Faculty Bibliography

BACKGROUND: Evolution of periarticular implant technology has led to stiffer, more stable fixation constructs. However, as plate options increase, comparisons between different sized constructs have not been performed. The purpose of this study is to biomechanically assess any significant differences between 3.5- and 4.5-mm locked tibial plateau plates in a simple bicondylar fracture model. MATERIALS AND METHODS: A total of 24 synthetic composite bone models (12 Schatzker V and 12 Schatzker VI) specimens were tested. In each group, six specimens were fixed with a 3.5-mm locked proximal tibia plate and six specimens were fixed with a 4.5-mm locking plate. Testing measures included axial ramp loading to 500 N, cyclic loading to 10,000 cycles and axial load to failure. RESULTS: In the Schatzker V comparison model, there were no significant differences in inferior displacement or plastic deformation after 10, 100, 1,000 and 10,000 cycles. In regards to axial load, the 4.5-mm plate exhibited a significantly higher load to failure (P = 0.05). In the Schatzker VI comparison model, there were significant differences in inferior displacement or elastic deformation after 10, 100, 1,000, and 10,000 cycles. In regards to axial load, the 4.5-mm plate again exhibited a higher load to failure, but this was not statistically significant (P = 0.21). CONCLUSIONS: In the advent of technological advancement, periarticular locking plate technology has offered an invaluable option in treating bicondylar tibial plateau fractures. Comparing the biomechanical properties of 3.5- and 4.5-mm locking plates yielded no significant differences in cyclic loading, even in regards to elastic and plastic deformation. Not surprisingly, the 4.5-mm plate was more robust in axial load to failure, but only in the Schatzker V model. In our testing construct, overall, without significant differences, the smaller, lower-profile 3.5-mm plate seems to be a biomechanically sound option in the reconstruction of bicondylar plateau fractures.

Insufficiency fractures present a significant problem in patients with osteoporosis. We report a case of bilateral iliac wing insufficiency fracture following low energy injury in an 87-year-old osteoporotic woman occurring 2 weeks after primary total hip arthroplasty. There are only a few reports of insufficiency fractures involving the ilium in the literature, and diagnosis has proven challenging, as radiographs are often negative at symptom onset. Magnetic resonance or radionuclide imaging is generally necessary for definitive diagnosis. This case highlights the importance of careful perioperative management of patients with osteoporosis.

Fixation of fragility fractures with plates and screws often results in loss of fixation and need for revision surgery. Locking plates and screw were introduced to improve fixation of fragility fractures and have been in use for a decade. This review was conducted to compile evidence that locking plates and screws improve fixation of fragility fractures. A search of PubMed was performed to identify biomechanical studies as well as clinical series of fragility fractures treated with locking plates. Biomechanics papers had to use models of osteoporotic bone and had to directly compare locking plates with traditional plates. Clinical studies included case series in which locking plates were applied to elderly patients with fractures of the proximal humerus and periprosthetic distal femur fractures. Most studies are retrospective case series. Locking plates lead to greater stability and higher loads to failure than traditional plates. When applied to proximal humerus fractures, uncomplicated healing occurs in 85% of patients. Constant and Dash scores approach normal values. For distal femoral periprosthetic fractures, union rates of 75% are reported with a malunion rate of 10%. Early evidence suggests that locking plates improve results of treatment of proximal humerus fractures and distal femoral periprosthetic fractures in the elderly. Loss of fixation is associated with failure to achieve stability at the fracture site. Principles of fracture fixation in osteoporotic bone defined prior to the introduction of locking plates should still be applied.

Clinical pathways reduce length of stay which is critical for hospitals to remain financially sound. We sought to determine if a multimodal pathway focusing on pre-op discharge planning and pre-emptive pain and nausea management lead to reduced length of stay, better pain management, and more rapid functional gains without an increase in post-op complications. A multimodal pathway incorporating pre-op discharge planning and pre-emptive pain and nausea management was initiated in August of 2007. Physical therapy began the day of surgery. Two hundred eleven patients treated over a 3-month period with the new pathway were compared to 192 patients treated in the last 3 months of an older pathway. Length of stay, VAS scores for pain, and the incidence of nausea were compared. Length of time to achieve functional milestones while in hospital and the incidence of complications out to 6 months were compared. Average length of stay was reduced by 0.26 days. VAS scores for pain were lower. Several functional milestones were achieved earlier and complications were not increased. Efforts to control nausea were not successful and severe nausea was experienced in 40% of patients in both groups. This enhanced pathway can lead to an important reduction in length of stay. Although this reduction seems small, it can significantly increase patient throughput and increase hospital capacity. Post-op nausea continues to be an impediment in patient care after TKR.