Faculty Bibliography

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

OBJECTIVE: To compare the fixation stability of intramedullary nails to that of locked plates for the treatment of distal metaphyseal tibia and fibula fractures. METHODS: A simulated, distal metaphyseal tibia fracture was created in 8 pairs of cadaveric tibia-fibula specimens. One of each pair was treated using an intramedullary nail (Trigen IM Nail System; SN Richards, Memphis, TN) and the other with a locked plate (Peri-Loc Periarticular Locked Plating System; SN Richards). Each specimen was vertically loaded to 250 N in central, anterior, posterior, medial, and lateral locations; loaded to 250 N in cantilever bending in anterior to posterior and posterior to anterior directions; and loaded to 250 N mm in torsion. Load-displacement curves were generated to determine the construct stiffness for each loading scenario, with comparisons made between the 2 treatment groups. Each specimen was then cyclically loaded with 750 N vertical loads applied for 10, 100, 1000, and 10,000 cycles. Measurements of fracture displacements were made and compared between treatment groups. A fibular osteotomy was then created in each specimen at the same level as the tibia fracture to simulate a same-level tibia-fibular fracture. Torsional stiffness assessment and cyclic vertical loading for 10, 100, 1000, and 10,000 cycles were repeated and fracture displacement measurements were again obtained. RESULTS: The locked plate construct was stiffer than the intramedullary nail construct for central, anterior, and posterior loading scenarios (P < 0.005, P < 0.03, and P < 0.02, respectively). The intramedullary nail construct was stiffer than the locked plate construct for both anterior to posterior and posterior to anterior cantilever bending (P < 0.03 and P < 0.02, respectively). No statistically significant difference in stiffness was noted between treatment groups for medial and lateral vertical loading or for torsional loading (P = 0.09, P = 0.32, and P = 0.84, respectively). There was no significant difference between treatment groups with respect to fracture displacement after cyclic vertical loading. After creation of the fibular osteotomy fracture, construct displacements after 1000 and 10,000 cycles significantly increased and torsional stiffness significantly decreased for both treatment groups. The locked plate constructs had significantly less displacement after cyclic loading of 1000 and 10,000 than the locked nail constructs (P < 0.001 and P < 0.0001, respectively). Locked plate constructs were stiffer in torsion after osteotomy than the intramedullary nail constructs (P < 0.05). CONCLUSION: This study demonstrated that, in the treatment of distal metaphyseal tibia fractures, locked plates provided more stable fixation than intramedullary nails in vertical loading but were less effective in cantilever bending. An intact fibula in the presence of a distal tibia fracture improved the fracture fixation stability for both treatment methods. In fracture patterns in which the fibula cannot be effectively stabilized, locked plates offer improved mechanical stability when compared with locked intramedullary nails

Gaucher disease is a rare, hereditary disease caused by lack of a lysosomal enzyme. This results in the accumulation of glucocerebroside in the cells of the reticuloendothelial system, including the bone marrow. The orthopaedic manifestations of this disease are important for the orthopaedic surgeon to recognize and understand. Patients with Gaucher disease are at risk for pathologic fracture, abnormal bony remodeling and delayed healing, increased intraoperative bleeding, and infection. Osteomyelitis and avascular necrosis, two common sequelae of the disease, can present in very similar fashions and warrant careful and accurate diagnosis to ensure proper treatment. The impact of Gaucher disease on the musculoskeletal system is reviewed with emphasis on the importance of understanding these effects for the treating orthopaedic surgeon.

Fracture-dislocation of the elbow is a signiicant injury with mixed outcomes. The purpose of the study was to evaluate patient perceived outcome following surgical stabilization of these complex injuries. Twenty-nine available patients (76%) from 37 identiied with 'terrible triad' injury patterns, in- cluding ulnohumeral dislocation, radial head fracture, and coronoid fracture, were available for a minimum 1-year follow-up (mean, 27 months). All patients were evaluated by their treating physician. Radiographic outcome was evaluated at latest follow-up. Functional outcome was based upon DASH, Mayo elbow performance, and Broberg-Mor- rey scores. Complications were recorded. Results included that the average lexion-extension arc of elbow motion was 109 degrees +/- 27 degrees , and the average pronation-supination arc was 128 degrees +/- 44 degrees . Grip strength averaged 72% of the contralateral extremity. The Mayo score was a mean of 81 (range, 45 to 100), the Broberg-Morrey mean was 77 (range, 33 to 100) The mean DASH was 28 (range, 0 to 72). When compared to the age-based normal values, the mean patient's DASH score was 1.4 SD worse than an average person of the same age None of the injury characteristics, patient demographics or treatment modalities was signiicantly associated with a poor outcome at the 95% conidence interval. Conclusions are that the results with terrible triad injuries are often unsatisfactory, but surgical management with the use of a systematic approach may be beneicial. Our approach led to the restoration of elbow joint stability in all patients

External fixation for the purpose of bony realignment has been in practice since the early 1900s and is widely used today. External fixators are primarily used for trauma but may also be used for deformity correction and arthrodesis, among other applications. The advantages of external fixation over open reduction and internal fixation and intramedullary nailing include simplicity of application, adjustability of the construct, and increased access for wound care and wound monitoring after fixation is achieved. Frame design requires a combination of pins, wires, clamps, rings, and rods to ultimately form a stable construct that can apply compressive, distractive, or neutral forces on bone

Tourniquet use is effective in producing a bloodless field. It is recommended that the least effective pressures be used to minimize tissue microstructure and biochemical damage from tourniquet application. When applied at the thigh, the minimum effective tourniquet pressure is 90 to 100 mm Hg above systolic BP, and in a normotensive, nonobese patient, pressure of 250 mm Hg is sufficient. Similarly, an arm tourniquet pressure of 200 mm Hg is recommended. The purpose of this survey was to assess the tourniquet pressures used by orthopaedic surgeons, both academic and community based, and their familiarity with associated literature. MATERIALS:: A Website-based survey was distributed to a random sample of academic and community-based surgeons. Respondents were asked the upper and lower-extremity tourniquet pressures they routinely use. They were asked if they were able to cite or were aware of literature to support their answer. They were also asked to specify their practice setting and years in practice. Results were statistically analyzed utilizing Fisher's exact test and Mann-Whitney test. RESULTS:: A total of 199 survey responses were collected. Out of these, 151 (76%) were complete for the lower extremity, and 141 (71%) were complete for upper extremity. The average years in practice were 12.6 years (range, 1-30). The median LE pressure was 300 mm (range, 150-400), and the median UE pressure was 250 mm (range, 150-300). Less than 20% of respondents routinely used pressures of 250 mm or less for the lower extremity. For upper extremity, only 11.3% used pressures at or below 200 mm. Surgeons in academic practice were more likely to use lower tourniquet pressures, and less likely to choose 'don't know' as the option for literature support, but the difference was not statistically significant. Although 60% of respondents thought that they were aware of literature supporting their answers, only 25% of these for the lower extremity and 11% for the upper used the correct pressures. CONCLUSION:: This survey demonstrates the existing gulf between tourniquet use and supporting literature. Tourniquet use is not benign and the correct pressure usage allows the least morbidity. We hope this survey will raise awareness of the correct tourniquet pressures and change practice patterns based on 'that's how we have always done it'