Faculty Bibliography

OBJECTIVES: To compare rebound pain and the need for narcotic analgesia following ankle fracture surgery for patients receiving perioperative analgesia through either a continuous infusion or a single injection nerve block. DESIGN: Prospective randomized controlled trial. SETTINGS: Surgeries were performed at two hospitals affiliated with a large urban academic medical center. PATIENTS/PARTICIPANTS: 50 patients undergoing operative fixation of an ankle fracture (AO/OTA Type 44). INTERVENTION: Participants were randomized to receive either a popliteal sciatic nerve block as a single shot (SSB group) or a continuous infusion through an On Q continuous infusion pump (On Q group). MAIN OUTCOME MEASUREMENTS: Visual Analog Scale and Numeric Rating Scale (0-10) pain levels and amount of pain medication taken. RESULTS: For all time points after discharge, mean postoperative pain scores and number of pain pills taken were lower in the On Q group vs. the SSB group. Pain scores were significantly lower in the On Q group at the 12 hour postoperative time point (p = 0.002) and at 2 weeks postoperatively. The number of pain pills taken in the first 72 hours was lower in the On Q group (14.9 vs. 20.0; p = 0.036). Overall, 7/23 patients in the On Q group had their pump malfunction and one patient accidently removed their catheter. CONCLUSIONS: Use of continuously infused regional anesthetic for pain control in ankle fracture surgery significantly reduces "rebound pain" and the need for oral opioid analgesia compared to single-shot regional anesthetic. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopy has been advocated as a possible adjunct to theoperative treatment of tibial plateau fractures. This reviewarticle provides a historical perspective on the developmentof the technique while focusing on its current role inthe management of these injuries. Topics include the possibleutility of employing arthroscopy in the diagnosis andmanagement of associated soft tissue lesions and potentialfor arthroscopic assistance to facilitate achieving fracturereduction without an open arthrotomy. Pertinent literatureis reviewed and discussed, with an emphasis on the datarelated to patient outcomes.

BACKGROUND: Previous studies have demonstrated the efficacy of popliteal block anesthesia in decreasing post - operative narcotic administration, nausea, and length of stay in patients undergoing foot and ankle surgeries. The purpose of this study was to compare the amount of narcotic medication administered, the need for anti-emetic medica - tion, PACU length of stay, and discharge status in patients treated surgically for ankle fractures who received popliteal blocks with those who received general anesthesia alone. METHODS: All patients being treated with open reduction and internal fixation for ankle fractures were randomized to receive either general anesthesia (GETA) or popliteal block. Postoperatively, data was collected on the duration of time in the PACU before discharge to home or to a hospital floor. Additional information was collection on the amount of anti-emetic and pain medication in the PACU. RESULTS: Fifty-one patients agreed to participate in the study. There was no significant difference between the two groups with regards to the need for anti-emetic medication, the amount of pain medication received in the PACU, or amount of time spent in the PACU. Patients who received a popliteal block were no more likely to be discharged to home from the PACU than those who received general anesthesia. DISCUSSION: While previous studies have demonstrated the efficacy of popliteal block in decreasing anti-emetic and pain medication administration in the PACU, we found no difference in the amount of medication administered. We found that popliteal block patients were no more likely to be discharged to home than those who received general anesthesia.

BACKGROUND: Rotational injuries are the most common and usually classified as per the Lauge Hansen classification; with the most common subgroup being the supination external rotation (SER) mechanism. Isolated fractures of the distal fibula (SE2) without associated ligamentous injury are usually treated with a splint or brace and the patient may be allowed to weight bear as tolerated. This study reports the functional outcomes following a stable, low energy, rotational ankle fracture supination external rotation (SER2) when compared to unstable SER4 fractures treated operatively. MATERIALS AND METHODS: 64 patients who were diagnosed and treated nonoperatively for a stable SER2 ankle fracture were followed prospectively. In the comparison group, 93 operatively treated fibular fractures were extracted from a prospectively collected database and evaluated comparison. Baseline characteristics obtained by trained interviewers at the time of injury included: Patient demographics, short form-36, short musculoskeletal functional assessment (SMFA) and American Orthopedic Foot and Ankle Society (AOFAS) questionnaires. Patients were followed at 3, 6 and 12 months postsurgery. Additional information obtained at each followup point included any complications or evidence on fracture healing. Data were analyzed by the Student's t-test and theFisher's Exact Test to compare demographic and functional outcomes between the two cohorts. P < 0.05 was considered to be significant. RESULTS: The average of patients' age in the stable fracture cohort was 43 versus 45 in the SER4 group. Nearly 64% of the patient population was female when compared with 37% in the operative group. In the SER2 by 6 months all patients had returned to baseline functional status. There were 18 delayed unions (all healed by 6 months). Based on the functional outcome scores all patients had returned to preoperative level. In comparison, SE4 patients had less functional recovery at 3 and 6 months (P < 0.05) based on the SMFA scores and at 3, 6 and 12 months based on the AOFAS (P < 0.001) scores. There was no difference in pain levels between the two groups at all time points. There were three nonunions in the SE4 group and six delayed unions. CONCLUSIONS: An SER2 ankle fracture is a relatively benign injury with functional limitations resolving by 3 months while the need for surgical fixation in SER ankle fractures appears to affect lower extremity function to a greater degree for a longer time period. Patients should be counseled as to these expected outcomes.

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.