Faculty Bibliography

The timing of operative fracture care is often confounded by multisystem injuries, conflicting or absent literature, and lack of communication between orthopaedic surgeons and other physicians providing care to the patient. Much has been published regarding the proper sequence of events in providing care to patients with multisystem injuries. Only recently has the role of complex musculoskeletal injuries and the timing of fixation in multiply-injured patients been explored in detail. Timing of care for pelvic injuries is frequently determined by the presence of injury to other organ systems, the presence of open wounds, and hemodynamic status. There is likely an optimal time window for fixation. However, existing data is often difficult to compare, given varying definitions and protocols. Furthermore, reports are often conflicting, making the determination of an optimal time-window difficult. Similar concerns are present with lower extremity long bone fractures. Injury to other organ systems must be considered with timing of femur fixation, particularly in the presence of lung injury. Tibia fractures are frequently complicated by the presence of a tenuous soft tissue envelope and other injury factors that often alter the timing of fixation. These issues and, last, the timing of care for calcaneus and talus injuries are reviewed, as risk of avascular necrosis and quality of articular reduction are related to the timing of fixation

Clavicle fractures remain one of the more common fractures encountered in the orthopaedic office. Nonoperative management remains the standard of care in most cases. However, studies have shown a higher nonunion rate and decreased patient satisfaction in fractures with increased shortening. The malunion resulting from nonoperative management has been shown to be problematic in patients with significant fracture shortening. When operative reduction and fixation is indicated, there are numerous techniques to aid the surgeon patient care. This article reviews the midshaft clavicle fracture and discusses recent outcome studies on patients with fracture shortening and approaches to operative management

BACKGROUND: Management of chronic posttraumatic osteomyelitis remains an important challenge in orthopaedics. In this investigation, 43 patients at a large university hospital were retrospectively identified who had been diagnosed with chronic osteomyelitis at 44 sites. METHODS: Diagnosis was based on the patient's history and physical examination, laboratory values, radiological evaluation, and intraoperative specimens. Patients' charts were reviewed and follow-up was obtained on 33 patients in whom Short Musculoskeletal Functional Assessment (SMFA) questionnaires were obtained. RESULTS: The mean follow-up of the cohort was 21.1 months (range, 10 to 54 months). Sites involved included: tibia (55%) and femur (36%), with the remainder involving the pelvis, radius/ulna, and calcaneus. Blood, bone, or wound aspirate cultures were positive in 85%, most commonly for Staphylococcus aureus. 84% of the patients in this investigation were completely cured after a single surgical intervention, removal of hardware and a course of intravenous antibiotics. Three patients required additional surgical intervention and two remained infected. Ultimately, the cohort reached a cure rate of 94%. SMFA data revealed that patients had a dysfunction score of 53.8 and bother index of 51.5, with 50 being the normal for the general population. CONCLUSION: The patients in this cohort functioned at a level less than one standard deviation below the general population. These results suggest that patients with chronic posttraumatic osteomyelitis do not function significantly below that of the normal population following eradication of their infections

Ankle stability in ankle fractures is dependent on multiple factors. The medial malleolus and the associated deltoid ligament provide for ankle stability on the medial side. Over the years, the relative importance of this medial malleolar osteoligamentous complex (MMOLC) has been debated. This review will describe the evolution of ankle fracture surgery from the perspective of the contribution of the MMOLC to re-establishing ankle stability. Also discussed are the surgical and nonsurgical treatment options, various presentations of medial sided injuries in ankle fractures, and, finally, current recommendations for fixation

Prior studies and techniques for harvesting iliac crest bone have shown significant postoperative pain, disability, and poor cosmesis. This retrospective study was conducted to examine bone graft donor-site morbidity by evaluating functional outcomes in patients who have undergone a modified anterior harvesting approach. The medical charts and hospital records of 43 patients were retrospectively reviewed over a 6-year period. Demographic information, operative notes, laboratory results, and the American Society of Anesthesiologists (ASA) classification were recorded. All patients were evaluated retrospectively at a mean 41 months after bone-graft harvesting. Patients available for follow-up were asked to quantify their pain level at the donor-site on a visual analog pain scale (0-10). They also completed SMFA forms, as well as a survey pertaining to sensory deficits, gait disturbances, and cosmetic appearance. Forty-four patients met the inclusion criteria consisting of 25 males and 18 females, mean age 47 years (range, 22 to 80 years). A total of 32 (73%) patients were available for long-term follow-up at a mean of 41.3 months (range, 8 to 83 months). Eight (25%) of these patients reported minimal postoperative pain at time of follow-up. Three of 32 (9%) patients reported minor ambulation difficulty as a result of donor-site pain. Other minor complications included hypertrophic scar formation (7%) and hematoma/seroma (3%). There were no major complications reported, such as deformity at the crest site (0%) or infection (0%). SMFA scores demonstrated a mean dysfunction score of 48.5 (range, 41.8 to 71.1) and a bother index of mean 47.9 (range, 42.6 to 73.9). Utilizing the anterior approach in iliac crest bone harvesting provides an abundant supply of both cortical and cancellous bone, an aesthetically favorable scar, and decreased postoperative donor-site pain. There were very few complications seen in our cohort as compared to previous studies with very good long-term functional outcomes

Two cases are presented in which adult, precontoured, lower-extremity periarticular locking plates were utilized for fixation of subtrochanteric femur fractures in pediatric patients. Recognition of the fact that a distal tibial locking plate in a small child and a proximal tibial locking plate in an adolescent anatomically ft the proximal femur in each case may provide a surgeon treating subtrochanteric hip fractures in this population increased options for operative stabilization

This article presents a collection development tool that identifies a list of key orthopedic journals to retain in print or license electronically in an academic or teaching hospital library. The authors developed an assessment tool comparing five measures of importance and use, including journal impact factor, cited half-life, interlibrary loan lending, electronic archival access, and library usage. This study assists medical librarians and orthopedic surgeons by identifying the titles in this subject area that may be of most enduring value for professional reading and for hospital library collections.

