Faculty Bibliography

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.

Planning for surgical correction of lower-limb deformity requires assessment of the character and extent of the deformity. Deformity measurements are defined; however, the reliability of these measurements has not been evaluated. This study was conducted to assess the interobserver and intraobserver reliability of lower extremity deformity measurements in the frontal and sagittal planes. Anteroposterior and lateral lower extremity radiographs were evaluated using Paley technique. Statistical analysis included intraclass correlation coefficient (2,1), median absolute difference, range, and agreement within 3 and 5 degrees. Reliability was good to very good for all measurements except for the anterior distal tibial angle, which had moderate reliability. Intraobserver reliability was higher than interobserver reliability, and measurements in the frontal plane had better reliability than measurements in the sagittal plane. Overall, these measurements are a reliable method of assessing lower extremity deformity and should be used to guide treatment and monitor outcome.

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

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

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: 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

Fracture-dislocation of the elbow is a signiicant injury with mixed outcomes. The purpose of the study was to evaluate patient perceived outcome following surgical stabilization of these complex injuries. Twenty-nine available patients (76%) from 37 identiied with 'terrible triad' injury patterns, in- cluding ulnohumeral dislocation, radial head fracture, and coronoid fracture, were available for a minimum 1-year follow-up (mean, 27 months). All patients were evaluated by their treating physician. Radiographic outcome was evaluated at latest follow-up. Functional outcome was based upon DASH, Mayo elbow performance, and Broberg-Mor- rey scores. Complications were recorded. Results included that the average lexion-extension arc of elbow motion was 109 degrees +/- 27 degrees , and the average pronation-supination arc was 128 degrees +/- 44 degrees . Grip strength averaged 72% of the contralateral extremity. The Mayo score was a mean of 81 (range, 45 to 100), the Broberg-Morrey mean was 77 (range, 33 to 100) The mean DASH was 28 (range, 0 to 72). When compared to the age-based normal values, the mean patient's DASH score was 1.4 SD worse than an average person of the same age None of the injury characteristics, patient demographics or treatment modalities was signiicantly associated with a poor outcome at the 95% conidence interval. Conclusions are that the results with terrible triad injuries are often unsatisfactory, but surgical management with the use of a systematic approach may be beneicial. Our approach led to the restoration of elbow joint stability in all patients