Faculty Bibliography

Periprosthetic femoral fractures associated with well-fixed total hip or total knee prostheses present a challenging management problem as these injuries typically occur in osteoporotic bone. Conventional management entails extensive periosteal stripping to allow for plate fixation. We reviewed a consecutive series of patients who sustained fractures associated with a well fixed total knee prosthesis, a total hip prosthesis, or both. Twenty four patients with a mean age of 69.4 years were included. All patients underwent fixation via percutaneous insertion techniques with a first generation locking plate and screws (LISS-Less Invasive Skeletal Stabilization, Synthes, Paoli, PA). Three patients sustained fractures distal to a well-fixed total hip prosthesis, eighteen fractures occurred above a well-fixed total knee femoral component, and three were interprosthetic. The mean length of time from the index procedure to fracture was 76 months, range (2-172 months). Blood loss was minimal in each case, with a mean operative time of 90min (range 60-120min). Twenty one of twenty four went on to unite at a mean 6.2 months (range 3-19 months). Three patients underwent further surgery. One failure of fixation was encountered. Percutaneous fixation is technically demanding as it requires stable fixation without direct visualisation of the fracture site or the entire fixation device. Our results suggest percutaneous fixation with the LISS plate is an effective although technically demanding method of treatment. Complication rates were comparable to existing reports of this treatment method, and appear to be improved over traditional methods of fixation

OBJECTIVES: At our institution, a standardized protocol using magnetic resonance imaging (MRI) to evaluate ankle stability and need for surgery following a positive manual stress test for isolated lateral malleolus fractures has been used. The purpose of this study was to evaluate the results using this standardized protocol. DESIGN: Retrospective review. SETTING: University teaching hospital. PATIENTS:: Twenty-one patients who had a positive ankle stress test (>or=5 mm clear space widening) after isolated Weber B lateral malleolus fracture were further evaluated by MRI to determine the status of the deep deltoid ligament. INTERVENTION: If the MRI showed the deltoid ligament was completely disrupted, the patient was advised to have operative ankle repair. However, if the MRI demonstrated that the deep deltoid was intact or only partially disrupted, the patient was treated nonoperatively in a walking boot with weightbearing as tolerated ambulation. MAIN OUTCOME MEASUREMENT: Patients were followed until fracture union and contacted at 12-month minimum follow-up to determine outcomes by radiographic evaluation, health related quality of life (HRQOL) based on Short Form (SF)-36 results and functional outcomes based on the American Orthopaedic Foot and Ankle (AOFAS) and patient report of treatment satisfaction. RESULTS: Twenty-one patients had an MRI after a positive ankle stress test and comprised the study group. There were 12 men and 9 women with an average age of 27 years (range, 16-62 years). Absolute medial clear space measurement on stress testing ranged from 5 to 8 mm. In all, 19 of 21 patients (90%) had evidence of partially torn deep deltoid ligament on MRI and were treated nonoperatively, whereas two patients had MRI findings of a complete deep deltoid injury and underwent surgical treatment. There were no statistically significant correlations between the medial clear space measurements and MRI documentation of complete deltoid ligament rupture. All fractures united without evidence of residual medial clear space widening or posttraumatic joint space narrowing. Of the 15 patients who were available for 1 year minimum follow-up and agreed to come back for clinical and radiographic evaluation, 14 had an AOFAS score of 100, with the remaining patient having a score of 85. HRQOL based on SF-36 results indicated all patients were above or at normal levels, and all patients reported that they were satisfied with their treatment; 93% (14/15) indicated that they would make the same treatment decision again. CONCLUSIONS: Using our protocol, we were able to identify and provide effective nonoperative care to 19 patients who otherwise might have underwent operative treatment after an isolated lateral malleolus fracture. Further work is needed to identify the subset of patients who could be treated nonoperatively without a need for MRI scanning

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

Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion. This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures. We retrospectively reviewed 279 patients (99 obese (BMI > or = 30) and 180 non-obese (BMI < 30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function. These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities

