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© 2003 The Journal of Bone and Joint Surgery, Inc. What's New in Orthopaedic Trauma1 Department of Orthopaedics, University of Minnesota Physicians, Mail Stop 11503L, 640 Jackson Street, St. Paul, MN 55101-2595
Specialty Update has been developed in collaboration with the Council of
Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
With trepidation and significant enthusiasm, I take the reins for this update from Dr. Donald A. Wiss, the insightful, critical, and thorough surgeon who has demonstrated career stamina that has resulted in a three-decade run in the medical literature and orthopaedic education. Dr. Wiss's Southern California orthopaedic practice has spawned a wealth of clinical information that still provides educational fodder for countless courses and scintillating dialogue. Proud of having maintained his status as "a true general orthopaedic trauma surgeon," he is likely still the favorite session moderator at an Orthopaedic Trauma Association (OTA) meeting or a Fireside Chat. He would seem the perfect choice for an annual column such as this, so it is with great humility that I accept this charge to follow Don. I do so with the respect of a long-time fan that utters those age-old words, "growing up, I used to watch those guys...." The purpose of this Specialty Update is to review the year in orthopaedic trauma for general orthopaedists who wish to stay abreast or catch up with developments in the field. I do not yet have the best method for such a review, but I know that this update should not be either a bird's-eye look at an important subject matter or a drone's scan from a hundred miles. With your feedback we can refine this feature in time. I welcome that! This update will begin with a perspective on some areas of perceived encroachment on the field of orthopaedic traumatology and an underscoring of the commitment that we have made to quality investigations in the field. The update will feature highlight studies presented at the 2002 Annual Meeting of the Orthopaedic Trauma Association as well as at the 2003 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). Furthermore, a selection of articles published in The Journal of Bone and Joint Surgery and the Journal of Orthopaedic Trauma between June 2002 and May 2003 will be reviewed. An example of an Evidence Report from the Agency for Healthcare Research and Quality (AHRQ) will be featured for its clinical relevance and significance at a time when evidence-based medicine has taken center stage in our profession's quest for reliable data and helpful solutions. Finally, we will preview what messages are coming down the pike with a sampling of observations from this year's OTA Program Committee review of the 2003 meeting abstracts.
In an editorial entitled, "Subspecialization in Orthopaedics. Has It Been All for the Better?" Dr. Augusto Sarmiento makes a compelling argument that the orthopaedic community is trivializing our profession and splintering our family with its glorification of subspecialization1. He states emphatically that it is a flawed argument that bodies of knowledge have expanded to such a degree that individuals cannot apply what there is to know. On the contrary, he argues, technology has advanced to an extent that it is easier to access information, diagnose patients, and execute surgeries. All the while, we have shrunk our medical purview in exchange for technical executions of particular procedures. Indeed, we have emerged in the new millennium with reams of superspecialties and their respective agendas while nonorthopaedists of many shades have not-so-subtly chipped away at our professional domains and livelihoods. Orthopaedic trauma is no exception, promoting specialty conferences for single implants and societies for each broken joint. Ironically, in our zeal to define our disciplines more clearly and narrowly, it is interesting that fellowship interest in the field of trauma is currently waning dangerously. The current President of the Orthopaedic Trauma Association, Dr. Marc Swiontkowski, is addressing both problematic ends of the spectrum through current leadership initiatives. The problem of waning fellowship interest may result from burned-out role models who have a hard time providing a desirable picture to impressionable trainees who once and for all seek a modicum of security for their decade of delayed self gratification, which they hope to terminate...and soon! Swiontkowski explains, "Burnout of the young orthopaedic traumatologist results primarily from inadequate support mechanisms in the workplace. Our young traumatologists sign on to job relationships that put them at a distinct disadvantage relative to most of their other specialist colleagues. Though they bring very considerable value to a practice group (economic and otherwise), they have not learned to negotiate the necessary variables for an enduring career."2 Current leadership members would like to generate an official document, endorsed by the Orthopaedic Trauma Association and the Academy, that would enumerate basic criteria for a successful job contract. This documented position would help the young prospect to negotiate her position as she stakes her claim to job security that beats the current 50% rate of early turnover. Regarding the problem of superspecialization, the current leadership has recognized steps that must be taken to expand its own educational and political influence with the general orthopaedic community rather than with a small selection of academicians whose interests may not reflect the larger concerns. So, the answer to the question as to whether those of us in the field of orthopaedic traumatology are an endangered species is...No! We have been threatened and we have been flogged, but we will stay off the endangered-species list. There may be more opportunities for current young orthopaedic trauma surgeons to choose from for a while, but there have been too many gains in technique, technology, and understanding for the American public to let go of the demand for our medical solutions.
