of five ipsilateral radial head fractures occurred in association with a Type-IV fracture. The lateral collateral ligament was intact in fifteen of the sixteen elbows. Metaphyseal comminution was observed in association with five fractures (including four Type-IV fractures and one Type-III fracture). Supplemental mini-fragment screws were used for four of eight Type-IV fractures and one of two Type-III fractures. All fractures healed, and no elbow had instability or weakness. Overall, the mean ulnohumeral motion was 123 degrees (range, 70 degrees to 150 degrees). Fourteen of the sixteen patients achieved a functional arc of elbow motion, and all patients had full forearm rotation. The mean Mayo Elbow Performance Index score was 92 +/- 10 points, with nine excellent results, six good results, and one fair result. Patients with a Type-IV fracture had a greater magnitude of flexion contracture (p = 0.04), reduced terminal flexion (p = 0.02), and a reduced net ulnohumeral arc (p = 0.01). An ipsilateral radial head fracture did not appear to affect ulnohumeral motion or the functional outcome. CONCLUSIONS: Despite the presence of greater flexion contractures at the time of follow-up in elbows with Type-IV fractures or fractures with an ipsilateral radial head fracture, good to excellent outcomes with functional ulnohumeral motion can be achieved following internal fixation of these complex fractures. Type-IV injuries may be more common than previously thought; such fractures often are associated with metaphyseal comminution or a radial head fracture and may require supplemental fixation

PURPOSE: To compare the stability of a novel, nonspanning external fixator with a standard volar locked plate for treatment of unstable distal radius fractures. METHODS: A simulated, unstable, extra- articular distal radius fracture was created in six matched pairs of fresh frozen human distal radii. One of each pair was treated with a nonspanning external fixator [Mirza Cross Pin Fixator (CPX), A.M. Surgical Inc. Smithtown, NY] and the other was treated with a volar locked plate [Distal Volar Radial Plate (DVR), Hand Innovations, Miami, FL]. Each specimen was axially loaded in central, dorsal, and volar locations, loaded in cantilever bending in volar to dorsal, dorsal to volar, and radial to ulnar directions and loaded in torsion. Load-displacement curves were generated to determine the construct stiffness for each loading schema, with comparisons made between the two treatment groups. Specimens were then cyclically loaded with 50 N axial loads applied for 1,000 and 10,000 cycles. Measurement of construct stiffness was repeated and comparisons made both between the two treatments and within treatments to their precycling stiffness. RESULTS: There was no significant difference in the mechanical stiffness of the nonspanning external fixator and the volar locking plate after axial loading in any of the loading modalities.Cyclic loads of 1,000 and 10,000 cycles resulted in no significant difference in construct stiffness between the nonspanning external fixator and volar locked plate. However, the nonspanning external fixator demonstrated decreasing stiffness after cyclic loading with 10,000 cycles (p < 0.02). CONCLUSION: This study demonstrated no significant difference in the mechanical stiffness of the CPX nonspanning external fixator and volar locked plate in a cadaveric fracture model. Both constructs appear to be biomechanically equivalent in this experimental model; however, this is only one factor in the choice of fixation device for the management of unstable distal radius fractures

BACKGROUND: Ankle fracture-dislocations require urgent reduction to protect the soft tissues, to minimize articular injury, and to allow swelling to decrease. Conscious sedation is commonly used to provide analgesia for closed reduction of this injury. We hypothesized that an intra-articular block of the ankle would provide similar analgesia and the ability to reduce the ankle with a lower risk than conscious sedation. METHODS: Between September 2005 and January 2007, forty-two patients with an ankle fracture-dislocation presented to our emergency department and were enrolled in a prospective randomized study. The patients were given either conscious sedation or an intra-articular lidocaine block for the reduction and for the application of a plaster splint. After the reduction maneuver, the patients used a visual analog pain scale to rate the level of pain before, during, and after the procedure, from 1 (no pain) to 10 (severe pain). The senior authors reviewed the injury and reduction radiographs to confirm the reduction of the ankle joint. RESULTS: Twenty-one patients were randomized to each group. There was no difference in demographic data or fracture patterns between the groups. Both the sedation and the block reduced the pain to a similar degree. The pain reduction (the initial pain level minus the level of pain after medication was given or injected) was an average (and standard deviation) of 4.6 +/- 3.3 for the block group and 4.2 +/- 3.5 for the sedation group (p = 0.64). The average change in the level of pain between the initial presentation and during the reduction was 3.6 +/- 3.8 for the block group and 4.1 +/- 3.3 for the sedation group. Overall, there was no difference in analgesia provided by these two methods (p = 0.71). An acceptable reduction was achieved for forty-one of the forty-two patients with one failure in the sedation group. The average time for ankle reduction and stabilization in a splint was 81.5 minutes for the sedation group and 63.8 minutes for the block group. CONCLUSIONS: Compared with conscious sedation, an intra-articular lidocaine block provides a similar degree of analgesia and sufficient analgesia to achieve closed reduction of ankle fracture-dislocations

A prospective study was undertaken to determine if patients recover pre-injury level of shoulder function 1 year after 1 part proximal humeral fractures. Of the 67 patients enrolled, 43 were female and 24 male with an average age of 64.8 years (range, 25-90 years). All patients underwent a similar treatment protocol consisting of early therapy for range of shoulder motion and strengthening. Baseline demographics and functional assessment, including the American Shoulder and Elbow Surgeons (ASES) evaluation form and the SF-36, were obtained at the time of injury. Functional and demographic data were evaluated with a Student's t test. Fifty-four patients (80%) completed a 1-year follow-up. By 3 months, all patients attained radiographic and clinical evidence of union and no loss of reduction. At 1 year, the ASES score was similar to pre-injury status (93.7 vs 99.1; P = .12). The range of shoulder motion of the affected side was diminished compared to the unaffected extremity in internal rotation (P < .001) and external rotation (P < .001) but not forward flexion. Patients, who sustain minimally displaced proximal humeral fractures treated nonoperatively, largely returned to preoperative functional status at 1-year follow-up. Patients should be counseled and made aware of the decreased range of shoulder motion following this fracture