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What's New in Orthopaedic Trauma

¹ Department of Orthopaedic Surgery, Regions Hospital, 640 Jackson Street, St. Paul, MN 55101. E-mail address: peter.a.cole{at}healthpartners.com
² Orthopaedic Trauma Service, Hamilton General Hospital, 7 North, Suite 727, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada. E-mail address: bhandam{at}mcmaster.ca

Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.

Institutional financial support for education and research was received from Synthes, Zimmer, DePuy, and Smith and Nephew. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from commercial entities (consulting was performed for Zimmer in 2004; honoraria were received from Synthes, Zimmer, and Smith and Nephew). Also, the Minnesota Medical Foundation and University of Minnesota Department of Orthopaedic Surgery provided grants for education and research.

	Introduction

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
The goal of this Subspecialty Update in orthopaedic trauma is to familiarize the orthopaedic general and specialist surgeon alike on the most relevant published literature from the past year. Only clinical articles are reviewed in this essay. We will continue to place cited articles in an evidence-based context for the reader, with the understanding that a "level of evidence" for a single study cannot be the same as a recommendation for a specific treatment or diagnostic strategy for a health-care question. Many factors must be taken into consideration before such a leap of recommendation could occur, not the least of which are the quality of the particular evidence designation and the circumstances that an individual surgeon and health system bring to bear for that patient.

We have expanded our search from last year to include more journals, choosing those that we believed to be most relevant to orthopaedic trauma. Our approach is strengthened by the large sample of journals that were reviewed, but it does not include all of the possible articles published globally in the field of orthopaedic trauma. We did not translate non-English-language articles, and we could feasibly review only 8814 abstracts for inclusion. Specifically, we searched the Cochrane Database, seven orthopaedic journals, one general-trauma journal, and four high-impact medical journals. We identified 318 potentially eligible studies. The complete abstracts of these 318 studies were reviewed by one of us (P.A.C.) for final inclusion. After a review of the abstracts, we summarized the salient findings of sixty-one studies (not including the 2004 Orthopaedic Trauma Association highlight papers), including seventeen Level-I studies, thirteen Level-II studies, six Level-III studies, twenty-five Level-IV studies, and zero Level-V studies. Of these, forty-one represented studies of therapy, seventeen involved prognosis, and three evaluated diagnostic tests (see Appendix).

In addition to this systematic review, we have included the ten clinical Orthopaedic Trauma Association (OTA) highlight papers that were selected from presentations at the 20th Annual OTA Meeting in our discussion and analysis. Although these selected OTA papers do not go through the same peer-review process as published manuscripts do, they help us to gauge the direction of orthopaedic investigation and they also serve as an interest barometer.

	General Topics in Fracture Care

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
From Osteoporosis to Open Fractures, Fracture-Healing, Traffic Accidents, and Chronic Pain
Geriatric themes dominated the year, so it is fitting that we start with two large randomized, controlled trials and a meta-analysis assessing the efficacy of osteoporosis treatment with use of oral supplements. At first glance, it may seem that this area of medical research is not germane to the population of orthopaedic surgeons wishing to study evidence on fracture care, but it is commonly the orthopaedic surgeon who first comes into contact with the most relevant patients. Without a respect for advances in medical treatment of osteoporosis, appropriate actions are not likely to follow.

In a study reported in the May 2005 issue of The Lancet, the use of cholecalciferol (vitamin D₃) and/or calcium dietary supplementation was evaluated with regard to whether it provided a protective effect against secondary fractures in a population of 5292 people who were more than sixty-nine years of age and had been mobile before the development of a low-trauma fracture¹. The participants in this trial received either oral vitamin D₃ (800 IU per day), calcium (1000 mg per day), oral vitamin D₃ (800 IU per day) combined with calcium (1000 mg per day), or placebo. After a minimum duration of follow-up of twenty-four months, the groups did not differ significantly with regard to all-new fractures, fractures confirmed on radiographs, hip fractures, death, number of falls, or quality of life. However, by twenty-four months, only 54% of the participants were still taking tablets. Compliance with tablets containing calcium was lowest, partly because of gastrointestinal symptoms¹. In a similar study in the British Medical Journal, 3314 women who were more than sixty-nine years of age were evaluated to assess the reduction in the risk of fracture in women with one or more risk factors for fracture². The study intervention included oral supplementation with use of calcium (1000 mg) and cholecaliferol (800 IU) as well as the provision of an information leaflet on dietary calcium intake and the prevention of falls (study group) or the provision of an information leaflet only (control group). Only 55% of the participants in the study group were still taking supplements at twenty-four months after the injury. After a median duration of follow-up of twenty-five months, there was no difference between these patients and the control group with regard to the rate of all clinical fractures (odds ratio for fracture in the supplementation group, 1.01; 95% confidence interval, 0.71 to 1.43). The authors concluded that there was no evidence that calcium and vitamin-D supplementation reduces the risk, over a two-year period, of clinical fractures in women with one or more risk factors for hip fracture. Neither study addressed previously healthy patients without fractures or patients within the nursing-home environment, many of whom would be cognitively impaired. The authors of the second study acknowledged that their data were underpowered given the rates of compliance and the lower-than-expected refracture rates in both groups.

This point underscores the value of the meta-analysis by Bischoff-Ferrari et al.³, which appeared in the April issue of the Journal of the American Medical Association. In a systematic review of English-language and non-English-language literature, the effectiveness of vitamin-D supplementation in preventing hip and nonvertebral fractures in older persons was evaluated. Only double-blind, randomized, controlled trials of oral vitamin-D supplementation with or without calcium supplementation or placebo that examined hip or nonvertebral fractures in older persons (those with an age of sixty years or more) were included. Five randomized, controlled trials of hip fracture (9294 patients) and seven randomized, controlled trials of nonvertebral fracture (9820 patients) met the inclusion criteria. A vitamin-D dose of 700 to 800 IU/d reduced the relative risk of hip fracture by 26% (as reported in three randomized, controlled trials with 5572 persons; pooled relative risk, 0.74; 95% confidence interval, 0.61 to 0.88) and reduced the relative risk of any nonvertebral fracture by 23% (as reported in five randomized, controlled trials with 6098 persons; pooled relative risk, 0.77; 95% confidence interval, 0.68 to 0.87) as compared with calcium or placebo. No significant benefit was observed in randomized, controlled trials involving a vitamin-D dose of 400 IU/d, leading the authors to conclude that oral vitamin-D supplementation between 700 to 800 IU/d appears to reduce the risk of nonvertebral fractures in elderly persons.

Gardner et al. studied the effects of an inpatient intervention program in a smaller prospective, randomized, controlled trial involving eighty patients who were cognitively screened, who were more than sixty-five years old, and who presented to a tertiary-care hospital with a low-energy hip fracture⁴. The inpatient intervention program included a fifteen-minute osteoporosis patient-education visit by a trained research coordinator and the provision of a list of five questions that the patient was to give to their primary-care physician. The five questions included (1) "When are you going to address my osteoporosis?", (2) "What kind of osteoporosis do I have, and how bad is it?", (3) "When are you going to perform a DEXA scan?", (4) "When are you going to give me calcium, vitamin D, exercise, and fall prevention?", and (5) "What drugs are you going to prescribe to treat my osteoporosis?" The patients in the control group simply received a brochure describing methods for preventing falls. At the time of the six-month follow-up, osteoporosis had been addressed by the primary-care physician for fifteen (42%) of the thirty-six patients in the study group, compared with only seven (19%) of the thirty-six patients in the control group (p = 0.036). Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment simply by developing an effective system for directing care to the primary-care provider.