Dr. Buckwalter, in his Presidential Guest Lecture at the International Cartilage Repair Society Meeting in Toronto last year, gave an eloquent chronology of the history of orthopaedic practice and its recent evolution from twenty centuries of empiricism3. He stated that our forefathers failed to recognize two basic principles for evaluating the efficacy of an operation: (1) nothing improves the apparent results of an operation like the absence of a comparison group, and (2) nothing causes the apparent results of an operation to deteriorate like follow-up of the patients. Buckwalter observed that Joseph Lister, in particular, and Louis Pasteur played pivotal roles in carrying medicine from empiricism to the age of science in medicine. He solemnly noted, however, that Lister and Pasteur, "would view the clinical and administrative demands placed on twenty-first century orthopaedic surgeons as incompatible with carrying out research. In addition, in the last twenty-five years, basic scientists have made such dramatic progress that it is difficult even for the most scientifically inclined orthopaedists to understand basic current research."4 Yet our professional commitment to science, however executed, is the very thing that will keep us thriving. In an editorial entitled, "Why We Should Collect Outcomes Data," Dr. Swiontkowski elaborates on why the orthopaedic community must revive the failed outcome study agendas of the 1990s5. These agendas failed because the financiers of such initiatives had unrealistic expectations for profit as well as unrealistic expectations for answers within short time-periods and because efforts were not directed to the most clinically useful information. Swiontkowski argues that there is growing public demand for this information and that it is our professional responsibility to improve results and to lessen the rate of complications. Furthermore, it is our professional obligation to regulate ourselves in a manner that optimally protects and benefits the community that we serve. Knowledge of end results and outcomes allows us to be able to do just that. Additionally, it is fallacious for tertiary-care centers and academic ivory towers to establish outcomes on which the entire orthopaedic community hangs its reputation; rather, it is incumbent on individual practices and practitioners to know the outcomes of interventions in their own hands. This would help us to understand who should do what and how much it takes for competency to be established. The increasingly educated patient, with survey results a keyboard stroke away, demands to know, "what can you do for me?"5 If, in fact, the members of our particular profession decide that research investigation is critical, then to a great degree we are granting that our very livelihood is at least partially defined by the results of such research. Therefore, it is logical to place high importance on the evaluation of such research, lest we base our very practice, and everything that follows, on erroneous conclusions. Recognizing that such critique is paramount, The Journal implemented a new component of the review process for published articles this year. In January 2003, The Journal implemented the practice of establishing a level-of-evidence rating for each clinical article that goes to print6. This five-level classification system will allow The Journal to monitor trends in the quality of clinical research and will place each clinical research study into context for the reader. On a similar note, the Journal of Orthopaedic Trauma instituted a new section this year entitled "Evidence-Based Orthopaedic Trauma." This section aims to provide readers with a summary of the published literature on a variety of topics, allowing them to evaluate expert opinion in the context of available published evidence. In the editorial introducing this new section, Bhandari and Sanders point out that some have perceived incorrectly that evidence-based medicine is a strict adherence to randomized trials and state that "often the best available evidence may come from nonrandomized studies that are important in developing hypotheses for future research" and that evidence-based medicine more accurately involves informed and effective use of all types of evidence7.
Bone Growth and Healing, Treatment of the Elderly, Articular Cartilage, and Deep Venous Thrombosis Although growth factor research has dominated the basicscience arena for a number of years, human studies are only beginning to emerge. In a prospective, randomized, single-blind study, 450 patients (from forty-nine centers) with an open tibial fracture that was treated with intramedullary nailing were randomized to receive either routine soft-tissue management or placement of a collagen sponge containing one of two concentrations of rhBMP-2 (6 or 12 mg) over the fracture at the time of definitive wound closure8. With 94% of the patients available for twelve-month follow-up, the group treated with 12 mg of rhBMP-2 had a 44% reduction in secondary interventions for delayed union; significantly fewer invasive interventions, infections, and hardware failures; and significantly faster fracture and wound-healing times than did the control group. A dose-dependent relationship was seen for most of the outcome parameters. Similar results were realized in a multicentered, prospective, randomized trial of 124 open tibial fractures treated with rhBMP-7, a study selected as an OTA highlight paper9. No adverse effects were noted in association with the intervention, and fewer secondary interventions were required for delayed union or nonunion (p = 0.02). Variables over which the surgeon does have control but that negatively affect fracture-healing may carry as much practical importance as factors that expedite repair. There has existed an unproven dogma that open fractures for which definitive treatment is delayed for more than eight hours are associated with increased rates of infection. Harley et al., in a retrospective review of 241 open long-bone fractures, found that delays of as long as thirteen hours before surgical care were not associated with either nonunion or infection10. Factors that were associated with infection and nonunion were lower-extremity involvement and fracture severity. Adding to a mounting