Faculty Bibliography

This study was undertaken to evaluate the safety and efficacy of retrievable inferior vena cava filters in high-risk orthopaedic patients. A total of 58 patients had a retrievable inferior vena cava filter placed as an adjunct to chemical and mechanical prophylaxis, most commonly for a history of previous deep-vein thrombosis or pulmonary embolism, polytrauma, or expected prolonged immobilisation. In total 56 patients (96.6%) had an uncomplicated post-operative course. Two patients (3.4%) died in the peri-operative period for unrelated reasons. Of the 56 surviving patients, 50 (89%) were available for follow-up. A total of 32 filters (64%) were removed without complication at a mean of 37.8 days (4 to 238) after placement. There were four filters (8%) which were retained because of thrombosis at the filter site, and four (8%) were retained because of incorporation of the filter into the wall of the inferior vena cava. In ten cases (20%) the retrievable filter was left in place to continue as primary prophylaxis. No patient had post-removal thromboembolic complications. A retrievable inferior vena cava filter, as an adjunct to chemical and mechanical prophylaxis, was a safe and effective means of reducing the acute risk of pulmonary embolism in this high-risk group of patients. Although most filters were removed without complications, thereby avoiding the long-term complications that have plagued permanent indwelling filters, a relatively high percentage of filters had to be left in situ

The strengths of 3 hip spacer constructs--Steinmann pins, a short intramedullary nail (both cement-incorporated), and a Charnley prosthesis--were determined and compared with the strength of a commercially available hip spacer. The hip prosthesis construct was more than twice as strong as the other 2 constructs and was equivalent in strength to the commercial spacer. For spacer applications in which limited weight-bearing is anticipated, the hip prosthesis construct appears more efficacious, but its pros and cons should be compared with those of the commercial product

Rugby football continues to grow in popularity internation- ally and within the United States. In 1995, rugby union, one form of rugby, turned from amateur to professional through- out Europe, increasing the potential for monetary reward, which, in turn, secondary to higher levels of play, increased the risk of injury. With this increased higher interest and the increasing number of inexperienced and professional players in the U.S., there is a need for a comprehensive analysis of professional rugby union injury in the American literature and increased awareness of rugby injuries, in general, for all levels of players. This paper provides an in-depth analysis of professional rugby union injuries that will assist ortho- paedic surgeons treating these injuries in the U.S. The data described highlights the potential impact of rugby injury in the U.S. and provides an overview of the international data to serve as the basis for future American studies. An additional goal of this review is to stimulate discussion regarding the necessity of implementing additional safety precautions for this high-risk sport. Finally, this analysis highlights the in- consistencies and discrepancies of the literature with respect to rugby union injury and the variability and weak interstudy reproducibility of current rugby injury data

Clavicle fractures are common skeletal injuries that are typically managed nonoperatively, which results in a high rate of fracture union with few or no long-term sequelae. Type II distal clavicle fractures are an exception, with reported rates of nonunion ranging from 22% to 44%. This high rate of nonunion has led to controversy regarding the appropriate treatment of type II injuries. The following case report describes a type IIB distal clavicle fracture, in which nonoperative management was complicated by the breakdown of skin over the fracture site and the subsequent development of infection. This is a rare complication of conservative management. Thorough operative debridement, fracture stabilization via external fixation, and identification of the causative organism allowed for successful outcome in the management of this complex presentation

Locked plate technology has evolved in an effort to overcome the limitations associated with conventional plating methods, primarily for improving fixation in osteopenic bone. The development of screw torque and plate-bone interface friction is unnecessary with locked plate designs, significantly decreasing the amount of soft tissue dissection required for implantation, preserving the periosteal blood supply, and facilitating the use of minimally invasive percutaneous bridging fixation techniques. The locked plate is a fixed-angle device because angular motion does not occur at the plate screw interface. The use of locked plate technology allows the orthopaedic surgeon to manage fractures with indirect reduction techniques while providing stable fracture fixation. The secure 'feel' of locked plates, ease of application, and the low incidence of complications noted in early clinical reports have contributed to the proliferation of this technology. Along with reports of clinical successes, as the use of fixed angle/locked plates has increased, clinical failures are being noticed. This review will focus on the biomechanics of locked plate technology, appropriate indications for its use, laboratory and clinical comparisons to conventional plating techniques, and potential mechanisms of locked plate failure that have been observed

The expandable nail concept uses high-pressure saline to inflate the diameter of a cylindrical implant to achieve fixation within the medullary canal of bone. Expandable nails are used clinically in a number of fracture management applications and have been more recently developed as a femoral component for total hip replacement. In this study, the expandable total hip replacement stem design was evaluated, specifically testing to determine if acrylic cement can be used in place of saline for permanent expansion, to observe the amount of stem subsidence after cyclic loading, and to document if stem expansion creates untoward stresses in the femur. The results included that the expandable femoral component could be expanded with cement if careful control of cement viscosity is used with a modified filling technique. Neither untoward hoop strains nor stem subsidence was found in tests with the cadaveric femurs. Bench testing has confirmed the stability of these stems. In addition, the substitution of cement for saline would make the construct permanent, avoiding the risk of deflation and loosening. The concept of an expandable femoral prosthesis is appealing and would have many potential clinical applications. The need for cemented stems or the more difficult and costly 'Ling technique' could be avoided with their use in tumor surgery, hip fracture management, and total hip replacements associated with osteoporosis or a patulous femora in both primary and revision settings