It is clear that orthopaedic surgeons are at the foot of a mountain of understanding osteoporosis that yet needs to be scaled. This theme is only amplified throughout the rest of this review. Topics related to the theme of fracture-healing continue to generate much attention as well. Beeton et al. studied human subjects with and without traumatic brain injury and with and without fractures to see if certain serum markers may be involved in altered fracture-healing after head injury⁵. Evaluation of the circulating levels of interleukin-6 (IL-6) and its soluble receptor (sIL-6R) in serum, measured within twelve hours after the injury, demonstrated that the level of IL-6 was significantly higher in patients with a head injury and fracture than it was in the control group as well as in the group of patients with a fracture only. This relative elevation continued for the three-week time-period of measurement. Although IL-6 is quite nonspecific, with known elevations in other clinical conditions, this study suggests a possible role for the administration of these cytokines to promote fracture-healing.

Inhibition of fracture-healing may be equally important to understand, and further credence regarding the inhibitory effect of smoking on healing and regarding the risk of complications in patients with tibial fractures was provided in another subanalysis of the data from the Lower Extremity Assessment Project (LEAP)⁶. That study was the first to prospectively examine time to union as well as major complications of the fracture-healing process while adjusting for potential confounding variables that usually exist in smokers. Patients with unilateral limb-threatening open tibial fractures were divided into three baseline smoking categories: never smoked (eighty-one patients), previous smoker (eighty-two patients), and current smoker (105 patients). After adjustment for covariates (i.e., income, education, alcohol consumption, comorbidities, social supports), current and previous smokers were 37% (p = 0.01) and 32% (p = 0.04) less likely to have union than nonsmokers, respectively. Current smokers were more than twice as likely to have development of an infection (p = 0.05) and were 3.7 times as likely to have development of osteomyelitis (p = 0.01). These striking data highlight the need for aggressive interventions to effect cessation of smoking by patients with fractures.

Surgeons do not often consider the negative effect on fracture-healing of some of their own interventions during surgery. In an OTA highlight presentation, Anglen compared the use of soap with the use of antibiotic solution for irrigation during the treatment of open fractures of the lower extremity in humans^7,8. In a prospective, randomized trial, 400 adult patients (458 open fractures) were assessed with regard to the development of infection, healing of the soft-tissue wound, and union of the fracture after a mean duration of follow-up of 500 days. Although the groups were controlled for possible confounding variables, the infection and bone-healing rates were not found to be significantly different; however, wound-healing problems occurred in association with nineteen fractures (9.5%) that had been treated with bacitracin solution and eight fractures (4%) that had been treated with castile soap solution (p = 0.03).

The study of open fractures is an area in which dogma dominates the choices of treatment, particularly with regard to the timing of surgery. Débridement, irrigation, antibiotics, and a tetanus protocol are the mainstays of effective open fracture care. Traditional teaching has imparted the "six-hour rule" for initial surgical intervention, but the importance of this timing was challenged in a study by Skaggs et al.⁹. That multicenter, retrospective report on 544 open fractures demonstrated no difference in the rate of infection between open fractures that had been treated before or after six hours (3% compared with 2%; p > 0.05). No significant differences were observed when the results were stratified according to the type of open fracture (i.e., Gustilo types I, II, and III).

It would seem that lower extremity open fractures are more common today as many authors have postulated that airbags save lives at the expense of greater numbers of survivors sustaining lower extremity injuries. Estrada et al., in a study from the University of Alabama, gave credence to this notion after an analysis of statistics from the National Highway Traffic Safety Administration on 15,188,292 front-seat occupants who had been involved in a frontal impact collision requiring a tow-away¹⁰. The effectiveness of combined seatbelt and airbag restraint systems was compared with that of airbag alone, seatbelt alone, and no restraint with respect to the incidence and location of lower extremity fractures. Compared with unrestrained occupants, occupants restrained with airbag alone had a significantly higher risk of all types of lower extremity fractures, whereas occupants restrained with either seatbelt alone or seatbelt and airbag had a lower risk of fracture. The greatest difference was seen in the risk of tibial and fibular fractures in patients restrained with airbag only (relative risk, 2.14), but this trend continued to be significant with femoral and pelvic fractures (relative risk, 1.13 and 1.23, respectively). Although airbags may reduce the risk of death, the results of that study demonstrate that they increase the risk of lower extremity fractures when used as the sole method of passenger protection. The social impact of such injuries is potentially astronomical when the outcomes of many lower extremity fracture conditions are considered.

This fact was underscored by another Lower Extremity Assessment Project (LEAP) investigation, presented as one of the annual OTA highlight papers, which aimed to study chronic pain after lower extremity trauma¹¹. The inclusion criteria related to lower extremity limb-threatening injury were met by 569 patients from eight level-I trauma centers in North America. Relative to the general population, an amputation at any level distal to the knee (p < 0.05), less than a high-school education (p < 0.01), less than a college education (p < 0.001), low self efficacy (p < 0.01), and high level of alcohol consumption (p < 0.05) were strong predictors of chronic pain, as were high pain intensities and psychological distress recorded three months after the injury (p < 0.0001). These data suggest that subpopulations of individuals who have sustained limb-threatening injuries could be identified as candidates for intervention at an early stage, and they raise interesting questions regarding the generalizability of these findings to other injuries.

	Spine

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
It is well known that cervical spine type-I and III odontoid fractures have a decidedly good prognosis following conservative orthotic treatment. A study from Helsinki, Finland by Koivikko et al. may shed more light into which and possibly why type-II odontoid fractures have a propensity for nonunion when treated similarly¹². In their study of sixty-nine such fractures that were treated conservatively with a halo vest, the authors reported a 46% rate of osseous union (including "fibrous union") after a mean duration of follow-up of twelve months. Anterior dislocation, gender, and age were unrelated to nonunion; however, a fracture gap (>1 mm), posterior displacement (>5 mm), delayed start of treatment (more than four days), and posterior redisplacement (>2 mm), were correlated with nonunion. As most believe that the indication for odontoid fracture surgery is either intolerance of external fixation (halo vest) or failure of conservative treatment, that report helps to support the use of early surgical stabilization in patients presenting with these risk factors.

Although the benefit of kyphoplasty for patients with acute fractures has been studied, Crandall et al. compared its relative benefit in patients with acute or chronic vertebral compression fractures after a mean duration of follow-up of eighteen months (range, six to twenty-four months)¹³. The procedure involved the use of polymethylmethacrylate cement injection after reduction with inflatable balloons placed into the vertebral body space. A prospective, consecutive cohort of forty-seven patients undergoing fifty-five such procedures were divided into two groups: those with fractures that were less than ten weeks old (acute) and those with fractures that were more than four months old (chronic). The mean age of the patients was seventy-four years, and all patients were assessed with use of radiographs, with use of the Oswestry Disability Index for Back Pain, and with regard to narcotic consumption. By two weeks after surgery, pain relief was reported in association with 90% of acute fractures and 87% of chronic fractures. Narcotic usage decreased, and scores improved in almost all patients. The mean vertebral body height improved significantly after kyphoplasty in both the acute fracture group (from 58% to 86% of estimated normal vertebral height, p < 0.001) and the chronic fracture group (from 56% to 79% of estimated normal vertebral height, p < 0.001). In addition, more acute fractures were reducible as compared with chronic fractures (p = 0.01). Furthermore, local kyphosis improved significantly after kyphoplasty, and no cement-related or neurological complications were reported.

	Shoulder

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
Clavicular fractures typically are treated with nonoperative measures. However, there is a certain subset of these injuries, which, if treated conservatively, may compromise function or may not reliably heal at all. Robinson et al. explored the possible factors contributing to clavicular nonunion in a prospective observational cohort study of 868 patients who were managed nonoperatively¹⁴. The overall nonunion rate in that study was 6.2%, with 8.3% of the medial end fractures and 11.5% of the lateral end fractures remaining ununited. Predictors for diaphyseal nonunion in that series included advanced age, female gender, displacement, and the presence of comminution.

