Faculty Bibliography

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

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

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

The intramedullary nail or rod is commonly used for long-bone fracture fixation and has become the standard treatment of most long-bone diaphyseal and selected metaphyseal fractures. To best understand use of the intramedullary nail, a general knowledge of nail biomechanics and biology is helpful. These implants are introduced into the bone remote to the fracture site and share compressive, bending, and torsional loads with the surrounding osseous structures. Intramedullary nails function as internal splints that allow for secondary fracture healing. Like other metallic fracture fixation implants, a nail is subject to fatigue and can eventually break if bone healing does not occur. Intrinsic characteristics that affect nail biomechanics include its material properties, cross-sectional shape, anterior bow, and diameter. Extrinsic factors, such as reaming of the medullary canal, fracture stability (comminution), and the use and location of locking bolts also affect fixation biomechanics. Although reaming and the insertion of intramedullary nails can have early deleterious effects on endosteal and cortical blood flow, canal reaming appears to have several positive effects on the fracture site, such as increasing extraosseous circulation, which is important for bone healing