argument against the use of nonsteroidal medications and for reaming in fracture care, a study from Toronto examined in vitro bone formation following nailing with and without reaming in a murine femoral fracture model11. Intramedullary reaming prior to pin insertion resulted in greater bone nodule formation than did pin insertion only. This stimulatory effect was reversed by antibodies to insulin-like growth factor I and II as well as by indomethacin. A clinical study by Burd et al., which was selected as an OTA highlight presentation, demonstrated a higher rate of long-bone nonunion in a group of patients with acetabular fractures who had been randomized to receive indomethacin for prophylaxis against heterotopic ossification12. The nonunion rate was 26% in the group of patients who had received indomethacin, compared with 7% in the group of patients who had received radiation or no treatment for prophylaxis against heterotopic ossification (p = 0.0004). In a study on the effects of nonsteroidal medications on the rate of spinal fusion in rabbits, a Washington University research team further elucidated the relative roles of such pharmacotherapy. While there was no significant difference in the arthrodesis rate between the control and celecoxib groups (in contradistinction to that between the control and indomethacin groups), the authors acknowledged a trend toward significance according to both gross inspection and histological examination of the fusion sites13. In a second investigation, it was demonstrated that the earlier indomethacin was administered postoperatively, the greater was its negative effect on fusion, underscoring its inhibitory role in fracture-healing14. The authors of these studies acknowledged the difficulty of determining healing at the site of the spinal fusions in rabbits, and this issue remains at least as relevant in clinical practice. As sophistication in clinical research grows, it is clear that rigorous methods for the evaluation of fracture-healing are necessary. However, little consistency exists. In a study by Bhandari et al., a cross-sectional survey of 577 orthopaedic surgeons was conducted to evaluate the degree of consensus on tibial fracture-healing15. There was great lack of consensus with regard to the variables that are important to making such a determination, what defines a tibial union in the first place, and what constitutes a malunion of the tibia. On the other hand, there is often agreement as to whether or not a nonunion exists, and the treatment of this entity remains a problem, particularly when the nonunion is recalcitrant. Most of the research on fracture-healing has focused on the fracture stimulus and the events that follow. Investigators at the Hospital for Special Surgery gained insight into fracture-healing from a study of twenty-one human nonunions16. Immunohistochemical analysis was performed to assess whether or not BMPs, BMP receptors, and Smads (intracellular protein messenger mediators) disappear from tissue during the development of a nonunion. Interestingly, BMP-2, BMP-4, BMP-7, and their receptors as well as pSmad-I were all present in 81% of the nonunions; however, one or more was absent in 19%. The presence of the Smads implied that BMP receptors existed in an activated state, and this occurred even in areas remote from bone formation; all of these findings suggest a lack of support for the theory that such signaling components are absent in nonunions. Pihlajamäki et al., in an uncontrolled, retrospective study of thirty-five consecutive femoral shaft nonunions, demonstrated that exchange nailing without extracortical bone-grafting was the most effective method for the treatment of a previously nailed femoral fracture. This method was successful for seven of eight nonunions, whereas dynamization was associated with femoral shortening (six of seventeen) and reoperation (four of seventeen)17. Interestingly, all five of the nonunions that were treated with extracortical grafting alone did not heal. In another study of a more challenging clinical entity, the infected long-bone defect, McKee et al. prospectively enrolled twenty-five patients requiring surgical débridement of culture-positive long-bone infections, sixteen of which were at the site of a nonunion. The protocol included radical débridement of all nonviable tissue, copious irrigation with bacitracin solution, removal of failed hardware (with subsequent fixation as needed), implantation of 4% tobramycin-spiked calcium-sulfate pellets, and completion with definitive softtissue coverage18. Although nine patients received autograft supplementation, fourteen of the sixteen nonunions healed and infection was eradicated in twenty-three of the twenty-five patients. Another difficult clinical entity is the relatively rare condition of distal humeral nonunion. Helfet et al., in the largest series of its kind, reported that successful union was achieved in fifty-one of fifty-two patients despite an average time to presentation of eighteen months and an average of 1.6 previous operations and despite the fact that the nonunion was intercondylar in thirteen patients and transcondylar in six19. This high rate of union, with an average arc of resultant motion of 94°, was attributed to immediate arthrolysis followed by stable fixation allowing for immediate postoperative motion. Demographic trends suggest that the baby-boom generation will reach the age of sixty-five years within ten years, and it is estimated that the number of people over the age of fifty-five years will increase by more than thirty-five million in the next twenty years. In an AOA Critical Issue Address in Victoria, British Columbia, this past year, it was pointed out that treatment of the 400,000 anticipated hip fractures in the next twenty years will require the services of 800 full-time orthopaedic surgeons20. The demands for joint arthroplasty will far exceed that number, yet these two entities represent <10% of the musculoskeletal conditions treated today. An exhortation for political activism to mobilize societal resources for the treatment of such conditions was appropriately expressed. Themes in the treatment of elderly patients and fixation methods in the context of osteoporosis are increasingly popular and have improved our