Locked proximal humeral plating has emerged as a popular treatment option for proximal humeral fractures; however, some patient populations seem to fare well with conservative fracture care. Court-Brown and McQueen reported the results of ninety-nine mature patients (mean age, sixty-eight years) who were managed nonoperatively for a varus impacted proximal humeral fracture¹⁵. The authors reported a 100% union rate and satisfactory outcomes, despite radiographic evidence of further varus collapse (>10°) in 53% of patients. Excellent to good results (according to the Neer criteria) were achieved in 79% of the cases.

Patients with good bone quality can be managed effectively with more traditional techniques as well. Gerber et al. reported on thirty-three patients with "good bone stock" in whom thirty-four complex proximal humeral fractures were treated with a variety of fixation strategies¹⁶. Fracture patterns dictated the fixation techniques, which included suture, pins, screws, and traditional plates. All fractures went on to union and were associated with superior functional outcomes as evaluated with the Constant and Murley score. Osteonecrosis occurred in 35% of the cases; however, after a mean duration of follow-up of sixty-three months, only two patients required shoulder arthroplasty.

Locked plating seems to have empowered the surgeon with a technique to treat proximal humeral fractures in older patients who have osteoporotic bone. Fankhauser et al. provided the first report on the use of this technology in a prospective study of twenty-nine complex humeral fractures in older patients¹⁷. The reported complications included one case of breakage and four cases of failure of fixation (varus collapse). Similarly, Bjorkenheim et al. reported a 3% rate of nonunion in retrospective review of seventy-two fractures of the proximal part of the humerus that were treated with a locking plate¹⁸. Those authors reported that complications related to the implant occurred because of technical error only, implying the requisite learning curve with new techniques.

	Elbow

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
Recognition and understanding of complex elbow fracture-dislocation patterns has facilitated rational treatment protocols for these difficult injuries. Although "simple" fracture patterns do occur in association with elbow trauma, the clinician must be attuned to patterns of instability that portend a poorer prognosis, particularly if left unaddressed. Doornberg et al. described the patterns of injury that are frequently associated with fracture-dislocations of the olecranon¹⁹. Injuries were described according to the direction of dislocation, with the series including ten anterior and sixteen posterior patterns. Associated fractures of the coronoid were reported in association with 50% and 100% of anterior and posterior patterns, respectively. Radial head fractures were more prevalent in association with posterior patterns, occurring in 81% of such cases. The authors found that poorer clinical results were associated with ineffective treatment of the associated injuries, most strikingly when there was inadequate fixation of the coronoid fracture.

The treatment of comminuted radial head and neck fractures remains controversial. Although excision has historically been accepted as an option for the treatment of so-called isolated radial head fractures, restoration of the lateral column of the elbow joint with either open reduction and internal fixation or prosthetic replacement is an important principle for such injuries. Herbertsson et al., in a report on sixty-one patients who were studied after an average duration of follow-up of eighteen years, reconfirmed that isolated radial head fractures that are treated with excision have reasonable long-term outcomes²⁰. Fifty-four percent of patients had pain, and 73% of elbows had early signs of arthrosis. Range of motion was functional but was decreased as compared with that of the uninjured elbow. The authors found no significant difference between patients who were managed with primary radial head excision (forty-three patients) as compared with delayed radial head excision (eighteen patients), but they did report that worse outcomes were correlated with the severity of the initial injury, with Mason type-IV fractures having the worst outcomes.

The operative plan for the treatment of complex elbow fracture-dislocations should address both osseous and ligamentous injuries in order to create a stable articulation that will allow for early motion in an effort to minimize stiffness. A standard surgical protocol was championed by Pugh et al.²¹. The surgical plan consists of fixation or replacement of the radial head, fixation of the coronoid, lateral ligamentous repair, and, if necessary, medial ligamentous repair and/or application of a hinged external fixator. With use of this methodology, thirty-six elbow dislocations associated with radial head and coronoid fractures were reviewed at a mean of thirty-four months postoperatively. The reported rate of excellent or good results was 78%, with a mean elbow arc of flexion of 112° and a mean arc of forearm rotation of 136°. However, there were eight complications necessitating reoperation, including synostosis, instability, elbow contracture, and infection.

Taking another approach, and underscoring the controversy, Ikeda et al. recommended open reduction of radial head fractures (rather than simple excision) when possible on the basis of a comparison of results of excision with those of open reduction and internal fixation for the treatment of Mason type-III and IV fractures²². The fixation group had superior range of motion, strength, and functional scores. Clearly, many variables come to bear with associated injuries and selection bias, but these results are suggestive of the benefit of salvage of the native radial head.

	Distal Part of the Radius

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
New surgical strategies and implants have empowered the surgeon to restore the fractured anatomy of the distal part of the radius. However, despite improved implants, some distal radial fractures may defy traditional methods of reduction and internal fixation. For example, high-energy distal radial fractures with extensive comminution at the metadiaphyseal junction require special consideration. Ruch et al. used a technique of distraction plate osteosynthesis to span the wrist joint dorsally after fixation of the articular surface²³. Once fracture consolidation occurred, the plate was removed and motion was instituted. This protocol, used for twenty-two cases, was associated with a 100% union rate with acceptable alignment. More importantly, 91% of the patients had an excellent or good clinical result, with average ranges of flexion and extension of 57° and 65°, respectively.

Despite the use of "new technology" for the treatment of distal radial fractures, closed reduction and percutaneous pinning continues to be an effective strategy for the treatment of such fractures. The exact method of percutaneous pinning, however, is not usually identified. In the prospective, randomized study by Strohm et al., the results of conventional Kirschner wire osteosynthesis (in which two pins from the styloid process were anchored in the opposite cortex) were compared with those of a modified Kapandji method ("intrafocal pinning")²⁴. Despite acceptable results for both patient cohorts, the functional and radiographic results of the Kapandji method were superior to those of the other technique.

Another traditional method for the treatment of distal radial fractures is external fixation with supplemental percutaneous pin fixation. However, in a study of seventy cases by Dicpinigaitis et al., this standard treatment modality was not reliable for maintaining fracture reduction after six months of follow-up²⁵. Although initial fracture reduction was effective for restoring dorsal tilt to within 0.9° of neutral alignment, 49% of the fractures lost 5° of volar tilt after removal of the fixator. Patient age, initial deformity, the use of bone graft, and the duration of treatment with the external fixator did not affect the loss of reduction. However, we occasionally are reminded that clinical results do not always correlate with radiographic results and that some human articulations are more forgiving than others, as evidenced by a 2004 Orthopaedic Trauma Association highlight paper by Borrelli et al.²⁶. Those authors evaluated the long-term radiographic and clinical results for sixteen patients with fractures of the distal part of the radius at an average of fourteen years after the injury. Seventy-six percent of the patients had evidence of radiocarpal arthrosis. A significant relationship was found between the residual articular incongruity at the time of union and the development of radiographic signs of arthritis (p < 0.01). However, despite the radiographic findings, all patients continued to have an excellent or good clinical result.

	Acetabulum

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
Insight into complications associated with injuries involving the acetabulum was provided by four selections, beginning with a meta-analysis on the operative treatment of displaced fractures of the acetabulum by Giannoudis et al.²⁷. That analysis suggests that much progress has been made in treatment, which, not so long ago, consisted of traction until healing. The meta-analysis included 3670 fractures as reported in thirty-four studies. The most common long-term complication was osteoarthritis, which occurred in approximately 20% of the patients. Brooker class-III and IV heterotopic ossification and osteonecrosis of the femoral head were present in <10% of patients, and sciatic nerve injury was present in 16.4% of the patients. Only 8% of the patients who were managed surgically needed an additional operation (usually total hip arthroplasty). Between 75% and 80% of the patients had an excellent or good result at a mean of five years after the injury. Factors that negatively influenced the functional outcome included the type of fracture (with the worst outcomes associated with anterior-wall and posterior-column fractures) and/or the type of dislocation, damage to the femoral head, associated injuries, and comorbidities that can be considered to be noncontrollable. Variables under the surgeon's control that influenced outcome included the timing of the operation and the quality of the reduction (2 mm compared with >2 mm). In this meta-analysis, the rate of thromboembolic complications (as recorded in eleven articles involving 806 patients) was surprisingly low (4.3%). Methods of prophylaxis and screening were poorly recorded, however, and therefore no conclusions can be drawn as to the adequacy of prophylaxis.

