Faculty Bibliography

OBJECTIVE: To characterize the timing, indications, and "success rates of secondary interventions, dynamization and exchange nailing, in a large series of tibial nonunions" (dynamization and exchange nailing are types of secondary interventions). SETTING: Retrospective multicenter analysis from level 1 trauma hospitals. PATIENTS: A total of 194 tibia fractures that underwent dynamization or exchange nailing for delayed/nonunion. INTERVENTION: Records and radiographs to characterize demographic data, fracture type, and cortical contact after tibial nailing were gathered. The radiographic union score for tibias (RUST) and the timing of intervention and time to union were calculated. MAIN OUTCOME MEASURES: The primary outcome was success of either intervention, defined as achieving union, with the need for further intervention defining failure. Other outcomes included RUST scores at intervention and union, and timing to intervention and union for both techniques. Two-tailed t tests and Fisher exact with P set at <0.05 for significance were used as indicated. RESULTS: A total of 194 tibia fractures underwent dynamization (97) or exchange nailing (97). No statistical differences were found between groups with demographic characteristics. The presence of a fracture gap (P = 0.01) and comminuted fractures (P = 0.002) was more common in the exchange group. The success rates of the interventions and RUST scores were not different when performed before versus after 6 months; therefore, data were pooled. The RUST scores at the time of intervention were not different for successful or failed dynamizations (7.13 vs. 7.07, P = 0.83) or exchanges (6.8 vs. 7.3, P = 0.37). Likewise, the time to successful versus failed dynamization (165 vs. 158 days, P = 0.91) or exchange nailing (224 vs. 201 days, P = 0.48) was not different. No cortical contact or a gap was a statistically negative factor for both exchange nails (P = 0.09) and dynamizations (P = 0.06). When combined, the success in the face of a gap was 78% versus 92% when no gap was present (P = 0.02). CONCLUSIONS: Previous literature has few reports of the success rates of secondary interventions for tibial nonunions. The indications for dynamization and exchange were similar. Comminuted fractures, and fractures with no cortical contact or "gap" present after intramedullary nailing, favored having an exchange nail performed over dynamization. Fracture gap was also found to be a negative prognostic factor for both procedures. Overall, this study demonstrates high rates of union for both interventions, making them both viable options. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE: To determine the reliability of the Radiographic Union Scale for Tibia (RUST) score and a new modified RUST score in quantifying healing and to define a value for radiographic union in a large series of metadiaphyseal fractures treated with plates or intramedullary nails. DESIGN: Healing was evaluated using 2 methods: (1) evaluation of interrater agreement in a series of radiographs and (2) analysis of prospectively gathered data from 2 previous large multicenter trials to define thresholds for radiographic union. INTERVENTION: Part 1: 12 orthopedic trauma surgeons evaluated a series of radiographs of 27 distal femur fractures treated with either plate or retrograde nail fixation at various stages of healing in random order using a modified RUST score. For each radiographic set, the reviewer indicated if the fracture was radiographically healed. Part 2: The radiographic results of 2 multicenter randomized trials comparing plate versus nail fixation of 81 distal femur and 46 proximal tibia fractures were reviewed. Orthopaedic surgeons at 24 trauma centers scored radiographs at 3, 6, and 12 months postoperatively using the modified RUST score above. Additionally, investigators indicated if the fracture was healed or not healed. MAIN OUTCOME MEASURES: The intraclass correlation coefficient (ICC) with 95% confidence intervals was determined for each cortex, the standard and modified RUST score, and the assignment of union for part 1 data. The RUST and modified RUST that defined "union" were determined for both parts of the study. RESULTS: ICC: The modified RUST score demonstrated slightly higher ICCs than the standard RUST (0.68 vs. 0.63). Nails had substantial agreement, whereas plates had moderate agreement using both modified and standard RUST (0.74 and 0.67 vs. 0.59 and 0.53). UNION: The average standard and modified RUST at union among all fractures was 8.5 and 11.4. Nails had higher standard and modified RUST scores than plates at union. The ICC for union was 0.53 (nails: 0.58; plates: 0.51), which indicates moderate agreement. However, the majority of reviewers assigned union for a standard RUST of 9 and a modified RUST of 11, and >90% considered a score of 10 on the RUST and 13 on the modified RUST united. CONCLUSIONS: The ICC for the modified RUST is slightly higher than the standard RUST in metadiaphyseal fractures and had substantial agreement. The ICC for the assessment of union was moderate agreement; however, definite union would be 10 and 13 with over 90% of reviewers assigning union. These are the first data-driven estimates of radiographic union for these scores.

