Faculty Bibliography

External fixation for definitive or initial management of tibial fractures has a long history, with pin-to-bar external fixation being the standard of care for definitive management of tibial fractures. However, the use of this method lessened because of the increased popularity of intramedullary nailing and drawbacks associated with external fixation. This method is still commonly in use in the military environment and can be used for temporary stabilization of tibial fractures, especially in the setting of periarticular injuries. These fixators also may be useful for salvage of open and/or infected fractures that are unsuitable for internal fixation.

CASE/METHODS:We present a case of a patient who sustained overlapping dislocation of the pubic symphysis (ODPS), which required an open reduction as well as anterior and posterior pelvic ring fixation. CONCLUSION/CONCLUSIONS:This case report is a valuable addition to the current literature on ODPS because we believe it to be the first report describing a patient who required both anterior and posterior fixation because of pelvic instability.

External fixation for definitive or initial management of tibial fractures has a long history, with pin-to-bar external fixation being the standard of care for definitive management. However, the use of this method has lessened because of the increased popularity of intramedullary nailing and drawbacks associated with external fixation. This method is still commonly used in the military environment and can be used for temporary stabilization of tibial fractures, especially in the setting of periarticular injuries. These fixators also may be useful for salvage of open and/or infected fractures that are unsuitable for internal fixation.

Management of tibia fractures by internal fixation, particularly intramedullary nails, has become the standard for diaphyseal fractures. However, for metaphyseal fractures or those at the metaphyseal-diaphyseal junction, the choice of fixation device and technique is controversial. For distal tibia fractures, nailing and plating techniques may be used, the primary goal for each being to achieve acceptable alignment with minimal complications. Different techniques for reduction of these fractures are available and can be applied with either fixation device. Overall outcomes appear to be nearly equivalent, with minor differences in complications. Proximal tibia fractures can be fixed using nailing, which is associated with deformity of the proximal short segment. A newer technique-suprapatellar nailing-may minimize these problems, and use of this method has been increasing in trauma centers. However, most data are still largely based on case series.

Today's increasingly complex health-care landscape requires that physicians take an active role in minimizing health-care costs and expenditures. Judicious choice of implants, a fracture-driven treatment algorithm, capitation models, use of generic fracture implants, and reuse of external fixation constructs all represent mechanisms that can result in substantial savings. In some health-care environments, these cost savings programs may be directly linked to physician reimbursement in the form of gainsharing plans. Evidence-based critical evaluations of implant usage patterns are necessary to help control implant-related health-care spending but are lacking in the current literature. Physicians need to acknowledge their influence and responsibility in this realm and assume an active role to help reduce costs.

We sought to determine whether computed tomography (CT) is an accurate tool for evaluation of reduction, prediction of neurologic deficit, and evaluation of need for revision surgery in unstable pelvic ring injuries treated with percutaneous sacroiliac (SI) screw fixation and whether any neural foramen penetration violation is safe. Using medical records and radiographic data, we retrospectively evaluated 46 patients with 51 fractures or widenings of the SI joint that were surgically treated with percutaneous SI screw fixation, either alone or associated with anterior fixation. Using the Young and Burgess classification, there were 3 vertical shear injuries, 13 lateral compression injuries, 17 anterior-posterior injuries, 7 sacral fractures, and 6 combination or unclassifiable pelvic injuries. Satisfactory reduction was obtained in all cases. All patients had postoperative CT scans, and 23 of 51 screws had some foramen penetration with an average of 3.3 mm (range, 1.4-7.0 mm). After percutaneous screw fixation, 10 of 46 patients had postoperative neurologic deficit, 4 of which were unchanged from preoperative evaluation. Of the 6 patients with new or worsened neurologic deficit, CT showed neural foramen penetration of 2.1 and 7.0 mm in 2 patients. Both patients underwent screw revision, resulting in improved neurologic deficit. The remaining 4 patients did not have foramen penetration; their neurologic function improved, with full return at 6 weeks without screw removal. Neural foramen penetration documented with CT did not correlate with neurologic deficit unless the penetration was greater than 2.7 mm. Postoperative CT showing neural foramen penetration was the cause of revision surgery in 2 of 10 patients with postoperative neurologic deficit after percutaneous SI screw fixation. Based on these findings, we recommend postoperative CT only in those cases where there is new neurologic deficit and screw removal if foramen penetration is greater than 2.1 mm. We also describe a new "safe zone" for screw insertion encompassing the superior 2 mm of the sacral foramen with adequate pelvic reduction.