In the second related study, reported by Borer et al.²⁸, the prevalence of pulmonary embolism during a time-period when a screening protocol for deep-vein thrombosis was being used was compared with that during a period when no such screening protocol was employed. From November 1, 1997 through November 31, 1999, a screening protocol for deep-vein thrombosis, involving ultrasound and magnetic resonance venography, was used. From January 1, 2000 through December 1, 2001, no screening program was used. The first time-period included 486 patients with a fracture of the pelvis or acetabulum, and the second time-period included 487 patients. In the period during which a screening protocol was in place, ten patients (2%) were diagnosed with pulmonary embolism on the basis of a pulmonary arteriogram, autopsy, or ventilation-perfusion scan. Interestingly, all but two patients who were diagnosed with pulmonary embolism had undergone screening for deep-vein thrombosis, and none of the screening tests were positive. In the period during which no screening for deep-vein thrombosis was done, seven patients (1.4%) were diagnosed with pulmonary embolism on the basis of a pulmonary arteriogram, autopsy, spiral computed tomography scan, or high level of clinical suspicion, leading to maintenance of the policy of no screening for deep-vein thrombosis.

The next study, from Leeds, sought to establish the outcome following a "double-crush syndrome" of combined acetabular fracture and sciatic nerve injury associated with an ipsilateral peroneal injury at the level of the knee²⁹. In this prospective cohort of 136 patients who underwent stabilization of the acetabular fracture, twenty-seven had a nerve injury and, of these, nine had the double-crush syndrome. At the time of the initial presentation, thirteen patients had a complete foot-drop, ten had weakness of the foot, and four had burning pain and altered sensation over the dorsum of the foot. At the time of the latest follow-up, clinical examination and electromyographic studies showed full recovery in five of the ten patients with initial muscle weakness and complete resolution in all four patients with sensory symptoms (burning pain and hypoesthesia). There was improvement of motor and sensory functional capacity in two patients who initially had presented with complete footdrop. In the remaining eleven patients who had had footdrop at the time of presentation, including all nine patients with the double-crush lesion, there was no improvement after a mean of 4.3 years of follow-up.

Last, in a study from the University of Michigan, Karunakar et al. evaluated the association between body-mass index and complications following the operative treatment of acetabular fractures³⁰. In this retrospective chart review, 169 consecutive patients undergoing open reduction of an acetabular fracture were stratified into four classes according to body-mass index: normal (<25), overweight (25 but <30), obese (30 but <40), and morbidly obese (40). When body-mass index was measured as a continuous variable, it was found to have a significant relationship with estimated blood loss (p = 0.003), the prevalence of wound infection (p = 0.002), and the prevalence of deep venous thrombosis (p = 0.03). Obese subjects were 2.1 times more likely than patients of normal weight to have an estimated blood loss of >750 mL and were 2.6 times more likely to have a deep venous thrombosis. Morbidly obese patients were five times more likely to have a wound infection. Heterotopic ossification and iatrogenic nerve palsy were not associated with obesity in that study.

	Hip

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
In a retrospective case series from the Mayo Clinic, seventy-three femoral neck fractures in patients between fifteen and fifty years old were treated with internal fixation and were followed until union, until conversion to hip arthroplasty, or for a minimum of two years³¹. Fifty-one of the seventy-three fractures were displaced. Fifty-three fractures healed after one operation and were associated with no evidence of osteonecrosis of the femoral head. Osteonecrosis developed in association with seventeen fractures, and a nonunion developed in association with six. Four of the six nonunions later healed after a secondary procedure, yielding an overall ten-year survival rate for the native femoral head of 85%. At the time of the latest follow-up, at 8.1 years, thirteen patients had a conversion to a total hip arthroplasty because of osteonecrosis (eleven), nonunion (one), or both (one). Three of the twenty-two nondisplaced fractures were associated with the development of osteonecrosis and one was associated with the development of nonunion, whereas eleven of the forty-six displaced fractures with a good to excellent reduction were associated with the development of osteonecrosis and two were associated with the development of nonunion. Four of the five displaced fractures with a fair or poor reduction were associated with the development of osteonecrosis, nonunion, or both, demonstrating that the results of treatment were influenced mainly by the initial fracture displacement and the quality of reduction. An unusual and rigorous study from India that was published in the British volume of The Journal of Bone and Joint Surgery compared closed reduction with open reduction and internal fixation for the treatment of displaced femoral neck fractures in young adults³². In that study, 102 patients ranging in age from fifteen to fifty years were randomized to receive either closed or open reduction and ninety-two patients were available for follow-up. There was no significant difference between the groups in terms of union or osteonecrosis at two years. Posterior comminution, poor reduction, and improper placement of the screws were the major factors contributing to nonunion. The overall prevalence of osteonecrosis was 16.3% (fifteen of ninety-two), and it was not influenced by these factors. It is important to interpret these results in the context of the medical setting because the mean time to surgery (from the time of admission and not from the time of injury) was more than forty-five hours in both groups, indicating that this injury was not treated emergently, with the shortest interval to surgery being six hours. It therefore stands to reason that the rate of osteonecrosis, and therefore the rate of nonunion, would not differ between the treatment groups as the patients in either case likely would be outside the window of opportunity to restore blood flow to the femoral head.

Although the standard of hip fracture care seems to have trended toward quick operative intervention, controversy remains with regard to whether a delay before surgery actually makes a difference in older patients. In a prospective, observational study, 2660 patients underwent surgical treatment of a hip fracture at one university hospital³³. The mortality rate following surgery was 9% at thirty days, 19% at ninety days, and 30% at twelve months. Of the patients who had been declared fit for surgery, those who underwent surgery without delay had a thirty-day mortality rate of 8.7% and those who underwent surgery after a delay of one to four days had a thirty-day mortality rate of 7.3%. The thirty-day mortality rate for patients who had surgery after a delay of more than four days was 10.7%, and this small group had a significantly higher mortality rate at ninety days (hazard ratio, 2.25; p = 0.001) and one year (hazard ratio, 2.4; p = 0.001). Patients who had been admitted with an acute medical comorbidity that required treatment prior to surgery had a thirty-day mortality rate of 17%, which was nearly 2.5 times greater than that for patients who initially had been considered to be fit for surgery (hazard ratio, 2.3, 95% confidence interval, 1.6 to 3.3; p < 0.001). Thus, the salient finding of this study is that patients with medical comorbidities that delayed surgery had 2.5 times the risk of death within thirty days after surgery as compared with patients without comorbidities for whom surgery was delayed. Furthermore, the mortality rate was not increased when surgery was delayed for up to four days for patients who were otherwise fit; however, a delay of more than four days significantly increased mortality.

McGuire et al., in a study from Case Western Reserve University that was selected for the 2004 Marshall Urist Award, analyzed 18,209 Medicare recipients who were sixty-five years of age or older and had had surgical treatment of a closed hip fracture³⁴. Patients for whom the delay between admission and surgery was two days or more had a 17% greater chance of dying by Day 30. That study also employed a statistical tool called an instrumental variable (in this case, the day of the week) to pseudorandomize the study population and demonstrated a 15% increase in the mortality rate among patients for whom surgery was delayed for more than two days, supporting the delay between admission and surgery as the important independent variable (apart from comorbidities, for example) that is responsible for increased mortality.