OBJECTIVE: To evaluate the effect of syndesmotic disruption on the functional outcomes of Weber B, SE4 ankle fractures treated operatively. SETTING: Multicenter trauma hospitals. PATIENTS: Data were prospectively gathered during a previous, multicenter randomized trial including 242 patients (136 women, 106 men) from 9 trauma centers with operatively treated Weber B SE4 ankle fractures. There were 81 patients (35%) with syndesmotic instability confirmed intraoperatively after fibula fixation. INTERVENTION: Functional evaluations were performed postoperatively at 6, 12, 26, and 52 weeks. The presence of symptomatic hardware and peroneal tendon discomfort was evaluated with 9-12 months of follow-up. MAIN OUTCOME MEASURES: Functional outcomes evaluated included Short Musculoskeletal Function Assessment (SMFA), Bother index, and American Orthopaedic Foot and Ankle Society (AOFAS) scores. The recovery curve of the 2 groups was analyzed using a mixed linear regression analysis for repeated measures and included gender and race in the model. Symptomatic hardware and peroneal tendon discomfort were compared between the 2 groups with a chi analysis. RESULTS: The adjusted mean linear regression analyses demonstrated that patients without a syndesmotic injury had better functional outcomes for some outcome measures. SMFA scores at 12 weeks were statistically lower in patients without syndesmotic injury (P = 0.02), but not at other visits. AOFAS scores were significantly higher (P = 0.0006), and Bother index trended toward lower results (P = 0.07) in patients without syndesmotic injury at all time points. Isolated analyses (T-tests) at 1 year demonstrated a difference in the SMFA (P = 0.04) and Bother index (P = 0.05), but not the AOFAS (P = 0.21). Men consistently demonstrated better recovery than women for all outcomes, whereas race was not significant for any measure. Symptomatic hardware and peroneal tendon irritation was not statistically different between the groups. CONCLUSIONS: The recovery curves after ankle fractures were different based on syndesmotic injury. However, the difference was at the limit of clinical significance. Syndesmotic injury has a slightly detrimental effect on outcomes of operatively treated Weber B SE4 fractures. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Bone quality should play an important role in decision-making for orthopaedic treatment options, implant selection, and affect ultimate surgical outcomes. The development of decision-making tools, currently typified by clinical guidelines, is highly dependent on the precise definition of the term(s) and the appropriate design of basic and clinical studies. This review was performed to determine the extent to which the issue of bone quality has been subjected to this type of process. QUESTIONS/PURPOSES: We address the following issues: (1) current methods of clinically assessing bone quality; (2) emerging technologies; (3) how bone quality connects with surgical decision-making and the ultimate surgical outcome; and (4) gaps in knowledge that need to be closed to better characterize bone quality for more relevance to clinical decision-making. METHODS: PubMed was used to identify selected papers relevant to our discussion. Additional sources were found using the references cited by identified papers. RESULTS: Bone mineral density remains the most commonly validated clinical reference; however, it has had limited specificity for surgical decision-making. Other structural and geometric measures have not yet received enough study to provide definitive clinical applicability. A major gap remains between the basic research agenda for understanding bone quality and the transfer of these concepts to evidence-based practice. CONCLUSIONS: Basic bone quality needs better definition through the systematic study of emerging technologies that offer a more precise clinical characterization of bone. Collaboration between basic scientists and clinicians needs to improve to facilitate the development of key questions for sound clinical studies.