Faculty Bibliography

Ankle fractures are a common orthopedic injury. Certain ankle injuries have been associated with patient demographics such as obesity and smoking. Obese patients are more prone to severe ankle injuries. Naturally, these injuries affect the lower extremity mobility significantly, which itself is a risk factor for obesity. Although obese patients have increased complications across the board, there are specific techniques that can be used to assure the best possible outcome. The perioperative, surgical, and postoperative considerations as well as the outcomes are discussed in this article

This article describes a case of a 21-year old man who presented with symptomatic heterotopic ossification of the patellar tendon 3.5 years postinjury. The patient sustained an open tibia fracture during a fall and was treated by reamed intramedullary nailing through a medial paratendinous approach. Radiographic evidence of heterotopic ossification in the patellar tendon was first noted at the 4-week follow-up. He presented at 3.5 years postinjury with new-onset anterior knee pain and reported no interval trauma to the knee. Radiographs revealed a well-circumscribed area of calcification within the patellar tendon, which was excised within 2 weeks. On excision, the patient's symptoms had resolved. This case is unique because the patellar tendon was not violated at initial or subsequent surgeries, and because of the delayed presentation of heterotopic bone within the patellar tendon. To date, there have been only 3 reported cases of heterotopic ossification of the patellar tendon after intramedullary nailing of the tibia. We present a case of late symptomatic heterotopic ossification of the patellar tendon after medial paratendinous intramedullary nailing of an open tibia shaft fracture

Standard techniques for immobilization of a tibia shaft fracture in the emergency department in a long-leg splint can be cumbersome, technically difficult, and often requires the use of an assistant. We have developed a novel technique for the reduction and splinting of tibial shaft fractures, which uses a 'hammock' constructed of stockinette, which allows a single consulting orthopaedic physician to rapidly reduce and place a long-leg plaster splint or cast on a patient. This technique was performed on 12 consecutive patients with a total of 12 tibial shaft fractures. Translation, angulation, and shortening of the fracture were documented in anteroposterior and lateral views of the injured tibia and these parameters were compared against values measured after the hammock technique was used to reduce and splint the fracture. Pre-'hammock' average values for fracture displacement in the anteroposterior plane for translation, angulation, and shortening were 10.5 mm (53.1%), 12.0 degrees , and 9.4 mm, respectively. Post-'hammock' average values for fracture displacement in the anteroposterior plane for the same parameters were 8.7 mm (44.4%), 4.2 degrees , and 7.9 mm, respectively. Pre-'hammock' average values for fracture displacement in the lateral plane for translation and angulation were 4.9 mm and 8.7 degrees . Post-'hammock' average values for fracture displacement in the lateral plane for the same parameters were 4.9 mm and 2.0 degrees , respectively. These results show that this technique is able to achieve the goals of fracture reduction and immobilization in a rapid fashion when help is not available

Background: Controversy exists regarding the use of one-third tubular plates for fixation of diaphyseal (Weber C) fibular fractures because of increased time to union and concerns about the plate's strength. No study has evaluated the efficacy of this type of plate for Weber C fractures. The purpose of this study was to evaluate one-third tubular plates in the fixation of diaphyseal fibular fractures regardless of whether or not the plate was locking or nonlocking. Methods: We prospectively followed 84 patients with displaced, unstable Weber C fractures. We excluded all OTA type 44-C3 fractures and those treated by any means other than a one-third tubular plate. Of the 50 patients who had sustained an OTA type 44-C1 or C2 fracture and were treated with one-third tubular plates, 39 patients (78%) had complete 1-year follow-up. Results: Union rates were 97% for Weber C fractures treated with onethird tubular plates. There was one wound infection and the overall complication rate was 10%. Two patients (5%) required revision open reduction and internal fixation. Finally, there was no evidence of wound necrosis, malunion, or post-traumatic osteoarthrosis in this cohort. Conclusions: One-third tubular plates provide adequate fixation for Weber C fractures. Theoretical concerns about fixation strength are clinically unfounded. Therefore, we recommend the use of one-third tubular plates for the treatment of Weber C fractures. 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