BACKGROUND: This prospective study was done to evaluate functional outcomes after acute avulsion fractures of the fifth metatarsal base. METHODS: Fifty-two patients who sustained an avulsion fracture of the fifth metatarsal base and presented to the outpatient clinic of our hospital system were treated according to a standardized protocol. A total of 49 patients (50 fractures) were available for 1-year followup. There were eight men and 41 women with an average age of 41.9 (range 17 to 81) years. The lower extremity was placed in a hard-soled shoe, and patients were allowed to bear weight as tolerated. Baseline data collection consisted of demographic information, and radiographic, and functional evaluation. Patients were seen at regularly scheduled visits for 6 months and then contacted at 1 year to obtain followup information. A Short Musculoskeletal Function Assessment (SMFA) questionnaire was obtained at 6 months and 1 year. Analyses were performed to determine differences in outcome based on demographics and injury information. A p value of less than 0.05 was considered significant. RESULTS: An average of 22 days were lost from work, with 23 patients (46.9%) taking up to 10 days, 18 (36.7%) taking 10 days or longer off work, and eight patients (16.4%) losing no days of work. Based on self-reports, 10 patients (20.4%) had returned to pre-injury functional status by 3 months, 42 patients (85.7%) by 6 months, and all 49 patients by 1 year. At six and 12 months, no differences in SFMA were found based on gender, fracture type, or amount of fracture displacement. CONCLUSIONS: Fracture of the fifth metatarsal base often is a source of lost work productivity. Although patients can be expected to return to their preinjury level of function, recovery may take 6 months or longer

OBJECTIVE: To determine the effect of reinforced calcium phosphate cement augmentation of the femoral neck defect created after dynamic hip screw removal in a cadaveric model. METHODS: The lag screws of dynamic hip screw implants were inserted and subsequently removed in 8 matched pairs of cadaveric, osteoporotic femurs to create a femoral neck defect. One of each pair had the defect augmented with osteoconductive calcium phosphate cement reinforced with poly(lactide-coglycolide) fibers (Norian Reinforced, Synthes, West Chester, PA), and the other defect was not augmented. Each specimen was first cyclically loaded with 750 N vertical loads applied for 1000 cycles to simulate early weightbearing, and then loaded to failure. RESULTS: Calcium phosphate cement augmentation of the lag screw defect significantly increased the mean femoral neck failure strength (4819 N) compared to specimens in which the defect was left untreated (3995 N) (P < 0.004). The mechanism of failure for each specimen was a fracture through the femoral neck. Regression analysis demonstrated that load to failure was directly related to the bone mineral density at Ward's triangle, and the impact of cement augmentation on failure strength was greatest for specimens with the lowest bone mineral density (correlation coefficient: -0.82, P < 0.0001). CONCLUSION: This study demonstrates that augmentation of the bony defect created by dynamic hip screw removal with reinforced calcium phosphate cement significantly improved the failure strength of the bone. Cement augmentation after hardware removal may decrease the risk of refracture and allow early weightbearing, especially in elderly patients with osteoporotic bone.

The purpose of this report was to evaluate patient outcomes after treatment of acute midshaft clavicle fractures with an intramedullary Hagie pin, including clinical results and the incidence of postoperative complications. Between 1993 and 2003, 16 patients who underwent intramedullary Hagie pin fixation of a midshaft clavicle fracture were identified. The medical records of each patient were reviewed to ascertain the mechanism of injury, indication for surgical intervention, and treatment course. Clinical outcomes were evaluated with respect to time to fracture union, postoperative shoulder range of motion, and symptoms related to the fracture site and ipsilateral shoulder. The inpatient postoperative course and outpatient follow-up visits were assessed in an effort to document the incidence of postoperative complications. The most common mechanism of injury was participation in athletic activity. Operative indications included significant deformity, polytrauma, and neurovascular compromise. The mean time from injury to operative fracture stabilization was 15.8 days. No intraoperative complications occurred. All 16 patients (100%) were available for follow-up to fracture union, which occurred in all cases at a mean of 12.4 weeks. Of the 16 patients, 14 were available for further follow-up, and at a mean follow-up of 9 months, 85.7% had regained near-full to full range of shoulder motion and 93% had no symptoms related to the fracture site or ipsilateral shoulder. Postoperative complications occurred in 8 patients (50%), including 3 cases of skin breakdown related to hardware prominence, 2 cases of hardware breakage, 2 cases of decreased sensation in the region of the surgical incision, and 1 case of persistent pain over the operative site. When indicated, the use of intramedullary devices for the stabilization of clavicle fractures offers theoretic advantages over traditional plate and screw fixation. In this case series, intramedullary Hagie pin fixation resulted in fracture union in 100% of cases, with a high percentage of patients regaining full range of shoulder motion and resolution of symptoms. However, there was a 50% incidence of postoperative complications associated with this treatment method. We believe that the complication rate associated with the use of the Hagie pin should preclude the use of this particular implant.