awareness of the pathology with which more patients present. This point was elucidated in a study by Gardner et al., which showed that during the period from 1997 to 2000, patients who presented with fragility hip fractures were more likely to receive medical intervention for osteoporosis in each progressive year21. These results reflected efforts at increased physician education about osteoporosis, at least in the three New York-area hospitals studied. Awareness about the prevention of such injuries was also reflected in a study from Belgium that was performed to define medical or social characteristics associated with a high prevalence of hip fractures22. This case-controlled study of 318 women demonstrated a sixfold increase in the risk of hip fracture in association with a self-perceived lack of safety of the patient's own residence. Two prior fractures, a fracture within the past year, inability to read a newspaper, and chronic use of psychotropic drugs were also associated with an increased risk, suggesting a role for identification and intervention strategies. The risk of refracture was further defined in a study from Edinburgh that examined 22,494 fragility fractures in patients who were forty-five to eighty-four years of age. The authors found that patients with a previous low-energy fracture had a relative risk of 3.89 of sustaining a subsequent low-energy fracture23. Interestingly, the risk was greater when the index fracture was sustained in the earliest decade than in each subsequent decade. The risk was almost twice as great in men as it was in women. An often-quoted publication this year was the written report of the AOA Symposium on Articular Cartilage, entitled "Articular Fractures: Does an Anatomic Reduction Really Change the Result?"24 This article illuminates the controversies that exist regarding outcomes after malreductions and challenges the pseudoreligious beliefs of traumatologists regarding the importance of articular reduction. It begins with an overview of the available basic science on articular injury and step-off, underscoring a critical role for articular impact in determining clinical outcome. The article proceeds with a literature-based argument regarding our inability to measure articular congruency and finishes with a thorough review of the existing literature on this topic as it regards the tibial plateau and plafond, the acetabulum, and the distal part of the radius. There are twelve designated Evidence-Based Practice Centers commissioned by the Agency for Healthcare Research and Quality. This organization is dedicated to the purpose of identifying critical and controversial medical questions and thoroughly evaluating existing data in the medical literature in order to produce scientific answers and to identify areas of necessary research. In one report from this year, entitled "Prevention of Venous Thromboembolism After Surgery," a panel of seventeen technical experts considered to be national authorities in the field and representing the academic, private, and managed-care sectors was assembled to design and execute the project25. Refined key questions were developed, and the investigation was limited to high-energy trauma patients. Multiple literature searches were performed for each question separately. Of the 4093 manuscripts that passed the initial screen, 227 were chosen for complete review and seventy-three were accepted in the final cut for meta-analysis. An examination of the incidence of deep venous thrombosis and pulmonary embolism was performed after combining groups of patients from different randomized trials who had received low-dose heparin, low-molecular-weight heparin, mechanical prophylaxis, or no prophylaxis. A meta-analysis of randomized, controlled trials and another meta-analysis of randomized and nonrandomized trials were performed to evaluate the same methods. Meta-analysis also was used to identify risk factors. The available literature did not support the ability to analyze methods of screening for prophylaxis meaningfully. Finally, the efficacy of vena cava filters, the two main complications of heparin administration (thrombocytopenia and bleeding), and the incidence of fatal pulmonary embolism were also studied. The pooled rates of deep venous thrombosis and pulmonary embolism were 11.8% and 1.5%, respectively, although the rates varied widely between studies. Neither low-dose heparin nor mechanical prophylaxis was significantly superior to no prophylaxis in preventing deep venous thrombosis after injury, and this held true whether just randomized trials or randomized and nonrandomized trials were used for analysis. Low-molecular-weight heparin was superior to both mechanical measures and low-dose heparin in preventing deep venous thrombosis, but no difference was found between low-molecular-weight heparin and low-dose heparin in preventing pulmonary embolism. Furthermore, there was no difference between the low-dose heparin group and the mechanical prophylaxis group with regard to the rate of deep venous thrombosis. Both older age and the Injury Severity Score were positively correlated with a greater incidence of deep venous thrombosis, but no specific age or Injury Severity Score could be gleaned as a critical threshold. The incidence of pulmonary embolism was lower in patients with a vena cava filter (0.2%) than in those without a filter (5.8%). Interestingly, low-dose heparin and low-molecular-weight heparin were found to be associated with similar rates of thrombocytopenia (1%) and bleeding (3%). Fatal pulmonary embolism was found to occur in one-third of patients who had a reported pulmonary embolism. This commission recommended that future research should be concentrated in two areas: (1) identifying the groups of trauma patients who are in need of prophylaxis against deep venous thrombosis and (2) evaluating different methods of prophylaxis with regard to safety and efficacy. It was thought that methods of screening should not represent a priority, as duplex ultrasonography was thought to be good and unlikely to be surpassed as a screening tool in the near future. On the basis of its findings, the commission recommended that a multicenter, randomized, controlled trial be performed with the inclusion of a group receiving no prophylaxis25.