Certainly, other perioperative factors besides the time to surgery affect outcome as well, as demonstrated with rather striking results in a study from New York on the effects of perioperative anemia³⁵. In that prospective observational cohort study of 550 patients who underwent surgery for hip fracture and survived to discharge, anemia (defined as a hemoglobin level of <12.0 g/dL) was present in 40.4% of patients at the time of admission, 45.6% of patients at the presurgery nadir, 93.0% of patients at the postsurgery nadir, and 84.6% near the time of discharge. The mean decrease in hemoglobin after surgery was 2.8 ± 1.6 g/dL. In multivariate analyses, higher hemoglobin levels at the time of admission were associated with shorter hospital stays and lower odds of death and readmission even after controlling for a broad range of prefracture patient characteristics, the clinical status at the time of discharge, and the use of blood transfusion. Additionally, higher postoperative hemoglobin levels also were associated with shorter lengths of stay and lower readmission rates but did not affect the mortality rates or mobility scores.

New approaches are emerging for the fixation of hip fractures, some of which may very well warrant a slot in the armamentarium of choices for the treatment of such fractures. Interest in the use of external fixation for the treatment of intertrochanteric hip fractures has increased following the realization that excessive medialization of the distal fragment relative to the proximal fragment, a common occurrence after the treatment of unstable variants with a dynamic hip screw-type device, is morbid and gait-altering. It certainly falls into a category of minimally invasive trends common to our discipline today as well. Moroni et al., from Bologna, Italy, conducted a prospective, randomized trial of forty consecutive patients in which a 135° four-hole sliding hip screw (Group A) was compared with an external fixation device with hydroxyapatite-coated pins (Group B)³⁶. The inclusion criteria were female gender, an age of at least sixty-five years, an AO/OTA type-A1 or A2 fracture, and a bone mineral density T score of less than 2.5. After controlling for other important variables, the study demonstrated that the average intraoperative time was 64 ± 6 minutes in Group A and 34 ± 5 minutes in Group B (p < 0.005) and that the average number of units of blood transfused postoperatively was 2.0 ± 0.1 in Group A and zero in Group B (p < 0.0001). The patients in Group B had less pain five days postoperatively (p < 0.05). Varus collapse of the fracture at six months averaged 6° ± 8° in Group A and 2° ± 1° in Group B (p < 0.002). No pin-track infections occurred in Group B. Additionally, there was no significant difference in terms of the average Harris hip scores, leading the authors to conclude that this technique has merits without apparent tradeoffs. It will be interesting to see if such treatment provides the first entrée to what is blatantly missing from contemporary locking plate inventories: an effective locking fixator for the proximal part of the femur.

The same group studied the possible effect of hydroxyapatite-coated screws in a prospective, randomized controlled trial of a similar population of patients with hip fractures that were treated with a dynamic hip screw³⁷. Patients were divided into two groups and were randomized to receive a 135° four-hole dynamic hip screw fixed either with standard lag and cortical AO/ASIF screws (Group A) or with hydroxyapatite-coated lag and cortical AO/ASIF screws (Group B). Lag-screw cutout occurred in four patients in Group A and in no patient in Group B (p < 0.05). In Group A the femoral neck shaft angle was 134° ± 5° postoperatively and 127° ± 12° at six months, and in Group B the femoral neck shaft angle was 134° ± 7° postoperatively and 133° ± 7° at six months (p = 0.003). The Harris hip score at six months was 60 ± 25 in Group A and 71 ± 18 in Group B (p = 0.02). The authors attributed the better results to increased fixation provided by the hydroxyapatite-coated screws.

Additional interest in the intertrochanteric hip fracture and reasons for suboptimal results were also expressed in similar reports from different parts of the world, which led to identical conclusions regarding partial explanations for previously reported failure rates. Both Gotfried and Im et al. focused on the intertrochanteric fracture variant with a broken lateral trochanteric wall as an important defining factor leading to instability, a slight departure from isolated focus on the medial calcar as the defining agent of instability^38,39. In the first study, which included twenty-four consecutive patients who had documented fracture collapse after treatment with a compression or dynamic hip screw device, the findings revealed unequivocally that, in all patients, this complication followed fracture of the lateral wall and resulted in a protracted period of disability until fracture-healing³⁸. In the second paper, sixty-six patients in whom a fracture of the trochanteric region had been treated with a sliding compression hip screw were evaluated with regard to loss of reduction as measured by the amount of medialization of the femoral shaft³⁹. Comminution of the lateral cortex (p = 0.0001) was the most striking factor found to be associated with excessive displacement, leading the authors to highlight that iatrogenic fragmentation of the lateral cortex at the time of surgery in apparently stable intertrochanteric fractures is responsible for subsequent loss of reduction.

It is perhaps likely that the history of treatment of femoral neck fractures has been even more problematic than that of intertrochanteric hip fractures. This is evident in the eagerness to evaluate current popular modes of fixation as well as in the increasing enthusiasm to yield to arthroplasty, a treatment that at the very least may offer a more predictable track record. It also seems that much more attention has been paid to implant positioning in intertrochanteric fractures than in femoral neck fractures as it relates to fixation failure. Gurusamy et al., in a study of 395 patients with femoral neck fractures that were treated with three cannulated screws, attempted to correlate screw position with the rate of nonunion on the basis of several radiographic criteria⁴⁰. No relationship between nonunion of the fracture and the position of the screws on the anteroposterior radiograph was found (although distance of the inferior screw to the calcar was not directly reported). However, a reduced spread of the screws on the lateral radiograph was found to be associated with an increased risk of nonunion.

In an Orthopaedic Trauma Association highlight paper, 224 patients from ten Dutch hospitals were screened with the modified Physiologic Status Score (PSS) and were evaluated to determine whether patients could be preselected for internal fixation or hemiarthroplasty in order to decrease the high rate of revision that had been previously reported in a meta-analysis of patients managed with internal fixation⁴¹. Interestingly, the rate of revision was still higher in the internal fixation group than in the hemiarthroplasty group (31% compared with 3%), despite surgical selection of patients with PSS scores of 20. However, a very important finding was that, at two years of follow-up, the mean Harris hip scores for both the internal fixation group and the internal fixation group managed with revision were significantly higher than that for the hemiarthroplasty group (p = 0.007 and 0.001, respectively), with no increase in mortality. It is indeed important to understand the context of function in the treatment of hip fractures and not to base treatment decisions strictly on the rates of revision surgery and mortality.

Even after the failure of femoral neck fixation, it seems that arthroplasty is a reasonable option for salvage. Mabry et al., in a large retrospective review from the Mayo Clinic with a mean duration of follow-up of 12.2 years, reported on the use of total hip arthroplasty for the treatment of nonunion of the femoral neck⁴². Between 1970 and 1977, ninety-nine patients were managed with cemented Charnley acetabular and femoral components for the treatment of a femoral neck nonunion. The mean age of the patients was sixty-seven years. Eighty-four patients were followed until death, revision, or component removal. Twelve patients were managed with revision or resection arthroplasty, eleven were lost to follow-up, and four died less than two years postoperatively. Of the remaining seventy-two unrevised hips that were followed for at least two years, sixty-nine had no or mild pain at the time of the latest follow-up.

There is growing interest in postoperative protocols as well. Koval et al. described a clinical pathway that has been used at the Hospital for Joint Diseases since 1990 and evaluated its possible effect on outcome variables⁴³. The comprehensive protocol nicely details every preoperative and postoperative parameter that can be controlled by a dedicated geriatric hip-fracture service and is exemplary in its comprehensiveness, making it an ideal template for the creation of similar such services in other hospitals. The results for the 747 patients who had been managed before the institution of the protocol were compared with those for the 318 patients who had been managed after the institution of the protocol. Use of the protocol was associated with significant decreases in the acute care hospital length of stay, in-hospital mortality, and one-year mortality (p = 0.03).

The rehabilitation component of postoperative treatment also has been the focus of study. Binder et al. performed a randomized, controlled trial at Washington University to determine whether extended outpatient rehabilitation that includes progressive resistance training improves physical function and reduces disability as compared with low-intensity home exercise among physically frail elderly patients with hip fracture⁴⁴. Ninety community-dwelling patients with an age of sixty-five years or more who had had surgical repair of a proximal femoral fracture were randomly assigned to six months of either supervised physical therapy and exercise training or home exercise. Changes over time in the Physical Performance Test and Functional Status Questionnaire scores both favored the physical therapy group. The patients in the physical therapy group also had significantly greater improvements than those in the control groups in terms of muscle strength, walking speed, balance, and perceived health but not in terms of bone mineral density or fat-free mass, leading the authors to conclude that six months of such extended outpatient rehabilitation can improve physical function and quality of life and can reduce disability.