It was recently reported that use of a perforated, stretchable cloth tape instead of silk tape reduced the incidenc of postoperative blisters around the hip from 41% to 10%. The present prospective randomized study was conducted to determine whether use of spica bandage (vs the cloth tape) could further reduce or eliminate the incidence of these blisters. Patients were randomized to 2 treatmen groups: perforated, stretchable cloth tape (Hypafix; Smit & Nephew, Memphis, Tenn) and elastic spica bandage tha was started at the lower thigh and was extended aroun the hip and abdomen. After surgery, cloth tape or spic bandage was applied over the postoperative dressing, with care taken not to produce skin tension. At the first dressing change, presence or absence of blisters was recorded, along with their number, size, location, and type. All subsequent dressing changes were done much as they wer at surgery, using the assigned type of dressing. Presence or absence of blisters was recorded at each subsequent dressing change. Two hundred ninety-four patients (300 hips) were enrolled. Twenty-two (7.33%) of the 300 hips developed a blister. Risk for developing a blister was 10% with the cloth tape versus 4.67% with the elastic spica bandage (P < .09). Surgery type (arthroplasty vs open reduction and internal fixation [ORIF], P < .03) and surgery duration (P < .05) had more of an effect on postoperative blister formation than dressing type

OBJECTIVE: Supracondylar humerus fractures (SCHF) are common in the pediatric population. Cubitus varus deformity (CVD) is the most common long-term complication of SCHFs and may lead to elbow instability and deficits in throwing or extension. Distal fragment malrotation in the axial plane disposes to fragment tilt and CVD; however, no simple method of assessing fracture malrotation exists. This study tested a mathematical method of measuring axial plane malrotation in SCHFs based on plain radiographs. DESIGN: A pediatric SCHF model was made, and x-rays were taken at known intervals of rotation. Five independent, blinded observers measured these films. Calculated rotation for each data set was compared to the known rotation. The identical protocol was performed for an aluminum phantom. RESULTS: The reliability and agreement of the rotation values were good for both models. CONCLUSIONS: This method is a reliable, accurate, and cost-effective means of calculating SCHF distal fragment malrotation and warrants clinical application

OBJECTIVE: To compare the fixation stability of intramedullary nails to that of locked plates for the treatment of distal metaphyseal tibia and fibula fractures. METHODS: A simulated, distal metaphyseal tibia fracture was created in 8 pairs of cadaveric tibia-fibula specimens. One of each pair was treated using an intramedullary nail (Trigen IM Nail System; SN Richards, Memphis, TN) and the other with a locked plate (Peri-Loc Periarticular Locked Plating System; SN Richards). Each specimen was vertically loaded to 250 N in central, anterior, posterior, medial, and lateral locations; loaded to 250 N in cantilever bending in anterior to posterior and posterior to anterior directions; and loaded to 250 N mm in torsion. Load-displacement curves were generated to determine the construct stiffness for each loading scenario, with comparisons made between the 2 treatment groups. Each specimen was then cyclically loaded with 750 N vertical loads applied for 10, 100, 1000, and 10,000 cycles. Measurements of fracture displacements were made and compared between treatment groups. A fibular osteotomy was then created in each specimen at the same level as the tibia fracture to simulate a same-level tibia-fibular fracture. Torsional stiffness assessment and cyclic vertical loading for 10, 100, 1000, and 10,000 cycles were repeated and fracture displacement measurements were again obtained. RESULTS: The locked plate construct was stiffer than the intramedullary nail construct for central, anterior, and posterior loading scenarios (P < 0.005, P < 0.03, and P < 0.02, respectively). The intramedullary nail construct was stiffer than the locked plate construct for both anterior to posterior and posterior to anterior cantilever bending (P < 0.03 and P < 0.02, respectively). No statistically significant difference in stiffness was noted between treatment groups for medial and lateral vertical loading or for torsional loading (P = 0.09, P = 0.32, and P = 0.84, respectively). There was no significant difference between treatment groups with respect to fracture displacement after cyclic vertical loading. After creation of the fibular osteotomy fracture, construct displacements after 1000 and 10,000 cycles significantly increased and torsional stiffness significantly decreased for both treatment groups. The locked plate constructs had significantly less displacement after cyclic loading of 1000 and 10,000 than the locked nail constructs (P < 0.001 and P < 0.0001, respectively). Locked plate constructs were stiffer in torsion after osteotomy than the intramedullary nail constructs (P < 0.05). CONCLUSION: This study demonstrated that, in the treatment of distal metaphyseal tibia fractures, locked plates provided more stable fixation than intramedullary nails in vertical loading but were less effective in cantilever bending. An intact fibula in the presence of a distal tibia fracture improved the fracture fixation stability for both treatment methods. In fracture patterns in which the fibula cannot be effectively stabilized, locked plates offer improved mechanical stability when compared with locked intramedullary nails