Faculty Bibliography

This study was undertaken to evaluate the safety and efficacy of retrievable inferior vena cava filters in high-risk orthopaedic patients. A total of 58 patients had a retrievable inferior vena cava filter placed as an adjunct to chemical and mechanical prophylaxis, most commonly for a history of previous deep-vein thrombosis or pulmonary embolism, polytrauma, or expected prolonged immobilisation. In total 56 patients (96.6%) had an uncomplicated post-operative course. Two patients (3.4%) died in the peri-operative period for unrelated reasons. Of the 56 surviving patients, 50 (89%) were available for follow-up. A total of 32 filters (64%) were removed without complication at a mean of 37.8 days (4 to 238) after placement. There were four filters (8%) which were retained because of thrombosis at the filter site, and four (8%) were retained because of incorporation of the filter into the wall of the inferior vena cava. In ten cases (20%) the retrievable filter was left in place to continue as primary prophylaxis. No patient had post-removal thromboembolic complications. A retrievable inferior vena cava filter, as an adjunct to chemical and mechanical prophylaxis, was a safe and effective means of reducing the acute risk of pulmonary embolism in this high-risk group of patients. Although most filters were removed without complications, thereby avoiding the long-term complications that have plagued permanent indwelling filters, a relatively high percentage of filters had to be left in situ

PURPOSE: To compare the stability of a novel, nonspanning external fixator with a standard volar locked plate for treatment of unstable distal radius fractures. METHODS: A simulated, unstable, extra- articular distal radius fracture was created in six matched pairs of fresh frozen human distal radii. One of each pair was treated with a nonspanning external fixator [Mirza Cross Pin Fixator (CPX), A.M. Surgical Inc. Smithtown, NY] and the other was treated with a volar locked plate [Distal Volar Radial Plate (DVR), Hand Innovations, Miami, FL]. Each specimen was axially loaded in central, dorsal, and volar locations, loaded in cantilever bending in volar to dorsal, dorsal to volar, and radial to ulnar directions and loaded in torsion. Load-displacement curves were generated to determine the construct stiffness for each loading schema, with comparisons made between the two treatment groups. Specimens were then cyclically loaded with 50 N axial loads applied for 1,000 and 10,000 cycles. Measurement of construct stiffness was repeated and comparisons made both between the two treatments and within treatments to their precycling stiffness. RESULTS: There was no significant difference in the mechanical stiffness of the nonspanning external fixator and the volar locking plate after axial loading in any of the loading modalities.Cyclic loads of 1,000 and 10,000 cycles resulted in no significant difference in construct stiffness between the nonspanning external fixator and volar locked plate. However, the nonspanning external fixator demonstrated decreasing stiffness after cyclic loading with 10,000 cycles (p < 0.02). CONCLUSION: This study demonstrated no significant difference in the mechanical stiffness of the CPX nonspanning external fixator and volar locked plate in a cadaveric fracture model. Both constructs appear to be biomechanically equivalent in this experimental model; however, this is only one factor in the choice of fixation device for the management of unstable distal radius fractures

Psoriatic arthritis is a complex, chronic inflammatory disease with both skin and joint involvement. Clinical presentation varies considerably among patients and during the course of the disease. Assessment of patients for psoriatic arthritis requires careful attention to patient history, a focused physical examination, and inspection for characteristic radiographic changes. Although this disease was once thought to be a rare and mild form of arthritis, recent studies have shown that patients with psoriatic arthritis may develop significant disability, with up to 20% of cases demonstrating a rapidly progressive, debilitating clinical course. Orthopedic manifestations of the disease can be severe and can cause significant physical disability. Although surgical intervention for psoriatic arthritis is relatively uncommon, having an understanding of the assessment, available treatment options, and surgical considerations allows for improved outcome in the management of this complex patient population

PURPOSE: To prospectively compare the efficacy of 2-octylcyanoacrylate (Dermabond; Ethicon Inc, Somerville, NJ) with standard suture repair in the management of nail bed lacerations. METHODS: Forty consecutive patients with acute nail bed lacerations were enrolled in this study. Eighteen patients were randomized to nail bed repair using Dermabond (2-octylcyanoacrylate), and 22 were randomized to standard repair using 6-0 chromic suture. At presentation, demographic information and laceration characteristics were recorded. The time required for nail bed laceration repair with each method was documented, and cosmetic and functional outcomes were assessed at 1, 3, and 6 months after injury. Comparisons between treatment groups were made using unpaired Student's t-tests. RESULTS: The Dermabond repair group was composed of 10 males and 8 females with a mean age of 32.3 years. The suture repair group was composed of 17 males and 5 females with a mean age of 29.5 years. The mean follow-up was 5.1 months (range 4-11 months) and 4.8 months (range 4-11 months) for the Dermabond group and suture group, respectively. There was no difference between the two treatment groups with respect to age, comorbidities, and length of follow-up (p>.05). The average time required for nail bed repair using Dermabond was 9.5 minutes, which was significantly less than that required for suture repair (27.8 minutes) (p<.0003). At each follow-up time point, there was no statistical difference in physician-judged cosmesis, patient-perceived cosmetic outcome, pain, or functional ability between the Dermabond and suture treatment cohorts (p>.05). CONCLUSIONS: Nail bed repair performed using Dermabond is significantly faster than suture repair, and it provides similar cosmetic and functional results. In the management of acute nail bed lacerations, Dermabond is an efficient and effective repair technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I