In recent years, the incidence and severity of ankle fractures in the elderly population have increased. Although surgical fixation has gained wide acceptance for younger ankle fracture patients, controversy exists within the orthopaedic community with respect to the optimal way to manage these fractures in the geriatric patient population. Although some authors categorise ankle fractures in the elderly as fragility fractures associated with osteoporosis, it appears that risk factors such as increased weight, poly-pharmacy and propensity for falls play larger roles than poor bone quality. The presence of osteoporosis may increase the level of difficulty involved with the surgical management of these patients, leading some authors to alter their standard operative technique. Early studies cited high complication rates and poor outcome following operative intervention, however, more recent investigations have demonstrated successful functional outcomes following surgical management and appropriate postoperative rehabilitation. Based on the current evidence, the literature appears to support surgical fixation of displaced ankle fractures in the elderly patient population

Although relatively uncommon, fractures of the distal humerus in the elderly patient population are significant injuries of which optimal management is a subject of debate in orthopaedic literature. The combination of complex anatomy, poor bone quality and extensive comminution often seen with these fractures makes successful treatment difficult. Currently, most surgeons support surgical fixation of distal humeral fractures with the belief that restoration of the patient's native elbow joint provides the best opportunity for a good functional outcome. Others have proposed the use of total elbow arthroplasty as a primary treatment method for geriatric distal humeral fractures based on the difficulties associated with ORIF and the relatively low demands of this patient population. To date, there have been no prospective randomised trials comparing these two treatment alternatives, and a comparison of available outcome data shows good functional outcome for both forms of fracture management. With the aging of the population and an associated increase in the incidence of distal humeral fractures, the debate over the optimal treatment regime will undoubtedly continue

PURPOSE: To retrospectively review the clinical outcome and incidence of post-operative complications after open end-to-end repair of acute Achilles tendon ruptures. METHODS: Seventy consecutive patients (74 open Achilles tendon repairs) operated on between 1989 and 2002 were identified for inclusion in this investigation. The medical records were reviewed and patients were contacted for a follow up interview in order to survey their post-operative function. Outcome scores were calculated based on the Boyden outcome and AOFAS ankle-hindfoot scoring systems. Post-operative complications were documented during the chart review and follow up interview, including an additional nine patients (nine repairs), who were not included in the clinical evaluation portion of the study. RESULTS: Fifty-two patients (54 repairs) were successfully contacted and completed the follow up interview. Within this cohort there were 44 males and 8 females with a mean age of 41 years. Achilles tendon rupture in this population was attributable to participation in athletic activity in 87% of cases. At a mean post-operative follow up of 45 months, 96% of cases achieved an overall Boyden outcome score of good to excellent. The mean AOFAS ankle-hindfoot score was 96, with 74% of cases scoring greater than 90. Forty-two cases (78%) reported no pain and 40 cases (74%) reported no activity limitations. Fourteen post-operative complications were identified after 83 open Achilles tendon repairs, resulting in an institutional complication rate of 16.8%. The complications included four superficial wound infections, five deep wound infections requiring irrigation and debridement, one heel ulcer secondary to post-operative boot wear, three partial Achilles tendon re-ruptures, and one complete Achilles tendon re-rupture. CONCLUSION: Our results demonstrate that open end-to-end repair of acute Achilles tendon ruptures provides long-term functional outcomes with consistent good to excellent results. However, this high clinical success rate was associated with a relatively high incidence of post-operative complications. With careful attention to the surgical wound and patient adherence to post-operative rehabilitation protocols, operative repair of acute Achilles tendon ruptures is a reliable treatment for active patients

The Z-effect phenomenon is a potential complication of two lag screw intramedullary nail designs used for fixation of intertrochanteric hip fractures, in which the inferior lag screw migrates laterally and the superior lag screw migrates medially during physiologic loading. The current investigation was undertaken in an attempt to reproduce the Z-effect phenomenon in a laboratory setting. Sixteen different simulated femoral head and neck constructs having varying compressive strengths were created using four densities of solid polyurethane foam and instrumented with a two-screw cephalomedullary intramedullary nail. Each specimen was then cyclically loaded with 250 N vertical loads applied for 10, 100, 1000, and 10,000 cycles. Measurement of screw displacement with respect to the lateral aspect of the intramedullary nail was made after each cyclic increment. The inferior lag screw migration component of the Z-effect phenomenon was reproduced in specimens with head compressive strengths that were higher than the compressive strengths of the neck. Specimens with the greatest difference in head-neck compressive strength demonstrated the most significant displacement of the inferior lag screw without any displacement of the superior lag screw. Specimens with a femoral neck compressive strength of 0.91 MPa of and a head compressive strength of 8.8 MPa resulted in more than one centimeter of inferior lag screw lateral migration after 10,000 cycles of vertical loading. Models where the femoral head had a higher compressive strength than that of the femoral neck may simulate fracture patterns with significant medial cortex comminution that are prone to varus collapse