OBJECTIVE: The objective of our study was to evaluate the diagnostic utility of conventional radiography for diagnosing bisphosphonate-related atypical subtrochanteric femoral fractures. MATERIALS AND METHODS: Retrospective interpretation of 38 radiographs of complete subtrochanteric and diaphyseal femoral fractures in two patient groups-one group being treated with bisphosphonates (19 fractures in 17 patients) and a second group not being treated with bisphosphonates (19 fractures in 19 patients)-was performed by three radiologists. The readers assessed four imaging criteria: focal lateral cortical thickening, transverse fracture, medial femoral spike, and fracture comminution. The odds ratios and the sensitivity, specificity, and accuracy of each imaging criterion as a predictor of bisphosphonate-related fractures were calculated. Similarly, the interobserver agreement and the sensitivity, specificity, and accuracy of diagnosing bisphosphonate-related fractures (i.e., atypical femoral fractures) were determined for the three readers. RESULTS: Among the candidate predictors of bisphosphonate-related fractures, focal lateral cortical thickening and transverse fracture had the highest odds ratios (76.4 and 10.1, respectively). Medial spike and comminution had odd ratios of 3.8 and 0.63, respectively. Focal lateral cortical thickening and transverse fracture were also the most accurate factors for detecting bisphosphonate-related fractures for all readers. The sensitivity, specificity, and overall accuracy for diagnosing bisphosphonate-related fractures were 94.7%, 100%, and 97.4% for reader 1; 94.7%, 68.4%, and 81.6% for reader 2; and 89.5%, 89.5%, and 89.5% for reader 3, respectively. The interobserver agreement was substantial (kappa > 0.61). CONCLUSION: Radiographs are reliable for distinguishing between complete femoral fractures related to bisphosphonate use and those not related to bisphosphonate use. Focal lateral cortical thickening and transverse fracture are the most dependable signs, showing high odds ratios and the highest accuracy for diagnosing these fractures

The purpose of this study was to compare fixation stability and lag screw sliding characteristics between 2 different hip-nail lag screw designs, a telescoping screwbarrel and a solid helical blade. Simulated, unstable, 4-part intertrochanteric hip fractures were created in 6 pairs of cadaveric femurs. Each nail type was randomly assigned within each femur pair. Lag screw sliding and inferior and lateral head displacements were measured following an applied static load of 750 N. Measurements were obtained before, during, and after cyclical loading with 750 N for 105 cycles. Ultimate failure strength was determined. After considering inferior head displacements, no significant differences between the 2 screw designs were found. Mean head displacement for the helical screw was 2.18 mm, compared with 1.87 mm for the telescoping screw (P = .731). A significant difference in the amount of lateral movement of the lag screws was found, however. The helical lag screws had mean lateral sliding of 2.68 mm, compared with 0.25 mm for the telescoping screws (P = .007). Neither of the lag screw constructs failed by screw cutout from the head. Both screw designs provide similar fixation strength for stabilization of 4-part intertrochanteric fractures. Both the telescoping lag screw and the helical blade facilitate fracture collapse, but the telescoping lag screw also minimizes lateral projection of the screw from the nail. This advantage may help minimize postoperative lateral soft-tissue impingement

BACKGROUND: The optimal treatment for high energy pilon fractures is controversial. Good clinical and functional results have been reported with traditional open reduction techniques and minimally invasive techniques utilizing external fixation (EF). The purpose of this study was to critically evaluate clinical, radiographic and functional outcomes following high-energy fractures of the tibial plafond. METHODS: Between 2000 and 2006, 62 patients who were diagnosed with 63 Type 43C pilon fractures were treated surgically by a single surgeon and retrospectively reviewed. Twenty-seven patients were treated with a hinged bridging external fixator (EF) with supplemental limited internal fixation and 35 were treated with open reduction and internal fixation (ORIF) utilizing traditional small fragment plates and screws. Out of the 62 patients, a total of 46 patients were available for review. Charts and radiographs were reviewed and a Short Musculoskeletal Function Assessment (SMFA) questionnaire was administered by a trained interviewer. Seventy-four percent of both the ex-fix patients and ORIF patients were available for followup with a mean of 18 and 22 months, respectively. Results were compared using student's T-tests. RESULTS: There were no differences between the cohorts with respect to mechanism of injury, presence of an open wound and age. Functional outcomes were similar between the two groups based on the American Orthopaedic Foot and Ankle Society (AOFAS) score and the 'function' index of the SMFA. The overall complication and union rates were similar between the two groups. CONCLUSION: Both ORIF and EF appear to be comparable for treatment of OTA type 43C (pilon) fractures with regard to final range of ankle motion, development of arthritis and hindfoot scores