	Femur

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
Femoral neck fractures are also a problem when they are combined with femoral shaft fractures in the higher-energy setting. It is estimated that as many as 10% of femoral shaft fractures occur in association with an ipsilateral femoral neck fracture and that as many as 50% of these neck fractures are missed either because they are occult or because of the distracting shaft injury. In a highlight podium presentation delivered at the 2004 Orthopaedic Trauma Association meeting, Tornetta et al. detailed how an established protocol decreased the rate of missed femoral neck fractures from 57% (four of seven) to 5% (one of nineteen)⁴⁵. The protocol consisted of a dedicated internal rotation radiograph, a fine-cut 2-mm computed tomography scan through the femoral neck, a fluoroscopic lateral radiograph made preoperatively in the operating suite, and postoperative anteroposterior and lateral radiographs made before awakening the patient. The authors found that the computed tomography scan was the most sensitive of the studies performed.

Damage-control orthopaedics is a term that had gained considerable attention over the past five years, and there is a growing body of data to support its role in the treatment of long-bone fractures in the multiply-injured patient. In the study by Harwood et al., alterations in the systemic inflammatory response after early total care were compared with those after early damage-control procedures in severely injured patients with a femoral shaft fracture⁴⁶. In that study, the Hannover trauma group sought to quantify the inflammatory response to the initial surgical procedure as well as to the conversion procedures and then to link this response to subsequent organ dysfunction and complications. Patients with a femoral shaft fracture and a New Injury Severity Score of 20 were included. Data were retrospectively collected for four days at the time of admission and at the time of exchange procedures (external fixation to intramedullary nailing), and the Systemic Inflammatory Response Syndrome (SIRS) score and the Marshall multiple-organ dysfunction score were calculated. One hundred and seventy-four patients met the inclusion criteria. The damage-control group had significantly more severe injuries (25.4 compared with 36.2; p < 0.0001) and significantly more head and thoracic injuries (p < 0.0001 for both); however, the mean SIRS score was significantly higher in the intramedullary nailing group from twelve hours until seventy-two hours postoperatively (p < 0.05). Furthermore, the mean peak postoperative SIRS score was significantly higher (p < 0.005) in this group than in the damage-control group at the time of the primary procedure and at the time of conversion, as was the time with an SIRS score of >1. At the time of conversion in the damage-control group, the preoperative SIRS score correlated with the magnitude and duration of elevation in the SIRS and multiple-organ dysfunction scores (p < 0.0001). Despite the greater severity of the injuries in the damage-control group, these patients had a lower, shorter postoperative SIRS and did not have significantly more pronounced organ failure than the intramedullary nailing group did. Interestingly, the patients in the damage-control group who underwent conversion while the SIRS score was raised had the most pronounced subsequent inflammatory response and organ failure. This body of data possibly provides an objective basis for decision-making with regard to the timing of conversion from external fixation to intramedullary nailing of a femoral fracture in a subset of polytraumatized patients.

In another OTA highlight paper, Ricci et al. presented a study evaluating the starting points used for antegrade femoral nailing procedures and their effect on complications, operative time, and function⁴⁷. Five institutions enrolled 108 patients to compare trochanteric and piriformis starting points for nailing. There were no significant differences with regard to complications, malalignment, or function, but the use of the trochanteric starting point was associated with less operative time and less fluoroscopy time, indicating that this technique seems to be a rational alternative to a conventional piriformis starting point given the newer generation of trochanteric nails, which are precontoured specifically to accommodate this entry point and the femoral anatomy.

Moving down the femoral shaft, Nork et al. described the importance of diagnostic vigilance in the workup of high-energy distal femoral fractures in order to avoid missing coronal plane fractures⁴⁸. One hundred and eighty-nine patients with 202 supracondylar-intercondylar distal femoral fractures were retrospectively evaluated clinically and radiographically. Coronal plane fractures were diagnosed in association with seventy-seven (38.1%) of these fractures. Fifty-nine of the coronal fractures involved a single condyle, and eighteen involved both the medial and lateral condyles. Eighty-five percent of the coronal fractures involving a single condyle were located laterally. Patients with an open distal femoral fracture were 2.8 times more likely to have a coronal plane fracture than patients with a closed fracture were. Coronal plane fractures were diagnosed in 47% of the 102 knees that were evaluated with computed tomography, compared with 29% of the 100 knees that were not (p = 0.008). Ten coronal plane fractures that had been unrecognized preoperatively were identified only at the time of operative fixation of the distal femoral fracture; none of these fractures were in patients who had been evaluated with computed tomography scanning preoperatively. Although computed tomography scanning should be an adjunct in the diagnostic workup, it is worth bearing in mind that this study group was characterized by young patients (mean age, forty-six years) with high-energy injury mechanisms.

Locked plating technology is revolutionizing the industry of plates and screws. Volumes of reports have emerged detailing techniques, risk-benefit tradeoffs, and small case series over the past five years, and, clearly, there is a tug of war over the appropriate indications for surgery. Two reports in the Journal of Orthopaedic Trauma described the clinical experience with 145 distal femoral fractures that were treated with use of the Less Invasive Stabilization System^49,50. In the first article, Kregor et al. described a retrospective analysis of ninety-nine prospectively enrolled patients with 103 fractures that were followed at least until union⁴⁹. Thirty patients were over the age of sixty-five years, and thirty-five fractures were open. Ninety-six fractures healed without bone-grafting, and all fractures eventually healed with secondary procedures (including bone-grafting). There were five losses of proximal fixation, two nonunions, and three acute infections. No cases of varus collapse or screw loosening in the distal femoral fragment were observed, indicating that the implant's fixed-angled properties were strong enough for physiologic stresses during rehabilitation. Malreductions of six femoral fractures were seen. In the second article, Weight and Collinge described a retrospective analysis of twenty-two consecutive AO/OTA type-A2, A3, C2, and C3 fractures of the distal part of the femur that were treated with the same minimally invasive technique⁵⁰. All fractures healed without secondary procedures at a mean of thirteen weeks (range, seven to sixteen weeks). There were no cases of failed fixation, implant breakage, or infection. A comparison of the postoperative and final radiographs of each femur demonstrated no case in which there was a >3° difference in either varus or valgus angulation. Complications included one malunion in which the fracture was fixed in 8° of valgus and two cases of external rotation between 10° and 15°. The average knee range of motion was 5° to 114°. These strikingly similar results from two independent series suggest that this treatment safely allows immediate postoperative initiation of joint mobility and progression of weight-bearing with high union rates and earlier healing times.

	Proximal Part of Tibia and Tibial Shaft

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
As the Less Invasive Stabilization System for the proximal part of the tibia was released a couple of years later than that for the femur, the clinical experience is not quite as broad, but the early results described in two studies suggested findings similar to those of the femoral series. In the studies by Cole et al.⁵¹ and Ricci et al.⁵², the collective results of 115 fractures were reported. The former study was a two-surgeon series in which seventy-seven intra-articular and extra-articular proximal tibial fractures involving both medial and lateral columns were followed until union (mean duration of follow-up, fourteen months)⁵¹. Fifty-five fractures were closed, and twenty-two were open. Seventy fractures (91%) healed without major complications. There were two early losses of proximal fixation, two nonunions, two deep infections, and one deep peroneal nerve palsy. Postoperative malalignment occurred in seven patients, with 6° to 10° of angular deformity. Four patients had removal of the hardware because of irritation. The mean time for allowance of full weight-bearing was 12.6 weeks, and the mean range of final knee motion was 1° to 122°. In the second paper, thirty-eight patients were followed for an average of twenty-three months⁵². Thirty-seven fractures healed, and the other fracture healed after implant removal without the need for additional surgery. Postoperative fracture alignment was satisfactory in thirty-seven of the thirty-eight cases and was maintained in all patients at the time of union. Both reports emphasized that the technique requires the successful use of new and unfamiliar surgical principles to effect an accurate reduction but that a single laterally based, locked, angled implant appears to be sufficient to prevent loss of fixation or varus collapse in the proximal articular fragment.

