Faculty Bibliography

The role of medical, social, and functional covariates on mortality after hip fracture was examined over a 16-year period. A total of 1109 patients with hip fractures were included in a prospective database. The inclusion criteria were patients who were age 65 years or older, ambulatory prior to fracture, cognitively intact, living in their own home at the time of the fracture, and had sustained a nonpathological femoral neck or intertrochanteric chip fracture. Data were analyzed using a Cox proportional hazards model. Mortality was compared with a standardized population, and standardized mortality ratios were calculated for 1, 2, 3, 5, and 10 years,respectively. The 1-, 2-, 5- and 10-year mortality rates were 11.9%, 18.5%, 41.2%, and 75.3%, respectively.The predictors of mortality were advanced age, male gender, high American Society of Anesthesiologists (ASA)classification, the presence of a major postoperative complication, a history of cancer, chronic obstructive pulmonary disorder, a history of congestive heart failure,ambulating with an assistive device, or being a household ambulator prior to hip fracture. The increased mortality risk was highest during the first year after hip fracture and returned to the risk of the standard population 3 years postoperatively. Males who are 65 to 84 years had the highest mortality risk

BACKGROUND: The standard radiographic series for evaluation of a suspected hip fracture in most centers includes an anteroposterior (AP) radiograph of the pelvis, as well AP and cross-table lateral views of the hip. The natural femoral neck anteversion, as well as the fracture deformity, however, may make accurate fracture classification difficult. We have noted that inexperienced physicians sometimes misclassify hip fractures based on the initial radiographic series, which may lead to errors both in surgical planning and implant choice. At our institution, we routinely obtain a physician-assisted traction-internal rotation radiograph of the affected hip in all fractures of the proximal femur. The purpose of the current study was to examine the usefulness of the traction-internal rotation radiograph for the classification of hip fractures by junior residents in our department. MATERIALS AND METHODS: Forty-seven sets of complete radiographs (AP pelvis, AP hip, cross-table lateral, traction- internal rotation views) of patients who sustained a proximal femur fracture were identified. Fifteen first year orthopaedic residents (PGY2) individually reviewed the cases and classified them as one of six possible choices: 1. nondisplaced femoral neck fracture, 2. displaced femoral neck fracture, 3. stable intertrochanteric fracture, 4. unstable intertrochanteric fracture, 5. intertrochanteric fracture with subtrochanteric extension, or 6. subtrochanteric fracture. Each fracture case was classified after first reviewing the standard hip series (AP pelvis, AP hip, and cross-table lateral). A traction-internal rotation radiograph was then added to each case, and any changes in the initial classification were noted. The resident's classification was then compared with those of the senior investigators (KJK, KAE), who used all four views for classification. RESULTS: Reviewing a traction-internal rotation radiograph led to a statistically significant increase in agreement between the resident and senior investigators' classification (71.9% to 77.9%, p value < or = 0.01). The residents were more accurately able to identify fracture patterns as femoral neck (from a prior 98.5% to 99.3% after reviewing a traction-internal rotation view), intertrochanteric (a prior 87.7% to 91.3%), and subtrochanteric (prior 22.9% to 28.9%) after reviewing the additional radiograph. There were a total of 57 (8.1% of all responses) changes in classification after the traction-internal rotation view, 42 of which involved a change from an incorrect to a correct classification. In 50% of the changed responses, the correct classification would have led to a change in implant or surgical procedure choice, or both. CONCLUSION: The routine addition of a traction-internal rotation radiograph increased the ability to accurately classify proximal femur fractures by junior residents in our department. This has a direct impact in accurate surgical planning and implant choice

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

The use of hip arthrodesis for. the treatment of various arthritic conditions has dramatically decreased since the advent and success of hip arthroplasty. Subtrochanteric femur fracture below a long-standing hip arthrodesis is a rare complication that is difficult to treat. There are many factors to be considered in selecting among multiple options for the treatment of this fracture. We present three cases of subtrochanteric femur fractures that occurred long after hip arthrodesis, in which treatment was tailored to the individual patient- and fracture-based characteristics, often requiring multiple procedures

Objectives: We evaluated early complications of self-lengthening intramedullary nails during limb lengthening in patients with post-traumatic or growth-related limb length deficiencies. Patients and methods: A retrospective review was undertaken of all patients who underwent femoral lengthening using the Internal Skeletal Distractor (ISKD Orthofix, McKinney, Texas) device beginning September 2003 at our tertiary care center. Data from the radiographic and clinical records of 11 limbs in nine patients (mean age 24 years; range 16 to 33 years) were derived. Complications were recorded and compared to the demographic data. Results: Preoperative leg length discrepancies averaged 3.7 cm (range 2.5 to 4.8 cm) and postoperative lengthening averaged 3.1 cm (range 2.3 to 4.4 cm). The mean follow-up was 16 months (range 12 to 26 months). The nails were removed after a mean of 11.5 months (range 8 to 16 months). Complications were encountered with eight ISKD nails (72.7%). Of these, seven complications necessitated the patients returning to the operating room. The average time to reoperation was 21 days (range 4 to 37 days). Two patients had two complications per ISKD. In all, there were four nails which failed to advance and required re-osteotomy, three premature consolidations which required osteoclasis, and one runaway nail advancement of 3.0 mm/day compared to the target lengthening rate of 0.8-1.0 mm/day. Conclusion: We believe that binding at the osteotomy site was responsible for failure of nail advancement in patients in whom lengthening failed. In the light of the high complication rate, surgeons' vigilance during the postoperative period is crucial

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

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

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

BACKGROUND: Persistent pain in the region of implanted hardware following fracture fixation commonly leads to implant removal. This prospective study evaluated patient outcomes and pain reduction following removal of orthopaedic hardware implanted for fracture fixation. METHODS: Sixty patients who had been treated previously for a fracture and complained of pain in the region of the fracture fixation hardware constituted the study cohort. Patients were carefully examined by the treating physician to rule out other causes of pain such as infection and nonunion. Baseline data were recorded preoperatively. Data obtained postoperatively at three, six, and twelve months included a visual analog pain scale score and results on the Short Musculoskeletal Function Assessment Questionnaire and the Medical Outcomes Study Short Form-36. At the one-year interval, a patient satisfaction questionnaire was completed and outcomes were analyzed. RESULTS: There were no complications associated with implant removal surgery. Three patients did not have complete follow-up, leaving a total of fifty-seven patients with complete follow-up. At one year, all patients indicated that they were satisfied, that they would have the procedure done again, and that their overall function had improved. The scores for pain on the visual analog scale decreased from a mean (and standard deviation) of 5.5 +/- 2.5 before hardware removal to 1.3 +/- 1.8 after hardware removal, with an overall improvement at one year of 76% (p = 0.00001). At one year, thirty (53%) of the fifty-seven patients had complete resolution of pain. In addition, the results on the Short Musculoskeletal Function Assessment Questionnaire showed a 43% improvement from baseline (p = 0.0001), and the results on the physical component of the Short Form-36 showed a similar improvement of 40% (p = 0.0001). CONCLUSIONS: Following fracture-healing, removal of hardware is safe with minimal risk. Improvement in pain relief and function can be expected