In a pair of studies from Oregon, circumferential pelvic compression was evaluated with the use of cadaveric models26,27. Circumferential compression was found to result in significant stabilization of open-book pelvic injury variants. The optimal placement of compression was at the level of the greater trochanter, where a sling tension of 180 N was noted to be effective. This same tension and position were not found to cause significant overreduction in unstable lateral compression fractures, implying safe application in the field. Enhanced fixation of vertically unstable pelvic injuries has been an ongoing challenge that was addressed in two different studies. In the first, Schildhauer et al. compared their previously described lumbopelvic triangular osteosynthesis with standard iliosacral screw fixation in a transforaminal fracture model with use of twelve human cadavers28. Superior ramus screw fixation was performed for the associated ramus fractures in both groups. In this single-leg-stance model, triangular osteosynthesis demonstrated smaller displacement under initial peak loads as well as fewer failures after 10,000 cycles of loading. In another biomechanical study, in which S1 pediculoiliac (as opposed to lumbopelvic) screw fixation was compared with iliosacral screw fixation and with anterior symphyseal double plating in polyurethane pelvic bone analogs, iliosacral screw fixation was found to be more stable in terms of early and ultimate failure loads when used for the treatment of zone-I sacral fractures and sacroiliac joint disruptions29. The combination of an iliosacral screw with pediculoiliac screw fixation demonstrated the best performance under load. A noted drawback to this technique is the inability to use it for sacral fractures medial to the ala. In the area of minimally invasive surgery, Rubel et al. described a technique for endoscopic fixation of pubic symphysis disruptions30. Endoscopy for the space of Retzius, well known to gynecologic surgeons, was a natural springboard for execution of this study, which defined four important "windows" and their respective vital structures and landmarks. Execution of endoscopic reduction and fixation on two patients was also presented. The minimally invasive theme was also applied to soft-tissue lesions associated with pelvic trauma. Tornetta and Normand presented another of this year's OTA highlight papers on the percutaneous treatment of the Morel-Lavallee lesion (the collection of fluid and devitalized fat resulting from the shearing and separation of subcutaneous tissue from the underlying fascia) through a small proximal and distal incision with a long plastic brush and copious pulse lavage31. No deep infections or cases of skin loss were reported in the study group of nineteen consecutive patients.
Two important papers highlighted the limitations of plain radiographs in determining acetabular fracture displacement. In the first, Moed et al. evaluated the functional results for sixty-seven patients who underwent open reduction and internal fixation of a posterior wall fracture and assessed postoperative reduction with use of a computerized tomographic scan and three standard radiographic views of the pelvis32. Sixty-five acetabular fractures were graded as anatomic on radiographs, whereas eleven had >2 mm of step and fifty-two had >2 mm of gap on computerized tomographic scans. Furthermore, there was a strong correlation between clinical outcome and the quality of reduction as determined with computed tomography. In a second study, Borrelli et al. reported that plain radiographs showed poor sensitivity (relative to computerized tomographic scans) for the detection of step and gap deformities both in a group of twenty patients with an acetabular fracture and in a group of osteotomized canine specimens with a known deformity. Three independent reviewers, who demonstrated excellent intraobserver reliability, were utilized in the study protocol33. A couple of small pearls from the career insights of Dr. Reinhold Ganz were shared in print this year regarding surgical approaches to the acetabulum. Although popularized in courses, surgical dislocation of the femoral head to address pathology on both sides of the joint has been sparsely mentioned in the literature. In the first paper, twelve of twelve patients who underwent surgical dislocation through a modified Kocher-Langenbeck approach for a transverse posterior wall fracture or an isolated comminuted posterior wall fracture had a good or excellent outcome (according to the Merle D'Aubigné score) after a minimum of two years of follow-up, and none had function-limiting heterotopic ossification or osteonecrosis of the femoral head34. In the second paper, a modification of the ilioinguinal approach incorporating features of the Smith-Petersen approach was described for the treatment of low anterior-column fractures and anterior-wall fractures35. The advantages of intra-articular inspection, better access to the quadrilateral surface, and a lower chance for iatrogenic injury to the lateral femoral cutaneous nerve were also described.