The paucity of soft-tissue complications in the aforementioned studies may have more to do with modern-day awareness and the ability of fracture surgeons to handle soft tissues than with their ability to handle a fracture through a single-sided approach or to use a single lateral plate. A study from Harborview Medical Center by Barei et al.⁵³ lends credence to this idea. In a review of eighty-eight bicondylar tibial plateau fractures that were treated with open reduction and internal fixation through two incisions with use of at least two plates, quite reasonable rates of complications were documented. Seven patients had development of a deep wound infection, and, of these, three had associated septic arthritis. All infections resolved after treatment. Secondary procedures for the treatment of complications were necessary for thirteen patients, and sixteen patients had deep venous thrombosis. These rates certainly seem to be reasonable given the severity of injury, and they point to the likelihood that conservative timing and distinctly separate incisions are at least largely responsible for modest rates of complications.

Bhattacharyya et al. reviewed a series of a relatively rare variant of tibial plateau fractures, the posterior shearing variant, to document the complications, technique, and outcomes of a posterior midline approach involving division of the medial head of the gastrocnemius⁵⁴. The consistent fracture pattern, identified in all thirteen patients, was a primary, inferiorly displaced posteromedial shear fracture with variable amounts of lateral condylar impaction. The surgical approach allowed for direct reduction and buttress fixation of articular fragments. The average duration of clinical follow-up was twenty months. All fractures healed, and two minor complications were treated nonoperatively. The functional outcome score was significantly related to the quality of articular reduction (p < 0.017, r = 0.456). The authors noted the challenge of regaining full extension and recommended an extension brace for two to three weeks postoperatively.

Given the importance of articular reduction, it is important to understand the performance of bone-void fillers, which are utilized above and below subchondral surfaces to prevent subsidence during healing and rehabilitation. This issue was addressed in two Orthopaedic Trauma Association highlight papers^55,56. In the first study, by Larsson and colleagues from Sweden, the technique of radiostereometry was used to evaluate subsidence in two groups of patients with lateral plateau fractures who were randomized to treatment with either an injectable calcium phosphate cement (Norian SRS, Synthes, West Chester, Pennsylvania) or autograft⁵⁵. Tiny tantalum markers were placed in the bone to detect radiographic changes of as little as 0.5 mm or 0.7°. Interestingly, significantly greater weight-bearing was tolerated at twelve weeks, significantly less pain was experienced by one week, function was better by six weeks, and less total subsidence (1.41 compared with 3.88 mm) was recognized in the Norian group relative to the autografting group. All of these variables (besides subsidence) equalized by one year, but the study seems to underscore the importance of maintaining the height of the lateral plateau throughout therapy. In the OTA Bovill Award-winning paper by Russell et al., another calcium phosphate cement (Alpha-BSM, DePuy, Warsaw, Indiana), was compared with autogenous bone graft to study the exact same issue (i.e., subsidence in patients with tibial plateau fractures)⁵⁶. In this multi-institutional study, 120 patients with all types of tibial plateau fractures, from twelve centers, were enrolled through a randomization process. The authors encountered reportable adverse effects and a significantly higher rate of articular subsidence in association with the autogenous bone-grafting procedure, leading to the conclusion that calcium phosphate cement should be used as a bone-void filler to treat articular depression.

There is an expanding interest in soft-tissue injuries that occur in association with tibial plateau fractures. In a prospective cohort study from the Hospital for Special Surgery, 103 consecutive patients with acute tibial plateau fractures who were scheduled to undergo operative intervention on the basis of radiographs and computed tomography scans were evaluated with magnetic resonance imaging⁵⁷. Not only did the study confirm recent reports of a high prevalence of such injuries, but only one patient in the series had complete absence of any soft-tissue injury. Seventy-nine patients had a complete tear or avulsion of one or more cruciate or collateral ligaments. Ninety-four patients had evidence of lateral meniscal pathology. Forty-five patients had medial meniscal tears. Seventy patients had tears of one or more of the posterolateral corner structures of the knee. The most frequent fracture pattern in that series (comprising 60% of the fractures) was a Schatzker type-II lateral plateau split-depression injury followed by equal numbers of Schatzker type-V and VI injuries. No pure depression fractures (without a crack in the cortical rim) were reported in that series. Although the natural history of these soft-tissue injuries is unclear and the appropriateness of intervention is therefore unknown, that study should at the very least raise the acuity level for symptoms during recovery from tibial plateau fracture treatment.

Sarmiento and Latta reported on another important reference series, ensuring that our collective surgical arrogance does not stray too far from what can be successfully accomplished with plaster and bracing⁵⁸. The authors studied 450 closed fractures of the distal one-third of the tibial diaphysis that were treated with a functional brace. These fractures represented 45% of the original 1000 tibial fractures that were treated with functional bracing as reported in 1995. Thirty-two percent of the fractures were considered to be high-energy, unstable fracture patterns associated with an intact fibula and were not included because of the propensity for varus collapse. Tibial fractures were converted to a functional brace from a long-leg cast an average of twenty-six days after the injury. The average healing time was 16.6 weeks (range, ten to forty weeks), and 90.1% of the fractures united. The average final shortening was 5.1 mm. Four hundred twenty-four fractures (94.2%) healed with <12 mm of shortening. The authors showed that axially unstable closed tibial fractures do not shorten beyond the initial shortening. Ninety percent of the fractures healed with <8° of angular deformity in either the frontal or sagittal plane, and 67.1% healed with <5° of deformity in any plane.

On the opposite end of the spectrum of treatment, Nork et al. described a series of thirty-eight fractures involving the distal 5 cm of the tibia that were treated with intramedullary nailing with reaming with use of at least two distal interlocking screws⁵⁹. Thirty-nine percent of the fractures were open, and ten fractures with articular extension were treated with supplementary screw fixation prior to intramedullary nailing. Acceptable radiographic alignment was obtained in thirty-three patients. No patient had any change in alignment between the immediate postoperative and final radiographic evaluations. Complications included one deep infection and one iatrogenic fracture at the time of intramedullary nailing. Thirty of the thirty-eight fractures united at an average of 23.5 weeks; however, three patients with associated traumatic bone loss also underwent a staged autograft procedure.

Certainly, it is common for orthopaedic trauma surgeons to partner with colleagues who have microvascular skills for the treatment of severe open fractures. Greater support for early tissue transfer and definitive soft-tissue coverage is mounting. Gopal et al. reported on outcome and function in a study of thirty-three patients with thirty-four severe open tibial (Gustilo type-IIIb and IIIc) fractures that were treated with urgent radical débridement, immediate osseous stabilization, and early soft-tissue coverage with use of a free or rotational muscle flap (usually within seventy-two hours after the injury)⁶⁰. The study included thirty Gustilo type-IIIb and four Gustilo type-IIIc fractures. Twenty-nine patients had primary internal fixation, and four had external fixation. Eleven patients (33%) later required additional surgery to achieve union, and two needed bone-transport procedures to reconstruct large segmental defects. The mean time to union was forty-one weeks. Perhaps most notable was the finding that infection occurred in only two patients overall and that delay to flap coverage was associated with a longer time to union. These excellent results in patients with such a severe category of injury underscore the importance of a principled and aggressive approach to soft-tissue management.

