Faculty Bibliography

BACKGROUND: This study investigated which variables influence patients' return to sports after operative fixation of an unstable ankle fracture. MATERIALS AND METHODS: Over a 5-year period, 488 patients underwent surgical repair of an unstable ankle fracture. 243 patients preoperatively identified themselves as participating in vigorous activity. Clinical evaluation, functional outcome scores, and radiographic findings were reviewed retrospectively. RESULTS: At 3 months postoperatively, only 3% of all patients had returned to full sports. At 6 months, 14% of patients had returned, while at one year, only 24% of patients had returned. Younger age was predictive of return to sports by 3 months (p = 0.02), 6 months (p = 0.02) and 12 months (p = 0.0001). Males were more likely to return to sports at 6 (p = 0.001) and 12 months (p = 0.040). At 1 year, 88% of recreational athletes had returned to sports, while only 11.6% of competitive athletes had returned to sports (p = 0.043). At 12 months, bimalleolar injuries were more likely to return to sports than unimalleolar ankle fractures (p = 0.042). Furthermore, patients without an associated syndesmotic injury were more likely to return to athletic activities at 12 months (p = 0.011). A patient with an ASA of one or two was ten times more likely to return to sports versus a patient with an ASA of three or four (odds ratio > 10, p = 0.010). CONCLUSION: Predictors of return to sporting activities at one year include younger age, male gender, no or mild systemic disease, and a less severe ankle fracture. Negative predictors include older age, female gender, and the presence of severe medical comorbidities

BACKGROUND: The outcome of operatively treated capitellar fractures has not been reported frequently. The purpose of the present study was to evaluate the clinical, radiographic, and functional outcomes following open reduction and internal fixation of capitellar fractures that were treated with a uniform surgical approach in order to further define the impact on the outcome of fracture type and concomitant lateral column osseous and/or ligamentous injuries. METHODS: A retrospective evaluation of the upper extremity database at our institution identified sixteen skeletally mature patients (mean age, 40 +/- 17 years) with a closed capitellar fracture. In all cases, an extensile lateral exposure and articular fixation with buried cannulated variable-pitch headless compression screws was performed at a mean of ten days after the injury. Clinical, radiographic, and elbow-specific outcomes, including the Mayo Elbow Performance Index, were evaluated at a mean of 27 +/- 19 months postoperatively. RESULTS: Six Type-I, two Type-III, and eight Type-IV fractures were identified with use of the Bryan and Morrey classification system. Four of five ipsilateral radial head fractures occurred in association with a Type-IV fracture. The lateral collateral ligament was intact in fifteen of the sixteen elbows. Metaphyseal comminution was observed in association with five fractures (including four Type-IV fractures and one Type-III fracture). Supplemental mini-fragment screws were used for four of eight Type-IV fractures and one of two Type-III fractures. All fractures healed, and no elbow had instability or weakness. Overall, the mean ulnohumeral motion was 123 degrees (range, 70 degrees to 150 degrees ). Fourteen of the sixteen patients achieved a functional arc of elbow motion, and all patients had full forearm rotation. The mean Mayo Elbow Performance Index score was 92 +/- 10 points, with nine excellent results, six good results, and one fair result. Patients with a Type-IV fracture had a greater magnitude of flexion contracture (p = 0.04), reduced terminal flexion (p = 0.02), and a reduced net ulnohumeral arc (p = 0.01). An ipsilateral radial head fracture did not appear to affect ulnohumeral motion or the functional outcome. CONCLUSIONS: Despite the presence of greater flexion contractures at the time of follow-up in elbows with Type-IV fractures or fractures with an ipsilateral radial head fracture, good to excellent outcomes with functional ulnohumeral motion can be achieved following internal fixation of these complex fractures. Type-IV injuries may be more common than previously thought; such fractures often are associated with metaphyseal comminution or a radial head fracture and may require supplemental fixation

OBJECTIVE: To compare the strength and stiffness of standard double-plate fixation with that of a single-locking plate for comminuted extra-articular distal humeral fractures. MATERIALS: Eight matched pairs of humeri were used. One of each pair was fixed with two 3.5-mm standard reconstruction plates applied dorsally; the other was fixed with one precontoured locking plate applied to the posterior aspect of the lateral column. A 1-cm gap was created to simulate a distal fracture model with 100% metaphyseal comminution with no bony apposition. Stiffness testing of these constructs was performed in axial compression, anterior, posterior and lateral bending, and torsion. They were then cyclically loaded for 4000 cycles with 60 N in posterior bending and the stiffnesses retested. Finally, each construct was posteriorly loaded to failure to determine its ultimate strength. RESULTS: The double-plate construct was significantly stiffer than the one locking plate construct in anterior bending (39%; p = 0.02), posterior bending (23%; p = 0.04), and lateral bending (60%; p = 0.01). No significant stiffness differences were seen in axial compression and torsion (p = 0.64 and 0.25, respectively). After cyclic loading, all construct stiffnesses were relatively unchanged. Both construct types had similar failure strengths (p = 0.76) of approximately 400 N. CONCLUSIONS: Double-plating provides a more rigid fixation than a single-locked plate for fixation of extra-articular comminuted distal humeral fractures. This could be clinically relevant in situations with 100% comminution as seen in gun shot injuries

PURPOSE: To review one surgeon's experience with a novel type of 'hybrid' locking plate (which has both 3.5mm and 4.5mm locking holes) for difficult fractures of the meta-diaphyseal humeral shaft. METHODS: Over a 2-year period, 24 patients who presented with a metaphyseal humeral fracture or nonunion (proximal or distal) were treated surgically by a single surgeon. A 'hybrid' locking plate containing 3.5mm locking holes on one end and 4.5mm locking holes on the other end (Metaphyseal plate, Synthes, Paoli, Pa) was used in all patients. The selection of this implant was based on fracture location and bone quality. Fractures were operated on through an anterolateral or direct posterior approach. All fractures were secured with a minimum of three 4.5mm screws on one side of the fracture and three 3.5mm screws on the other side. All patients were treated with a similar post-operative protocol for early range of shoulder and elbow motion. RESULTS: Three patients were lost to follow-up. The cohort consisted of 15 women and 6 men with a mean age of 49 years (range 18-78). There were 14 acute fractures and 7 nonunions. Twelve fractures involved the distal metaphyseal segment and 9 involved the proximal metaphyseal segment. Twenty-two patients completed a minimum 6-month clinical and radiographic follow-up and form the basis for this report. All 21 patients healed their fractures or nonunions at a mean of 4.5 months. There were no infections or hardware failures. In every case the 'hybrid' nature of the plate design was felt to be advantageous. CONCLUSION: This 'second generation' metaphyseal locking plate, which affords the surgeon the ability to place a greater number of smaller calibre screws within a short bone segment, while using traditional large fragment screw fixation in the longer segment, is clearly an improvement in plate design. Meta-diaphyseal upper extremity long bones may serve as the most ideal location for this implant

Complex pertrochanteric fractures, such as those with reverse obliquity and subtrochanteric extension, represent a subset of hip fractures that sometimes is difficult to treat. Critical assessment of the available literature and a review of treatment indications, implant recommendations, and technical pitfalls will provide insight to physicians to enable better care of patients with these complex injuries

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