Rugby football continues to grow in popularity internation- ally and within the United States. In 1995, rugby union, one form of rugby, turned from amateur to professional through- out Europe, increasing the potential for monetary reward, which, in turn, secondary to higher levels of play, increased the risk of injury. With this increased higher interest and the increasing number of inexperienced and professional players in the U.S., there is a need for a comprehensive analysis of professional rugby union injury in the American literature and increased awareness of rugby injuries, in general, for all levels of players. This paper provides an in-depth analysis of professional rugby union injuries that will assist ortho- paedic surgeons treating these injuries in the U.S. The data described highlights the potential impact of rugby injury in the U.S. and provides an overview of the international data to serve as the basis for future American studies. An additional goal of this review is to stimulate discussion regarding the necessity of implementing additional safety precautions for this high-risk sport. Finally, this analysis highlights the in- consistencies and discrepancies of the literature with respect to rugby union injury and the variability and weak interstudy reproducibility of current rugby injury data

Clavicle fractures are common skeletal injuries that are typically managed nonoperatively, which results in a high rate of fracture union with few or no long-term sequelae. Type II distal clavicle fractures are an exception, with reported rates of nonunion ranging from 22% to 44%. This high rate of nonunion has led to controversy regarding the appropriate treatment of type II injuries. The following case report describes a type IIB distal clavicle fracture, in which nonoperative management was complicated by the breakdown of skin over the fracture site and the subsequent development of infection. This is a rare complication of conservative management. Thorough operative debridement, fracture stabilization via external fixation, and identification of the causative organism allowed for successful outcome in the management of this complex presentation

The Z-effect phenomenon is a potential complication of two lag screw intramedullary nail designs used for fixation of intertrochanteric hip fractures, in which the inferior lag screw migrates laterally and the superior lag screw migrates medially during physiologic loading. The current investigation was undertaken in an attempt to reproduce the Z-effect phenomenon in a laboratory setting. Sixteen different simulated femoral head and neck constructs having varying compressive strengths were created using four densities of solid polyurethane foam and instrumented with a two-screw cephalomedullary intramedullary nail. Each specimen was then cyclically loaded with 250 N vertical loads applied for 10, 100, 1000, and 10,000 cycles. Measurement of screw displacement with respect to the lateral aspect of the intramedullary nail was made after each cyclic increment. The inferior lag screw migration component of the Z-effect phenomenon was reproduced in specimens with head compressive strengths that were higher than the compressive strengths of the neck. Specimens with the greatest difference in head-neck compressive strength demonstrated the most significant displacement of the inferior lag screw without any displacement of the superior lag screw. Specimens with a femoral neck compressive strength of 0.91 MPa of and a head compressive strength of 8.8 MPa resulted in more than one centimeter of inferior lag screw lateral migration after 10,000 cycles of vertical loading. Models where the femoral head had a higher compressive strength than that of the femoral neck may simulate fracture patterns with significant medial cortex comminution that are prone to varus collapse

The development of cerclage systems for fixation of greater trochanteric osteotomies has progressed from monofilament wires to multifilament cables to cable grip and cable plate systems. Cerclage wires and cables have various clinical indications, including fixation for fractures and for trochanteric osteotomy in hip arthroplasty. To achieve stable fixation and eventual union of the trochanteric osteotomy, the implant must counteract the destabilizing forces associated with pull of the peritrochanteric musculature. The material properties of cables and cable grip systems are superior to those of monofilament wires; however, potential complications with the use of cables include debris generation and third-body polyethylene wear. Nevertheless, the cable grip system provides the strongest fixation and results in lower rates of nonunion and trochanteric migration. Cable plate constructs show promise but require further clinical studies to validate their efficacy and safety

Complex primary total hip arthroplasty (THA) is defined as primary THA in patients with compromised bony or soft-tissue states, including but not limited to dysplastic hip, ankylosed hip, prior hip fracture, protrusio acetabuli, certain neuromuscular conditions, skeletal dysplasia, and previous bony procedures about the hip. Intraoperatively, provisions must be made for the possible use of modular implants and/or bone grafts. In this article, we review the principles of preoperative, intraoperative, and postoperative management of patients requiring a complex primary THA

In recent years, the incidence and severity of ankle fractures in the elderly population have increased. Although surgical fixation has gained wide acceptance for younger ankle fracture patients, controversy exists within the orthopaedic community with respect to the optimal way to manage these fractures in the geriatric patient population. Although some authors categorise ankle fractures in the elderly as fragility fractures associated with osteoporosis, it appears that risk factors such as increased weight, poly-pharmacy and propensity for falls play larger roles than poor bone quality. The presence of osteoporosis may increase the level of difficulty involved with the surgical management of these patients, leading some authors to alter their standard operative technique. Early studies cited high complication rates and poor outcome following operative intervention, however, more recent investigations have demonstrated successful functional outcomes following surgical management and appropriate postoperative rehabilitation. Based on the current evidence, the literature appears to support surgical fixation of displaced ankle fractures in the elderly patient population