We reviewed 11 cases of luxatio erecta (inferior shoulder dislocation) managed acutely at our institutions to gain insight into the diagnostic and management principles of this condition. We then compared our findings with those in the current literature. Luxatio erecta requires careful clinical and radiographic evaluation and a high index of suspicion for associated injuries, as they occur frequently and can be significant given their tendency to be associated with higher energy trauma. Our results indicate that the majority of patients return to preinjury level of shoulder function, despite associated injuries. Closed reduction constituted definitive management in 100% of the cases in our series, and there was no recurrent instability at follow-up

Low-energy shotgun fractures involving the arm are complex injuries. Previously published reports have emphasized various problems associated with these injuries. This case report describes a low-energy shotgun wound managed by a staged treatment protocol involving: (1) a spanning external fixator and immediate soft tissue management, followed by (2) osteosynthesis and autogenous bone grafting and (3) epineural suturing of injured radial nerve, with a successful outcome. Although adequate debridement of the fracture and soft tissue wound is the key to open fracture management, some difference of opinion exists with regard to the timing of bone reconstruction and grafting. In severe type III open fractures, or in wounds that are marginal, it may be best to delay cancellous bone grafting until soft tissue has stabilized following acute trauma when the risk of infection has been minimized. If early coverage of vital structures is not possible, local or remote flap coverage may be necessary

OBJECTIVE: This study was performed to evaluate the results of operative treatment of ankle fractures in patients who required syndesmotic stabilization in addition to malleolar fracture fixation compared with patients who required malleolar fixation alone. DESIGN: The authors conducted a retrospective review of prospectively collected data. SETTING: Academic medical center. PATIENTS: Between October 2000 and November 2006, 347 patients who underwent surgical repair of an unstable ankle fracture were enrolled in a prospective database. INTERVENTION: Patients who had an associated syndesmotic disruption requiring surgical stabilization in association with either an ankle fracture or a fracture-dislocation were identified and compared with a cohort treated during the same time period who had sustained an ankle fracture or fracture-dislocation without syndesmotic disruption. MAIN OUTCOME MEASUREMENTS: All patients were followed and evaluated at 3, 6, and 12 months with clinical and radiographic examination as well as functional status (Short Musculoskeletal Functional Assessment, American Orthopaedic Foot and Ankle Society). Patient-reported pain and postoperative complications were recorded as well. RESULTS: Three hundred forty-seven patients met the inclusion criteria and had 1-year minimum follow up. Seventy-nine patients (23%) who had syndesmotic stabilization were identified and compared with 268 patients (77%) who did not. No differences were found between the two groups with respect to age or American Society of Anesthesiologists status; however, there was a greater percentage of men in the syndesmotic injury group (P = 0.04). There was a greater percentage of Type C fractures requiring syndesmosis stabilization, whereas Type B fractures were less likely to require syndesmosis stabilization (P = 0.001) At 6- and 12-month follow up, there was a clear difference in outcome based on American Orthopaedic Foot and Ankle Society and Short Musculoskeletal Functional Assessment scores; patients who underwent syndesmotic stabilization had worse American Orthopaedic Foot and Ankle Society scores with lower function ratings (P = 0.04) and worse pain ratings (P = 0.02). Short Musculoskeletal Functional Assessment scores were also worse at 12 months in patients who had syndesmotic stabilization because the dysfunction index was higher in the syndesmotic injury group (P = 0.009). Radiographically, 18 of 144 (13%) syndesmotic screws were noted to be broken on follow-up radiographs, eight of which were subsequently removed. There were no other differences in complication rates. CONCLUSION: Patients who required syndesmotic stabilization in addition to malleolar fracture fixation had poorer outcomes at 12 months compared with patients who required malleolar fracture fixation alone. This information is important for patient counseling to manage expectations regarding outcomes after injury