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Minimally invasive treatment of pilon fractures with a low profile plate: preliminary results in 17 cases

Borens, Olivier; Kloen, Peter; Richmond, Jeffrey; Roederer, Goetz; Levine, David S; Helfet, David L
OBJECTIVE: To determine the results of 'biologic fixation' with a minimally invasive plating technique using a newly designed low profile 'Scallop' plate in the treatment of pilon fractures. DESIGN: Retrospective case series. SETTING: A tertiary referral center. PATIENTS/PARTICIPANTS: Seventeen patients were treated between 1999 and 2001 for a tibial plafond fracture at the Hospital for Special Surgery with a newly designed low-profile plate. Eleven of the fractures (65%) were high-energy injuries. Two fractures were open. INTERVENTION: Staged surgical treatment with open reduction and fixation of the fibular fracture and application of an external fixator was performed in 12 cases. As soon as the soft tissues and swelling allowed, i.e. skin wrinkling, the articular surface was reconstructed and simply reduced, if necessary through an small incision, and the articular block was fixed to the diaphysis using a medially placed, percutaneously introduced flat scallop plate. In the remaining five cases the operation was performed in one session. MAIN OUTCOME MEASUREMENTS: Time to healing and complications including delayed union, non-union, instrument failure, loss of fixation, infection, quality of reduction and number of reoperations were evaluated. Quality of results and outcome were graded using the ankle-hindfoot-scale and a modified rating system. RESULTS: All patients went on to bony union at an average time of 14 weeks. There were no plate failures or loss of fixation/reduction. Two superficial wound-healing problems resolved with local wound care. At an average follow up of 17 months (range 6-29 months) eight patients (47%) had an excellent result; seven (41%) had a fair result whereas two (12%) had a poor result. The average ankle-hindfoot-score was 86.1 (range 61-100). Four patients have had the hardware removed and one of them is awaiting an ankle arthrodesis. CONCLUSIONS: Based on these initial results, it appears that a minimally invasive surgical technique including new low profile plate can decrease soft tissue problems while leading to fracture healing and obtaining results comparable with other more recent series. We believe that this new 'Scallop Plate' is effective for the treatment of pilon fractures and should be used in conjunction with a staged procedure in the acute trauma setting
PMID: 16951937
ISSN: 1434-3916
CID: 146037

Anterior tension band plating for anterior tibial stress fractures in high-performance female athletes: a report of 4 cases

Borens, Olivier; Sen, Milan K; Huang, Russel C; Richmond, Jeffrey; Kloen, Peter; Jupiter, Jesse B; Helfet, David L
Stress fracture of the anterior tibial cortex is an extremely challenging fracture to treat, especially in the high-performance female athlete who requires rapid return to competition. Previous reports have not addressed treating these fractures in the world-class athlete with anterior plating. We hypothesize that anterior plating is a biomechanically sound approach to treatment of these fractures, and will lead to an earlier return to full activity than either nonoperative treatment or intramedullary nailing. We present a retrospective series of 4 case reports of 4 world-class female athletes with stress fractures of the anterior tibial cortex treated by anterior plating between 2001 and 2004. Average follow-up was 15 months (range 12 to 48 mo). Anterior tension band plating resulted in fracture healing in all 4 cases and return to full activity at a mean of 10 weeks. All patients returned to preinjury competitive levels. There were no complications of infection, nonunion, or malunion. Anterior tension-band plating of an anterior tibial stress fracture leads to rapid fracture healing and return to competition for high-performance female athletes. This approach should be considered in those athletes who wish to avoid the more prolonged convalescence associated with nonoperative treatment, or the problems, especially of the knee, associated with intramedullary nailing
PMID: 16825970
ISSN: 0890-5339
CID: 146038

Hip fracture outcomes in patients with Parkinson's disease

Idjadi, Jeremy A; Aharonoff, Gina B; Su, Hsiu; Richmond, Jeffrey; Egol, Kenneth A; Zuckerman, Joseph D; Koval, Kenneth J
In a prospective, consecutive study conducted at a university teaching hospital, we evaluated the effects of Parkinson's disease (PD) on hip fracture outcomes. We followed 920 community-dwelling patients, aged 65 or older, who sustained a hip fracture that was operatively treated between July 1, 1987, and June 30, 1998. Presence or absence of PD had no bearing on type of surgery performed. Examined outcomes were postoperative complication rates; in-hospital mortality; length of hospital stay; discharge status (to home or to a skilled nursing facility); and mortality rate, place of residence, recovery of prefracture ambulatory ability, and return to prefracture activities of daily living (ADLs) 1 year after surgery Thirty-one patients (3.4%) had a history of PD before hip fracture. Patients with PD were more likely to be male, to live with another person, to have less ambulatory ability, and to be dependent in ADLs before hip fracture. Compared with patients without PD, they were hospitalized significantly longer and were more likely to be discharged to a skilled nursing facility. In addition, they declined more in level of independence in basic ADLs but not as much in instrumental ADLs at 1-year follow-up. Rates of postoperative complications, recovery of ambulatory ability within 1 year, and mortality within 1 year did not differ. These findings may guide orthopedic surgeons in counseling patients with PD and a hip fracture
PMID: 16130353
ISSN: 1078-4519
CID: 58890