A Toronto study analyzed thirty-eight patients under the age of sixty years who had sustained a femoral neck fracture to determine the outcomes and the rates of osteonecrosis associated with early and late fixation36. Fifteen patients were treated early (less than twelve hours after the injury), and twenty-three were treated late (more than twelve hours after the injury). Although there was no difference between the groups with regard to clinical outcome according to the Short Form-36 instrument after a minimum duration of follow-up of two years, osteonecrosis developed in six patients in the delayed-fixation group and in no patient in the early-fixation group. The short duration of follow-up and the nonrandomized design were acknowledged as shortcomings of the study, but the difference in the rate of osteonecrosis confirmed the benefits of treating this condition as a surgical emergency. In an Edinburgh study, a group of 107 patients between the ages of sixty and eighty years who underwent salvage total hip arthroplasty following the failure of internal fixation of an intracapsular hip fracture (Group I) was compared with an age and gender-matched control group who underwent primary total hip arthroplasty for the same condition (Group II)37. Group I had a greater rate of complications, including superficial and deep infections and dislocations. Furthermore, Group I had a significantly higher revision rate, lower prosthetic survival rates at five and ten years, and lower functional outcome scores at the time of the final follow-up. The authors pointed out that the study did not address relative outcomes in patients with a successfully treated femoral neck fracture. Saudan et al. tossed more gas (or should I say "water"?) on the sliding hip-screw versus intramedullary hip-screw debate in a prospective, randomized trial of 206 patients who had sustained an AO/OTA 31-A1 or A2 pertrochanteric hip fracture38. The authors did not find any significant differences intraoperatively, radiographically, or clinically between the two groups of patients. It should be noted that there were no significant differences with regard to the mean number of units of blood given, the number of patients requiring a transfusion for a hematocrit of <27, or the rates of technical problems and postoperative complications. Taking the debate down the femur to shaft fractures, Stephen et al. compared manual traction with fracture-table traction (the supine technique) in a prospective, randomized trial of eighty-seven patients39. Interestingly, internal malrotation of >10° was more common in the fracture-table group (prevalence, 29% compared with 7%) and no differences were found between the groups with regard to the number of assistants required, fluoroscopy time, or other complications. Not surprisingly, operative time (including setup time) was an average of twenty minutes shorter in the manual-traction group. A small-diameter nail was inserted and used as a joystick to reduce the fracture in a quarter of the patients in the manualtraction group.
There seems to have been a recent investigative movement away from skeletal fixation and toward the soft-tissue injuries associated with knee trauma. This trend has been reflected in a number of papers, beginning with that by Dickson et al., who documented the clinical and magnetic resonance imaging findings for twenty-seven knees after fixation of a femoral diaphyseal fracture (AO/OTA type 32)40. Anterior and posterior cruciate ligament injuries were detected in 19% and 7% of the knees, respectively. Lateral and medial meniscal tears were found in 26% and 15% of the knees, respectively. The medial collateral ligament was injured in 41% of the knees, with approximately one-fifth of the injuries classified as complete. The lateral collateral ligament was injured in 30% of the knees, with one-half of the injuries classified as complete. Bone bruises were recognized in 63% of the femora and 30% of the tibiae. The injury spectrum was a bit different in a University of Southern California Medical Center study of twenty consecutive patients with minimally displaced proximal tibial plateau fractures that were treated nonoperatively and that were also assessed with magnetic resonance imaging41. There were eleven lateral, three medial, and six bicondylar plateau fractures in the study group. Ninety percent (eighteen) of the twenty patients had soft-tissue injuries, including 80% (sixteen of twenty) with meniscal tears (60% medial, 55% lateral) and 40% (eight of twenty) with complete ligamentous disruptions (5% lateral collateral, 10% anterior cruciate, 30% medial collateral). It was not stated how many patients eventually needed soft-tissue surgery, and discrepancies between the clinical and magnetic resonance imaging findings were explained by either inadequate physical examination or overreading of the magnetic resonance images. Using a different approach to assessment, Twaddle et al. reported on the soft-tissue injury findings in sixty patients with sixty-three knee dislocations that were treated surgically soon after injury42. Seventy-one percent of these dislocatable knees had bicruciate injuries, and eight knees had an intraarticular fracture. All patients with an ankle-brachial index of <0.9 had arteriograms. These nine knees (14%) sustained a substantial popliteal artery injury. Peroneal nerve palsies occurred in 14% of the knees. Interestingly, all of the knees with complete peroneal nerve palsies had anterior cruciate ligament, posterior cruciate ligament, and lateral collateral ligament disruptions. A large percentage of ligaments (including 19% of the anterior cruciate ligaments, 51% of the posterior cruciate ligaments, 64% of the medial collateral ligaments, and 84% of the lateral collateral ligaments) had reattachable lesions, and meniscal avulsions tended to occur when the collateral ligament injury was a distal avulsion. There was no difference in the pattern of injury between sports-related injuries and motor-vehicle accidents. Weigel and Marsh reported the results of a long-term study of thirty-one high-energy tibial plateau fractures (mostly bicondylar) that were treated with limited internal fixation and a monolateral external fixator43. Twenty patients (twenty knees) returned for follow-up at a minimum of five years. The average articular step-off after surgery was 3.3 mm. After healing, no patient required reconstructive surgery and the average range of motion was from 3° to 120° of flexion. The average Iowa Knee Score was 90 of 100 points at the time of the final follow-up. The twelve patients who had been assigned a score between two to four years after surgery had an average score of 92 points at that time and maintained an average score of 92 points at the time of the latest follow-up. In another eighteen knees, there was no deterioration in the radiographic grade of arthritis over the same time-period, suggesting that at least in a substantial subset of these injuries, no deterioration takes place between about two and eight years. Although it may seem from the former study that the knee in particular is forgiving of some articular step-off, Welch et al. studied the use of a calcium phosphate cement as a bone-graft substitute to prevent subsidence at the site of subchondral lateral plateau defects in goats44. This substitute outperformed autograft cancellous bone in 8 x 10-mm defects with no internal fixation at all time-points from twenty-four hours to eighteen months. Moving below the knee, Milner et al. performed a long-term follow-up study to assess the effect of tibial malalignment on outcome45. One hundred and sixty-four knees were evaluated between thirty and forty-three years after treatment. Forty-seven (29%) of these knees healed with coronal angulation of >5°. There were no significant univariate associations between these tibial shaft malunions and the development of osteoarthritis. There was, however, excess subtalar stiffness and a trend toward excess knee pain in this group.
