Faculty Bibliography

PURPOSE: To examine our incidence of early complications that occur using the Proximal Humeral Internal Locking System (PHILOS) and to determine the contributing factors. SETTING: Academic medical center. PATIENTS: Fifty-one consecutive patients treated with a proximal humerus locking plate. OUTCOME: Development of an intraoperative, acute postoperative, or delayed postoperative complication. METHODS: A retrospective analysis was undertaken of a consecutive series of proximal humerus fractures treated with a locking plate between February 2003 and January 2006 at our institution. Fifty-one fractures or fracture nonunions were identified in 18 male and 33 female patients with an average age of 61. All acute injuries were treated with a similar protocol of open reduction internal fixation with the PHILOS plate followed by early range of shoulder motion. Nonunions were treated in a similar manner with the addition of iliac crest bone graft placement. Patients were objectively assessed on their outcome by physical as well as radiological examination. All complications were recorded. Statistical analyses were performed to determine if patient age, fracture type, or number of screws placed in the humeral head contributed to complications. RESULTS: Fifty-one patients were available for minimum 6-month follow-up (mean, 16 months; range, 6 to 45 months). Radiographically, 92% of the cases united at 3 months after surgery, and 2 fractures had signs of osteonecrosis at latest follow-up. Sixteen complications were seen in 12 patients (24%). Eight shoulders in eight patients (16%) had screws that penetrated the humeral head. Two patients developed osteonecrosis at latest follow-up. One acute fracture and one nonunion failed to unite after index surgery. Significant heterotopic bone developed in 1 patient. Early implant failure occurred in 2 patients; one was revised to a longer plate, and one underwent resection arthroplasty. There was one acute postoperative infection. CONCLUSION: The major complication reported in this study was screw penetration, suggesting that exceptional vigilance must be taken in estimating the appropriate number and length of screws used to prevent articular penetration; although the device provides exceptional fixation stability, its indication must be scrutinized for each individual patient, taking the extent of trauma/fracture and age into consideration and carefully weighing it against other forms of treatment

Despite the relatively common occurrence of fractures of the proximal humeral amongst the elderly, the subgroup of isolated greater and lesser tuberosity fractures have remained less well understood. While the majority of two-part fractures result from a standing-height fall onto an outstretched hand, isolated tuberosity fractures are also commonly associated with glenohumeral dislocations or direct impact to the shoulder region. Inasmuch as isolated greater tuberosity fractures are considered uncommon, isolated lesser tuberosity fractures are generally considered exceedingly rare. Non-operative treatment including a specific rehabilitation protocol has been advocated for the majority of non-displaced and minimally displaced fractures, with generally good outcomes expected. The treatment for displaced fractures, however, has included both arthroscopically assisted fixation and open or percutaneous reduction and internal fixation (ORIF). The choice of fixation and approach depends not only on fracture type and characteristics, but also on a multitude of patient-related factors. With an expected increase in the level of physical activity across all age groups and overall longer lifespans, the incidence of isolated tuberosity fractures of the proximal humeral is expected to rise. Orthopaedic surgeons treating shoulder trauma should be aware of treatment options, as well as expected outcomes

Rapid advances in the field of orthopaedic trauma have improved treatment options while keeping pace with the changing characteristics of the trauma population. The availability of locking implants has changed the approach to treating fractures in older patients with osteoporotic bones as well as in those with comminuted and complex injuries. Minimally invasive approaches have allowed the preservation and protection of soft tissues while allowing adequate reduction and fixation of fractures. This biologically friendly approach coupled with newer implants and instruments will improve early and long-term outcomes in trauma care

Bilateral asymmetric dislocations of the hip are rare compared to unilateral dislocations. This case study describes a female restrained passenger involved in a motor vehicle accident who sustained asymmetric bilateral hip dislocations. The patient underwent successful closed reduction of both hips. The clinical course and follow-up assessment of the patient was otherwise uneventful. Computed tomography scans, essential for diagnosing intra-articular loose bodies and subtle fractures, were performed after reduction and revealed in the right hip a nondisplaced acetabular rim fracture of the posterior wall on the side of the posterior dislocation. Hip dislocations are an injury requiring careful trauma evaluation to rule out concomitant injuries. Time to presentation and, more importantly, reduction of a hip dislocation, is essential in treating this injury and preventing long-term complications, such as avascular necrosis and posttraumatic arthritis. The incidence, anatomy, mechanism of injury, treatment options, and long-term sequelae of hip dislocation, with literature review, are discussed

Objectives: High-energy tibial plateau fractures are complex injuries that have varying outcomes. Our purpose was to evaluate outcomes of operatively treated Schatzker type V and VI tibial plateau fractures and compare them to the radiographic results. Patients and methods: Eighty consecutive patients underwent operative treatment for Schatzker type V (21 fractures) or type VI (62 fractures) tibial plateau fractures. There were 64 closed (77.1%) and 19 open fractures (22.9%), with 11 extremities (13.3%) having compartment syndrome. Fifteen patients (18.8%) with 18 fractures were lost to follow-up. Finally, 65 patients with 65 extremities were available for clinical and radiographic examinations after a mean follow-up of 17 months (range 10 to 40 months). Functional assessments were made using the WOMAC (Western Ontario and McMaster Universities Arthritis Index) questionnaire. Results: The mean range of knee motion at the latest follow-up was 1 degrees (0 degrees to 20 degrees) - 115 degrees (60 degrees to 140 degrees) and the mean WOMAC score was 76.6+/-55. Radiographically, 15 knees (23.1%) had evidence for collapse and I I patients (16.9%) had evidence for post-traumatic arthritis. Both loss of fracture reduction (p=0.001) and arthritic changes (p=0.04) were associated with a poorer functional score on the WOMAC. Complications included five deep wound infections (7.7%), two nonunions (3.1%), and 10 patients required additional unplanned surgery (15.4%). Conclusion: Early loss of surgical reduction and development of radiographic evidence for arthritic changes are predictors of functional scores in Schatzker type V and VI tibial plateau fractures