Nonunions of the distal tibia treated by reamed intramedullary nailing

Richmond, Jeffrey; Colleran, Kevin; Borens, Olivier; Kloen, Peter; Helfet, David L
OBJECTIVE: The purpose of this study is to determine the efficacy of reamed intramedullary nailing in the treatment of nonunions of the distal one-fourth of the tibia. Nonunions of the distal tibia are particularly difficult to treat given the short distal segment, the proximity to the ankle joint, and the fragile soft-tissue envelope. Intramedullary nailing is an attractive solution to this problem because it avoids extensive dissection, and the implant remains intraosseous, posing minimal problem for the soft tissues. DESIGN: Retrospective review of patient charts and radiographs. SETTING: Tertiary care orthopaedic hospital. PATIENTS/PARTICIPANTS: Thirty-two patients with nonunions of the distal one-fourth of the tibia. Prior treatments included casting, internal fixation with plates and screws, intramedullary nailing, and external fixation. Seven patients had a history of infection, but no patient had signs of active infection at the time of surgery. INTERVENTION: Study patients were treated by reamed, locked intra-medullary nailing. MAIN OUTCOME MEASUREMENTS: Main outcome measurements included time to union, correction of deformity, and complications including infection and reoperation. RESULTS: Average length of follow-up was 25 months (range 4-81 months). Twenty-nine out of 32 patients achieved union at an average of 3.5 months after reamed, locked intramedullary nailing. Of the remaining three, 2 patients united after dynamization (one at 4 months after dynamization and the other at 7 months), and the third patient united 4 months after exchange nailing. Deformity was corrected to a maximum of 4 degrees in all planes. Four patients had positive intraoperative cultures, and only 2 required removal of the nail after achieving union to control infection. There were no signs of chronic osteomyelitis in these 2 patients at the date of the last follow-up visit; 5.5 years and 2 years following nail removal. CONCLUSIONS: Reamed, locked intramedullary nailing is a reliable and safe procedure in the treatment of nonunions in the distal one-fourth of the tibia, even in the setting of prior infection or external fixation. It allows for excellent correction of deformity, which is an essential component of the procedure
PMID: 15448449
ISSN: 0890-5339
CID: 146039

Complex open trauma of the shoulder: a case report

Borens, Olivier; Kloen, Peter; Richmond, Jeffrey; Warren, Russell F; Helfet, David L
PMID: 15074463
ISSN: 1078-4519
CID: 146040

Mortality risk after hip fracture. 2003

Richmond, Jeffrey; Aharonoff, Gina B; Zuckerman, Joseph D; Koval, Kenneth J
PMID: 14696770
ISSN: 0890-5339
CID: 44535

Mortality risk after hip fracture

Richmond, Jeffrey; Aharonoff, Gina B; Zuckerman, Joseph D; Koval, Kenneth J
OBJECTIVE: To determine the mortality risk following hip fracture and identify factors predictive of increased mortality. DESIGN: Retrospective review of prospectively collected data. SETTING: Tertiary care orthopaedic hospital. BACKGROUND: Approximately 250,000 hip fractures occur annually in the United States. The greatest mortality risk following hip fracture has been demonstrated to be within the first 6 months of fracture, and some studies report that the risk approaches expected mortality after 6 months. However, more recent studies have demonstrated that an increased risk of mortality may persist for several years postfracture. The purpose of this study was to assess the excess mortality associated with hip fracture at up to 2 years postinjury. METHODS: All patients with a hip fracture who were admitted to our institution over a 10-year period were evaluated. Criteria for inclusion included: Caucasian, age 65 or older, previously ambulatory, and home dwelling. Patients were followed prospectively to determine the mortality risk associated with hip fracture over a 2-year follow-up period. Mortality was compared to a standardized population and standardized mortality ratios were calculated. RESULTS: Eight hundred thirty-six patients met the inclusion criteria and were included. The mortality risk was highest within the first 3 months following fracture, with standardized mortality ratios approaching that of the control population by two years. Patients age 65-84 had higher mortality risk when compared with patients age > or =85. American Society of Anesthesiologists classification was predictive of increased mortality risk in younger patients, with these patients having triple the mortality risk when compared to the reference population at 2-year follow-up. More elderly patients had minimal excess mortality associated with hip fracture at 1- and 2-year follow-up, regardless of ASA classification. CONCLUSION: The data demonstrate that hip fracture is not associated with significant excess mortality amongst patients older than age 85. Amongst younger patients, however, those with ASA classifications of 3 or 4 have significant excess mortality following hip fracture that persists up to 2 years after injury
PMID: 12499968
ISSN: 0890-5339
CID: 44549

Controversies in intramedullary nailing of femoral shaft fractures

Wolinsky, Philip; Tejwani, Nirmal; Richmond, Jeffrey H; Koval, Kenneth J; Egol, Kenneth; Stephen, David J G
PMID: 12064115
ISSN: 0065-6895
CID: 65622

Controversies in intramedullary nailing of femoral shaft fractures [Review]

Wolinsky, P; Tejwani, N; Richmond, JH; Koval, KJ; Egol, K; Stephen, DJG
ISSN: 0021-9355
CID: 54912