Faculty Bibliography

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group

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

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

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'

This study was performed to determine if picture archiving communication systems can provide a more accurate method of determining implant length for intramedullary tibial nailing. Postoperative radiographs of 40 patients who underwent intramedullary nailing of their tibial shaft fractures using picture archiving communication systems were retrieved. In phase one and two of this investigation, tibial nail lengths were measured using 'measuring distance' and 'measure calibration' tools displayed on the respective digital systems. Phase 3 of this study involved 5 tibial Sawbones (Pacific Research Laboratories, Vashon, Wash) radiographically captured on the picture archiving communication systems with a radiograph marker of known length. Using the 'measuring distance' and 'measure calibration' tools in phases one and two did not result in accurate measurements. Of 40 digital radiographic images measured and calibrated with the on-screen ruler and using the digital system tools, 100% of our measurements were inaccurate. An average of 19.4-mm and 10.6-mm difference was noted in uncorrected measurements on anteroposterior (AP) and lateral views, respectively. An average 25.8 mm and 15.7 mm was noted in calibrated (corrected) measurements on AP and lateral views respectively. Digitally measured and calibrated lengths were an average 22 mm and 25 mm greater from the actual known length of the tibial nail, respectively. Phase 3 of our study presented the most accurate results in length determination of tibial nail length

Proximal humerus fractures in the elderly are a relatively rare injury, the treatment of which remains controversial, especially regarding Neer displaced two-part, and three-part and four-part fractures. Operative indications for most displaced proximal humerus fractures in the elderly remain poorly defined, but recent literature is actually supporting less aggressive approaches except for the most severe fractures. Recent epidemiological and larger scale retrospective studies fail to show a significant functional difference between operative and non-operative treatment of displaced two-part and three-part fractures in the elderly. Most four-part fractures appear to be best treated with hemiarthroplasty. Recent meta-analyses show a need for well-executed, randomized, prospective studies that can be used to provide evidence-based templates for appropriate management of displaced proximal humerus fractures in the elderly

The treatment of subtrochanteric fractures of the femur in the elderly is constantly evolving, yet these fractures remain some of the most challenging that the orthopaedic surgeon faces. The high stresses seen by the subtrochanteric region of the femur make designing the ideal implant difficult. In addition, the muscular forces exerted on the proximal fracture fragment add to the difficulty in reduction and fixation. Currently, there are numerous implants, both intramedullary and extramedullary, designed to treat subtrochanteric fractures. Although there are clear biomechanical advantages to intramedullary devices, these advantages have not translated to improved outcomes compared with extramedullary devices, and good results can be obtained with either intra- or extramedullary implants. Any form of operative management of these fractures is technically demanding and requires a thorough knowledge and understanding of both the anatomy and the chosen implant

OBJECTIVES: To compare the pullout strengths of 6.5-millimeter diameter partially threaded cancellous screws and 4.5-millimeter diameter fully-threaded cortical screws versus 3.5-millimeter diameter cortical screws in the proximal tibia. DESIGN: Three screws were inserted in the lateral tibial plateau of each leg of fifteen paired cadaveric tibias. In one tibia, large-fragment fixation was used, consisting of a unicortical 6.5-millimeter screw in the subchondral bone, and bicortical 4.5-millimeter screws in the metadiaphyseal and diaphyseal bone. In the contralateral tibia, small-fragment fixation consisting of three 3.5-millimeter screws was used, placing the screws in the same positions as described above. MAIN OUTCOME MEASUREMENTS: A materials-testing machine was used to determine axial pullout strengths of each screw. The mean pullout strengths of large-fragment and small-fragment screws in each position were compared. RESULTS: No significant difference in pullout strengths was found between the large-fragment and small-fragment screws in subchondral and metadiaphyseal bone. A statistically significant difference was found between pullout strengths of large-fragment and small-fragment screws in diaphyseal bone. CONCLUSIONS: In human proximal tibial bone, the data from this study do not suggest that the pullout strength of 3.5-millimeter screws differs from that of 6.5-millimeter screws in subchondral bone, or that the pullout strength of 3.5-millimeter screws differs from that of 4.5-millimeter screws in metadiaphyseal bone. However, the pullout strength of 3.5-millimeter screws is significantly less than that of 4.5-millimeter screws in diaphyseal bone. The authors of the present study believe this supports the use of small-fragment fixation in the treatment of tibial plateau fractures

Thrombocytopenia-absent radius (TAR) syndrome is defined by bilateral absence of the radius and hypomegakaryocytic thrombocytopenia (<150,000/mm3). Lower extremity and nonorthopaedic anomalies also are frequently present. Charts and radiographs of 23 patients with TAR syndrome were reviewed, with extremity and other anomalies documented. Upper and lower extremity management, which included surgery and multiple attempts at orthotic and prosthetic fitting, was evaluated. Upper extremity prostheses were generally rejected, as most patients were able to perform tasks by approximating themselves closely enough to an object to use their own hands. Adaptive devices for feeding, dressing, and toileting were well tolerated. In the lower extremity, most affected patients either rejected any lower extremity intervention or had involvement that eventually precluded functional ambulation, necessitating power wheelchair or motorized cart use. The greatest degree of independence for these patients comes not from surgical, prosthetic, or orthotic intervention, but from the use of simple adaptive devices and powered mobility aids if required