Objectives: The purpose of this study was to review our experience with compartment syndrome (CS) of the thigh and to provide guidelines for its management. Patients and methods: The study included 10 cases of thigh CS in seven male patients (mean age 26 years; range 17 to 47 years). The mechanisms of injury included trauma due to a motor vehicle accident, sports injuries (n=2), blunt trauma, crush injuries (n=2), and after intramedullary nailing of a femur fracture. Four patients developed CS of the ipsilateral leg, of whom two also had CS of the ipsilateral foot. Three patients had bilateral CS of the thighs, two of whom also had bilateral CS of the legs. One patient had acute CS of the forearm. Decision for fasciotomy of the thigh was based on clinical evidence for tense compartments with elevated compartment pressures, increased need for analgesia, and pain with passive range of motion. All wounds were treated with delayed primary closure. The mean follow-up was one year (range 3 to 36 months). Results: Associated morbidities included rhabdomyolysis in four patients, of which one progressed to acute renal failure. Three patients developed deep vein thrombosis. At fasciotomy, there was evidence for muscle necrosis in two patients. One patient had hematoma. One patient sustained an injury to the superficial femoral artery. The mean length of stay was 30 days (range 7 to 43 days). Upon discharge, five patients had intact neurovascular status. Two patients had a foot drop, one with bilateral, which did not resolve at three years' follow-up. All patients underwent multiple debridements, ranging from 2 to 39 including definitive wound closure. Conclusion: Emergent fasciotorny and release of affected compartments minimize morbidity and future complications

Periprosthetic femoral fractures associated with well-fixed total hip or total knee prostheses present a challenging management problem as these injuries typically occur in osteoporotic bone. Conventional management entails extensive periosteal stripping to allow for plate fixation. We reviewed a consecutive series of patients who sustained fractures associated with a well fixed total knee prosthesis, a total hip prosthesis, or both. Twenty four patients with a mean age of 69.4 years were included. All patients underwent fixation via percutaneous insertion techniques with a first generation locking plate and screws (LISS-Less Invasive Skeletal Stabilization, Synthes, Paoli, PA). Three patients sustained fractures distal to a well-fixed total hip prosthesis, eighteen fractures occurred above a well-fixed total knee femoral component, and three were interprosthetic. The mean length of time from the index procedure to fracture was 76 months, range (2-172 months). Blood loss was minimal in each case, with a mean operative time of 90min (range 60-120min). Twenty one of twenty four went on to unite at a mean 6.2 months (range 3-19 months). Three patients underwent further surgery. One failure of fixation was encountered. Percutaneous fixation is technically demanding as it requires stable fixation without direct visualisation of the fracture site or the entire fixation device. Our results suggest percutaneous fixation with the LISS plate is an effective although technically demanding method of treatment. Complication rates were comparable to existing reports of this treatment method, and appear to be improved over traditional methods of fixation

BACKGROUND: Recommendations for surgical treatment and expected outcomes differ for two unstable patterns of supination-external rotation ankle injuries. We compared the demographic characteristics and functional outcome following surgical stabilization between the two types of supination-external rotation type-4 fractures: distal fibular fracture with a deltoid ligament rupture and bimalleolar fracture. METHODS: Demographic data on 456 patients in whom an unstable fracture of the ankle was treated surgically were entered into a database and the patients were prospectively followed. Two hundred and sixty-six of these patients sustained either a bimalleolar fracture or a lateral malleolar fracture with insufficiency of the deltoid ligament and widening of the medial clear space. No medial fixation was used in the patients with a deltoid ligament injury. All patients followed a similar postoperative protocol. The patients were followed clinically and radiographically at three, six, and twelve months after the surgery. Function was assessed with the Short Musculoskeletal Function Assessment and the American Orthopaedic Foot and Ankle Society score. RESULTS: Bimalleolar fractures were more commonly seen in female patients, in those older than sixty years of age, and in patients with more comorbidities. There was no significant association between the fracture pattern and either diabetes or the length of the hospital stay. At a minimum of one year postoperatively, the patients with a bimalleolar fracture had significantly worse function, even after we controlled for all other variables. The overall complication rate, including elective hardware removal, was also higher in the group with a bimalleolar fracture (seventeen compared with nine patients). CONCLUSIONS: At one year after surgical stabilization of an unstable ankle fracture, most patients experience little or mild pain and have few restrictions in functional activities. However, the functional outcome for those with a bimalleolar fracture is worse than that for those with a lateral malleolar fracture and disruption of the deltoid ligament, possibly because of the injury pattern and the energy expended

Despite advances in surgical techniques, fractures of the radial head are challenging to manage. Most radial head fractures can be managed nonsurgically, with emphasis on early motion to achieve good results. Treatment of more complex radial head fractures, however, especially those associated with elbow instability, remains controversial. The choice for such injury is between open reduction and internal fixation and arthroplasty. Modern implants and techniques have led to improvements in both of these technically demanding procedures. With proper care and understanding of the mechanism of elbow function, better long-term results can be achieved. The current literature suggests that the Mason classification guides choice of the best treatment modality to achieve optimal long-term function. Fracture complexity also should be used as a guide when selecting treatment, and proper surgical technique is critical for success