The intermediate-term outcomes of procedures at both ends of the tibia were published this year, and it seems as though the tibial plafond is less forgiving than the knee is toward high-energy injuries and their treatment. In the study by Marsh et al., thirty-five of fifty-six ankles were assessed between five and twelve years after treatment of a tibial plafond fracture with a monolateral transarticular external fixator coupled with articular fixation with screws46. Thirteen percent of the ankles required arthrodesis. The average Iowa Ankle Score was 78 of 100 points, and the scores on the SF-36 and Ankle Osteoarthritis Scale demonstrated long-term negative effects on general health, pain, and function parameters. The average arc of motion in ankles that were not fused was 62% of that on the contralateral side. The majority of patients had limitation with regard to recreational activities, and fourteen patients changed their jobs. Although measures of reduction were significantly correlated with multiple outcome variables, reduction quality and injury severity were tightly linked and their independent effects could not be sorted out. Interestingly, the patients' perception of improvement continued for an average of 2.4 years after the injury. One question that has remained unsolved over the years is whether or not a displaced talar neck fracture represents a surgical emergency. In the largest investigation of its kind, in a retrospective study of 102 talar neck fractures treated at Harborview Medical Center in Seattle, the mean time to fixation was 3.4 days in patients in whom osteonecrosis developed compared with 5.0 in those in whom it did not47. All patients were treated through a two-incision approach. Osteonecrosis developed in association with 39% of Hawkins type-II fractures (56% of which went on to collapse), compared with 64% of Hawkins type-III fractures (67% of which went on to collapse). Both osteonecrosis and posttraumatic arthritis were associated with an open talar neck fracture as well as comminution of the talar neck. While an early analysis of the results of a Canadian multicenter, prospective, randomized, controlled study of calcaneal fractures (treated by six surgeons at four centers) demonstrated no differences in outcome after operative or nonoperative treatment, stratification of the results revealed a different picture48. At a minimum of two years (range, two to eight years) after injury, both general and disease-specific outcomes of 471 displaced calcaneal fractures demonstrated that, among patients who were not receiving Workers' Compensation, significantly higher satisfaction scores were found for the operatively treated group. Furthermore, women who were managed operatively scored significantly higher on the SF-36, as did operatively treated patients who had a Böhler angle of between 15° and 36°, a light workload, or an anatomic reduction (or a step-off of <2 mm). The results of the former study48 were strongly supported by those of a follow-up study, performed by the same Canadian study group, on the variables that led to forty-four subtalar fusions49. Patients who had received nonoperative care were six times more likely to have a fusion. Patients with a Böhler angle of <0° were ten times more likely to have a fusion and those with a Sanders type-IV fracture pattern were 5.5 times more likely to have a fusion, indicating the importance of injury severity. Patients receiving Workers' Compensation were three times more likely to have a fusion. Articular step-off was not analyzed. The authors suggested that a heavy laborer who is receiving Workers' Compensation and has a Böhler angle of <0° should be a strong candidate for a primary subtalar arthrodesis.