BACKGROUND: This study was performed to evaluate when patients recover sufficiently to drive an automobile after operative repair of various other lower extremity fractures. METHODS: A computerized driving simulator was developed and tested. Three groups of individuals were compared: (1) 12 healthy, volunteers tested once to establish normal mean values for variables tested (group I); (2) 22 patients with right-sided long bone lower extremity fractures (9 femur, 13 tibial shaft) tested at 6 weeks, 9 weeks, and 12 weeks after operative repair (group II); and 35 patients with right-sided articular fractures (12 plateau, 4 pilon, 12 calcaneus, 7 acetabulum) tested at 12 weeks, 15 weeks, and 18 weeks after operative repair (group III). Individuals were tested under a series of driving scenarios (city, suburban, and highway). Short musculoskeletal functional assessment scores were recorded at the time of each driving test and compared with results of the driving test. Analyses were performed to determine the relationship between time from initiation of weight bearing on the right lower extremity and brake travel time (BTT). RESULTS: For group I, BTT was 302 +/- 90; for group II, BTT was 444 msec +/- 153 msec, 377 msec +/- 127 msec, and 359 msec +/- 116 msec at 6 weeks, 9 weeks, and 12 weeks after surgery; and for group III, BTT was 412 msec +/- 161 msec, 343 msec +/- 112 msec, and 339 msec +/- 116 msec at 12 weeks, 15 weeks, and 18 weeks after surgery. Short musculoskeletal functional assessment scores improved with respect to function and bother indexes, but did not correlate with improvement in BTT (r = 0.36, p = 0.07, and r = 0.31, p = 0.12, respectively). CONCLUSION: BTT was significantly reduced until 6 weeks after initiation of weight bearing in both long bone and articular fractures of the right lower extremity

Partial articular fractures of the distal humerus commonly involve the capitellum and may extend medially to involve the trochlea. As the complex nature of capitellar fractures has become better appreciated, treatment options have evolved from closed reduction and immobilization and fragment excision to a preference for open reduction and internal fixation. The latter is now recommended to achieve stable anatomic reduction, restore articular congruity, and initiate early motion. More complex fracture patterns require extensile surgical exposures. The fractures are characterized by metaphyseal comminution of the lateral column and have associated ipsilateral radial head fracture. With advanced instrumentation, elbow arthroscopy may be used in the management of these articular fractures. Though limited to level IV evidence, clinical series reporting outcomes following open reduction and internal fixation of fractures of the capitellum, with or without associated injuries, have demonstrated good to excellent functional results in most patients when the injury is limited to the radiocapitellar compartment. Clinically significant osteonecrosis and heterotopic ossification are rare, but mild to moderate posttraumatic osteoarthrosis may be anticipated at midterm follow-up

OBJECTIVES: External fixation is frequently used for provisional and/or definitive stabilization of open and closed fractures and dislocations involving the lower extremity. There is some concern, however, that application of an external fixator with subsequent reduction of the fractures with distraction may precipitate the development of compartment syndrome. The hypothesis of this study was that application of external fixation and restoration of limb length would have no effect on the compartment pressures. DESIGN: Prospective cohort study. SETTING: Academic medical center, 2 level 1 trauma centers. PATIENTS: Between October 2003 and May 2006, 25 patients who met inclusion criteria and underwent immediate knee-spanning external fixation. INTERVENTION: All 4 compartments of the injured leg were measured with a Solid-State Transducer Intra Compartment device or an arterial line set-up during the temporizing procedure at 4 different time points. In addition, at the time each pressure reading was taken, the patient's diastolic pressure was recorded from the anesthesia monitor. MAIN OUTCOME MEASUREMENT: Elevation of compartment pressure at any of 4 distinct time points during the procedure. Each of the compartments was measured and recorded 4 times: (1) after the patient had been draped but before any fixation or reduction of the fracture, (2) immediately after the insertion of the fixator pins, (3) immediately after reduction of the fracture, and (4) 5 minutes after the reduction. A threshold of less than 30 mm Hg differential from diastolic pressure in conjunction with clinical examination was set as an indication for 4-compartment fasciotomy. RESULTS:: Twenty-five patients with a mean age of 52 years (range, 21-69 years) were enrolled in the study. Injuries included proximal tibial fractures (Orthopaedic Trauma Association types, 41) in 21 patients; knee fracture-dislocation (Moore type II) in 2 patients, and knee (femoro-tibial) dislocations in 2 patients. Two fractures were open, and all other injuries were closed. Fasciotomy was required in 3 cases at initial compartment measurement. In the remaining 22, there were no significant trends toward increased compartment pressures as a result of external fixation placement and knee reduction. There were 9 patients (41%) who had a transient DeltaP < 30 mm Hg at some point during surgery. No patient had a DeltaP < 30 mm Hg sustained through the conclusion of the procedure, and no compartments were released in any of these patients. None of the patients in the study developed compartment syndrome after surgery, and no sequelae of compartment syndrome were noted at minimum 6-month follow-up. CONCLUSIONS: Application of knee-spanning external fixation as a temporary measure for stabilization of high-energy proximal tibial fractures and dislocations may result in transient elevation of intracompartmental pressure of the leg. Although DeltaP may fall below the threshold of 30 mm Hg, this does not appear to lead to compartment syndrome