Faculty Bibliography

This retrospective study over a 3 year follow-up was designed to establish the significance of the Weber classification of ankle fractures with regards to functional and radiographic outcome. One hundred and seven patients were available for follow-up, of which 88 ankles could be classified with the Weber system. Medial malleolar fractures alone and pilon fractures could not be classified with this system. A correlation was found between the type of Weber fracture and the overall ankle score. This held true for unimalleolar fractures alone. More complex bimalleolar and trimalleolar fractures did not follow this convention. Logistical regression analysis was used to evaluate other predictors of outcome. Bimalleolar and trimalleolar fractures were statistically significant predictors of a poorer outcome (P = 0.033, P = 0.021). The initial degree of displacement was also determined to be a predictor of outcome (P = 0.0133) as was the operative reduction (P = 0.0113). Using linear regression, older age (> 62 years) was also established as a predictor of a poorer outcome (P < 0.05). The Weber classification was found to be a predictor of outcome in unimalleloar ankle fractures and not for multimalleolar fractures. We have identified further predictors of a poorer outcome in ankle fractures as the degree of initial injury, the number of malleoli fractured and older age. These factors were found to have greater significance in predicting outcome than the level of fibular fracture alone. We have identified a deficiency of the Weber system in excluding these criteria and have addressed this by modifying the existing system to include the number of malleoli involved, thus providing a more useful prognostic tool

We retrospectively reviewed 75 total hip arthroplasties to examine the effect of acetabular component position. In group A, 38 of the components were implanted according to manufacture's instructions with all peripheral fins in contact with acetabular bone; as such, the acetabular components were in a relatively vertical position with a mean angle of inclination of 61.9 degrees. Three of these patients developed recurrent dislocations necessitating revision of the acetabular component. In group B, 37 hips, a more horizontal orientation was used despite the fact that all of the peripheral fins of the acetabular component did not engage acetabular bone; in this group the mean angle of inclination was 49.7 degrees. Only one of these hips recurrently dislocated and required revision. There were no problems in this group associated with provisional component stability caused by inadequate peripheral fixation. Radiographs of all patients were obtained at 4 years after surgery (range, 4.0-4.3 years). Pelvic osteolysis had occurred in 24% of hips in group A and 13% of group B. Asymmetric polyethylene wear was observed in 5.1% of the hips in group A; no hip in group B showed wear asymmetry. Acetabular component migration developed in 19% of group A hips and 5% of group B hips. The Mayo clinical hip score was excellent in both groups: group A 71/80, group B 73/80. At an intermediate follow-up it is clear that significant problems can be encountered when this component is positioned in a relatively vertical position to facilitate engaging all four peripheral fins in bone. We have addressed this problem by placing the cup in a more anatomic position of inclination while maintaining provisional rim fixation. This has resulted in a decreased incidence of pelvic osteolysis and fewer complications overall.

Ninety patients who had undergone 92 total knee replacements were reviewed to determine predictors of postoperative pyrexia and to evaluate the relative value of septic screening in this group of patients. Postoperative pyrexia was defined as an axillary temperature greater than 37 degrees C (98.4 degrees F) on any or all of the 5 days after surgery. All of the patients in this series developed a postoperative pyrexia after knee arthroplasty. None of 16 patients (17% of arthroplasties) with a temperature of 39 degrees C (102 degrees F) or greater had evidence of infection. None of the 4 patients with urinary tract infections developed a pyrexia exceeding 38 degrees C (101 degrees F). At a minimum of 2 years' follow-up, none of the 90 patients had developed an infected arthroplasty. Logistic regression analysis showed that the risk of becoming significantly febrile (temperature > 39 degrees C) doubled for every unit drop in hematocrit and increased fourfold for each unit of blood transfused after surgery. Perioperative blood loss and pyrexia were correlated, but the correlation was not statistically significant. The duration of procedure, tourniquet time, and patient age or sex were not associated with risk of pyrexia. In this series, there was no association between a pyrexia greater than 37 degrees C, septic screening, and the presence of an infective focus. Early postoperative pyrexia after arthroplasty is a normal physiological response, and a significant pyrexia can be predicted by a drop in hematocrit and/or after postoperative transfusion. Pyrexia in the early postoperative period following total knee arthroplasty warrants detailed laboratory and radiographic investigation only in the presence of positive physical findings.

OBJECTIVE:To describe our experience with four cases of severe pelvic dislocation associated with difficult parturition. DESIGN/METHODS:Retrospective case series. PATIENTS/METHODS:Four patients, each with rupture of the symphysis pubis and sacroiliac joints during labor. All injuries were associated with significant initial pain and disability. All developed persistent symptoms related to the sacroiliac disruption. INTERVENTIONS/METHODS:The three patients who had presented acutely were freated with closed reduction and application of a pelvic binder. Two underwent closed reduction of their pelvic dislocation while anesthetized with a general anesthetic. One patient (N.A.), who presented late, had not been treated with a binder. RESULTS:All four patients had persistent posterior pelvic (sacroiliac) pain. In two patients a postpartum neuropathy persisted. CONCLUSIONS:Severe pelvic dislocations are rare during labor, with conservative treatment reported to be successful in most cases. The persistence of symptoms in our patients emphasizes the need for careful examination and follow-up of these rare injuries. Because the outcome in our patients was poor and results in the literature are equivocal, we suggest the consideration of an operative approach to treatment in patients with symphyseal diastasis of > 4.0 cm.

We report a case of chondromyxoid fibroma of the ala of the sacrum: its presentation, diagnosis, treatment, and resolution. Although this tumor is admittedly rare, our case demonstrates the need for careful evaluation of pack pain in an adolescent.

Seventeen patients who sustained severe trauma resulting in dislocation or fracture-dislocation of the elbow were treated using osseous suture anchors to repair the soft-tissue constraints of the elbow. In 15 of these patients, the medial collateral ligament and flexor-pronator origin were repaired. Ten patients underwent repair of the lateral collateral ligament using anchors. Five patients were also treated with a hinged external fixator. All of the elbows were rendered grossly unstable by the injury; all of the patients had stable elbows at follow-up. Elbow flexion averaged 127 degrees; an average 19 degrees extension loss was noted. The arc of forearm rotation averaged 156 degrees. The aggressive approach detailed in this report is applicable only to severe injuries to the elbow, not routine dislocations. These cases demonstrate the reliability of the osseous suture anchor in the operative treatment of massive trauma to the elbow.

A 74-year-old male involved in a pedestrian-automobile collision sustained a comminuted supracondylar-diaphyseal femur fracture. The fracture was stabilized by retrograde intramedullary fixation with a Synthes unreamed tibial nail. Knee motion reached 0 degree-120 degrees by the sixth postoperative day and the fracture healed within twelve weeks. Twelve months after his injury, his knee motion was symmetric to his uninjured side and he had resumed full preinjury activities, including martial arts training. Although antegrade intramedullary nailing remains the treatment of choice for fractures of the femur, this case highlights the usefulness of retrograde nailing and demonstrates the adjunctive application of an existing implant, the tibial nail, in certain special trauma situations.