Considerable debate continues to swirl around the treatment options for complex proximal humeral fractures. In a study from The Netherlands involving sixty Neer-type three and four-part humeral fractures, internal fixation with a cerclage wire or T-plate demonstrated promising results at a mean of ten years after surgery50. Eighty-seven percent of the patients had a good or excellent result according to the Constant score, and 85% of the patients were satisfied with the result. It is notable that osteonecrosis of the humeral head developed in 37% of the patients, but 77% of those patients also had a good or excellent Constant score. It is important to recognize that thirty-two patients who had died of unrelated causes during the short follow-up period (average, 2.5 years) and seventeen patients who had had a hemiarthroplasty after a failure to obtain fixation intraoperatively were not included in the study group. Nevertheless, positive outcomes were found to be probable in selected patients undergoing open reduction and internal fixation with these techniques. Ring et al. studied a complex group of twenty-one patients who had sustained an articular fracture that was isolated to the distal part of the humerus, at or distal to the olecranon fossa51. The authors pointed out that existing classification systems were inadequate to address the different fracture patterns and proposed a system that addresses the findings of posterior impaction and extension into the trochlea and medial epicondyle. Union was achieved in all twenty-one patients, and no instability was detected. One patient had a failure of fixation. The average arc of motion achieved was 96°. At a mean forty months of follow-up, the result according to the Mayo Elbow Performance Index was excellent for four patients (19%) and good for twelve (57%). Eight patients were advised to have contracture releases, two patients underwent an ulnar nerve transposition for an evolving neuropathy, and no patient was found to have clinically important osteonecrosis. In the aforementioned study51, buried articular fixation was recommended for capitellar fractures and their variants. In one biomechanical study that was published recently, fixation strategies were evaluated for the capitellum, and two notable findings were reported52. Headless screws with a graded pitch outperformed countersunk 4.0-mm cancellous screws, and fixation in the posteroanterior direction was more stable than fixation in the anteroposterior direction. This approach also has the benefit of not violating the articular surface.
On the other side of the elbow, highly comminuted radial head fractures
were found to be associated with unsatisfactory clinical
results53.
Fifty-six patients with a radial head fracture were divided into two groups
(those with a Mason type-2 injury and those with a Mason type-3 injury), and
these groups were stratified further on the basis of fracture comminution.
Thirteen of the fourteen patients with a Mason type-3 (complete articular)
fracture with more than three fragments had a poor result, whereas all twelve
of those with a Mason type-3 fracture with two or three fragments had an arc
of forearm rotation of The Bovill Award is given to the winning podium presentation at the Annual Meeting of the Orthopaedic Trauma Association. At the 2002 meeting, held in Toronto, Kreder et al. were recognized for their report on the results of a randomized, controlled trial in which open reduction and internal fixation (ORIF) was compared with indirect reduction and percutaneous pinning (IRPP) for displaced intra-articular distal radial fractures54. Indirect reduction and percutaneous pinning resulted in a more rapid return to function and superior functional outcomes within two years after the injury, provided that articular step-off and gap were minimized. These findings led the authors to conclude that indirect reduction and percutaneous pinning should be attempted prior to the use of open reduction and internal fixation.
It is insightful to peek into the OTA Program Committee's review of the 392 abstracts that were submitted for the Nineteenth Annual OTA Meeting, held in Salt Lake City in October 2003. Indeed, a kaleidoscope of emerging themes gives one a glimpse of current research activity and interest worldwide. This snapshot may represent the clinical predominance of the applicant pool but is nevertheless noteworthy. Despite the vast array of potential topic matter for such a broad specialty as orthopaedic trauma, a shocking thirty-eight abstracts (10%) were related directly to the subject of locked internal fixation. Computer-assisted surgical navigation was also a common theme, representing twenty-one submissions (5%), followed closely by studies on bone-graft substitutes and osteobiologic interventions. Other fresh trends include a more rigorous look at the injured shoulder girdle; a heightened emphasis on injury prophylaxis, from helmets and vehicular design to automatic collision notification and hip protectors; a closer examination of imaging quality and imaging modalities in the context of the new digital age; a different look at the subject of reaming of long bones; and further work on precontoured implant designs. The treatment of elderly patients also is of major concern to the orthopaedic trauma community, with a wide cross-section of submitted geriatric studies focusing on new fixation techniques in the setting of osteoporosis, the treatment and diagnosis of osteoporosis, the relative function of elderly people, series of patients in their tenth decade, and the expanding role of arthroplasty in the treatment of fractures. What is clearly reflected in the collective research effort is improved management of long-term databases, greater leadership and funding of multicentered clinical trials, and enhanced familiarity with clinical outcome-measuring tools. These advances are leading to larger studies with longer follow-up, yielding more definitive information that is guiding surgeons toward better treatment of patients.
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Introduction
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100° and only one had a nonunion. Four of the
fifteen patients with a comminuted Mason type-2 (partial articular) fracture
had a poor result as indicated by a lack of rotation, and all four of these
fractures had been associated with a fracture-dislocation of the forearm or
elbow. No specific analysis of articular reduction or alignment was presented.
The authors concluded that a high degree of comminution and an association
with a fracture-dislocation are poor prognostic variables that may warrant
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