Management of tibia fractures by internal fixation, particularly intramedullary nails, has become the standard for diaphyseal fractures. However, for metaphyseal fractures or those at the metaphyseal-diaphyseal junction, choice of fixation device and technique is controversial. For distal tibia fractures, nailing and plating techniques may be used, the primary goal of each being to achieve acceptable alignment with minimal complications. Different techniques for reduction of these fractures are available and can be applied with either fixation device. Overall outcomes appear to be nearly equivalent, with minor differences in complications. Proximal tibia fractures can be fixed using nailing, which is associated with deformity of the proximal short segment. A newer technique-suprapatellar nailing-may minimize these problems, and use of this method has been increasing in trauma centers. However, most of the data are still largely based on case series.

We retrospectively compared the outcomes of early functional weight-bearing after use of 2 different approaches (minimally invasive, standard) for surgical repair of the Achilles tendon. We reviewed the cases of 63 consecutive patients who underwent repair of an acute closed Achilles tendon rupture and had follow-up of at least 6 months. Of these 63 patients, 33 were treated with a minimally invasive posterolateral approach (minimal group), and 30 were treated with a standard posteromedial approach (standard group). Two weeks after surgery, each patient was allowed to weight-bear as tolerated in a controlled ankle movement boot with a 20 degrees heel wedge. At 6 weeks, the patient was placed in a regular shoe with a heel lift. We examined range of motion and incidence of reruptures, sural nerve injuries, and wound complications at 6 weeks and 3 months and calf strength at 6 months. Neither group had any reruptures. Mean incision length was 2.5 cm (minimal group) and 7.2 cm (standard group). One patient (3.2%) in the minimal group and 6 patients (20%) in the standard group developed a superficial wound infection. Four (12.9%) of 31 minimal patients and no standard patients developed a sural nerve deficit. There were statistically significant differences between the groups' wound complication rates (P = .04) and nerve injury rates (P = .043). At final follow-up, the groups did not differ in their functional outcomes (ability to perform a single heel raise, American Orthopaedic Foot and Ankle Society scores). Used after a minimally invasive posterolateral or standard posteromedial approach, early functional weightbearing is an effective and safe method for treating acute ruptures of the Achilles tendon, and it has a lower rate of soft-tissue complications. A standard posteromedial approach has a higher rate of wound complications, and a minimally invasive posterolateral approach has a higher rate of sural nerve injury.

BACKGROUND: Bisphosphonate therapy for osteoporosis has been associated with atypical femoral fractures. To date, there have been few reports in the literature regarding the preoperative and postoperative courses of patients who have sustained bisphosphonate-associated complete atypical femur fractures. OBJECTIVES/PURPOSES: The purposes of this study were to (1) characterize the preoperative course of patients who eventually presented with bisphosphonate-associated complete atypical femur fractures (duration of bisphosphonate treatment, pain history, risk of converting a nondisplaced fracture to a complete fracture); (2) evaluate the percentage of patients who achieved radiographic union of those fractures after treatment; and (3) determine the patients' recovery of function using the Short Musculoskeletal Functional Assessment. METHODS: Thirty-three patients with 41 atypical, low-energy femur fractures associated with >/= 5 years of bisphosphonate use were treated with intramedullary nailing between 2004 and 2011 at one center. The main outcome measurements were Short Musculoskeletal Functional Assessment for function and radiographic evaluation for fracture healing. Patients had been treated with bisphosphonates for an average of 8.8 years (range, 5-20 years) before presentation. RESULTS: Patients reported a mean of 6 months of pain before presentation (range, 1-8 months). Sixty-six percent of patients with surgically treated complete fractures became pain-free and 98% were radiographically healed by 12 months. Sixty-four percent of patients who underwent intramedullary nailing reported a functional return to baseline within 1 year. Patients who reported major functional limitations at latest followup listed pain and apprehension as the major causes of their limitation. CONCLUSIONS: Patients with surgically treated bisphosphonate-associated complete femur fractures achieved generally reliable although delayed fracture healing if malaligned, and nearly two-thirds of patients returned to self-reported baseline function within 1 year. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.