The distinction of best poster at the 2004 Orthopaedic Trauma Association meeting was given to a prospective, randomized study in which recombinant human bone morphogenic protein-2 (rhBMP-2/ACS) in combination with allograft was compared with autogenous bone graft for the treatment of diaphyseal tibial fractures associated with traumatic bone loss⁶¹. That multicenter trial included only tibial fractures that were treated with staged reconstruction six to twelve weeks after the original operation for bone defects that were at least 1 cm in length and involved at least 50% of the bone circumference. Ten of fifteen patients in the autograft group and thirteen of fifteen in the rhBMP-2 group had healing. There was significantly increased blood loss in the autograft group, and donor site pain lasting for five days to more than one year was reported in fourteen of the fifteen patients in that group. These results encourage the use of growth factors to treat bone defects and avoid the complications and symptoms of iliac crest bone-graft harvest.

	Ankle and Foot

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
Sirkin et al. reported good results following the treatment of fifty-six complex AO-OTA type-43A-C pilon fractures of the tibia⁶². Group I included thirty-four closed fractures, and Group II included twenty-two open fractures (including three Gustilo type-I, six type-II, eight type-IIIA, and five type-IIIB fractures). The protocol consisted of immediate treatment (within twenty-four hours) with use of open reduction and internal fixation of the fibula (when fractured) and application of an external fixator spanning the ankle joint. Formal open reconstruction of the articular surface with plating was performed when soft-tissue swelling had subsided. In Group I, the average time from external fixation to open reduction was 12.7 days. All wounds healed, and none exhibited wound dehiscence requiring secondary soft-tissue coverage. There was a single case of osteomyelitis, which resolved after fracture-healing and metal removal. In Group II, the average time from external fixation to formal reconstruction of the open fracture was fourteen days. Two patients had partial-thickness wound necrosis, which was treated with local wound care and antibiotics. All surgical wounds healed. There were two cases of deep infection in this group, one of which eventually required a below-the-knee amputation.

On the other end of the spectrum of ankle injuries, diagnostic acumen may be required for the detection of subtle but possibly critical ligamentous injuries as may occur in association with the Weber type-B supination-external rotation fibular fracture. In a study that was performed to determine whether soft-tissue indicators such as swelling or ecchymosis predict deltoid incompetence⁶³, 138 patients who presented acutely with a Weber type-B supination-external rotation fibular fracture were evaluated for clinical signs in order to compare such findings with the findings on stress radiographs. Patients who presented with an apparently isolated fibular fracture and an intact ankle mortise (with a medial clear space of 4 mm and no talar subluxation) were evaluated with a stress radiograph to determine deltoid competence. Of the ninety-seven patients who presented with an isolated fibular fracture and an intact mortise, sixty-one had a stable supination-external rotation stage-2 injury and thirty-six had an unstable stress-positive supination-external rotation stage-4 injury, according to the Lauge-Hansen classification. Medial tenderness, ecchymosis, and swelling were not predictive of deltoid incompetence (instability). The authors concluded that stress radiographs are necessary for the accurate diagnosis of deltoid incompetence in patients with Weber type-B supination-external rotation fibular fractures and no other osseous injury. Egol et al. followed a similar protocol to correlate physical examination findings with stress radiographs and also found that medial tenderness, swelling, and ecchymosis were not sensitive for the prediction of widening of the medial clear space on stress radiographs⁶⁴. Twenty patients were managed nonoperatively and were followed for a mean of 7.4 months. Two of these twenty patients had evidence of persistent widening of the medial clear space at the time of the latest follow-up, but only one was symptomatic, and the American Orthopaedic Foot and Ankle Society Scores for these patients did not differ from those of a similar group of patients with an operation. So, interestingly, both of those studies demonstrated the unreliability of clinical signs alone, which points to the importance of stress radiographs; however, the question is raised as to whether a wide medial clear space necessitates an operation⁶⁴. Longer-term follow-up with greater numbers of patients is required to answer the question as to the natural history of talar subluxation.

Curiosity continues with regard to the optimal fixation of a wide or incompetent syndesmosis in a patient with an ankle fracture. Weening and Bhandari attempted to define predictors of functional outcome following transsyndesmotic screw fixation⁶⁵. Fifty-one consecutive fractures that were treated with syndesmotic screw fixation at three university hospitals were evaluated with regard to indications, technique, and outcome. Seventy percent of the injuries were pronation-external rotation injuries, and 30% were supination-external rotation injuries. On the basis of a critical review of standardized postoperative radiographs, 16% of syndesmoses were not reduced. At the time of the latest follow-up, the only significant predictor of functional outcome was reduction of the syndesmosis (p = 0.04). This variable alone accounted for 18% of the variation in physical function scores and 15% of the variance in the Olerud and Molander (running subscale) outcome measure, again showing the importance of anatomic reduction of articular surfaces.

Perioperative swelling is a challenge in lower extremity injuries in particular. Caschman et al. performed a prospective, randomized, controlled study to determine the efficacy of the A-V Impulse "in cast" system (Novamedix Services, Andover, United Kingdom) for the treatment of posttraumatic swelling following ankle fracture⁶⁶. Sixty-four patients with an isolated ankle fracture were randomized to treatment with limb elevation (control group) or with an A-V Impulse bladder that was fitted under the arch of the foot within a splint for intermittent pneumatic pedal compression (study group) while awaiting surgery. Four of the twenty-seven patients in the study group complained about the pump but completed the protocol. Statistical analysis revealed a significant reduction in time taken for ankle swelling to settle prior to surgery in the study group (p = 0.01), together with a reduction in wound and skin complications (p < 0.01) and final preoperative ankle swelling based on circumferential measurements (p = 0.03).

The treatment of ankle swelling around the time of surgery may be most important in patients with comorbidities such as diabetes, in whom complications occur with increased frequency. In a retrospective review of forty-two patients with both diabetes mellitus and an acute, closed, rotational ankle fracture, patients were individually matched to controls with regard to age, gender, fracture type, and treatment type (surgical or nonsurgical)⁶⁷. Twenty-one diabetic patients with comorbidities were then compared with twenty-one patients without diabetic comorbidities. The authors found that diabetic patients and controls did not differ significantly with regard to total complication rates, although the diabetic patients required longer-term bracing. However, diabetic patients with comorbidities had a higher rate of complications than matched controls did (p = 0.034). The highest rates of complications occurred in patients with Charcot neuroarthropathy. That study indicated the need to individualize decision-making around stratified diabetic patients.

In the prospective, randomized study reported by Takao et al., seventy-two patients with unstable Weber type-B ankle fractures were randomized to treatment with arthroscopy-assisted open reduction and internal fixation (forty-one patients) or with open reduction and internal fixation without arthroscopy (thirty-one patients)⁶⁸. Arthroscopic findings demonstrated that thirty (73.2%) of forty-one patients had osteochondral lesions of the talar dome and that thirty-three (80.5%) of forty-one patients had disruptions of the tibiofibular syndesmosis, all which were addressed at the time of surgery. The patients who were managed with arthroscopy did somewhat better than those who were not, suggesting that a precise intraoperative diagnosis and treatment of combined intra-articular disorders is important and that missed intraarticular injuries may be one explanation for late ankle symptoms in patients with no apparent cause.

There is much less literature regarding the pathology on the other side of the ankle joint to help surgeons to counsel patients regarding the outcomes of treatment. Two studies may help us in that regard. Vallier et al. retrospectively reviewed sixty fractures of the talar neck that had been treated at a single center with open reduction and internal fixation; the records were reviewed at an average of thirty-six months after the procedure⁶⁹. Radiographic evidence of osteonecrosis was seen in nineteen of the thirty-nine patients with complete radiographic data. However, seven of these nineteen patients demonstrated revascularization of the talar dome without collapse. Overall, twelve of the patients with osteonecrosis demonstrated collapse of the talar dome. Osteonecrosis was seen in association with nine of twenty-three Hawkins group-II fractures and nine of fourteen Hawkins group-III fractures. Twenty-one of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09). These two patient groups also demonstrated a worse functional outcome.

The second study was a retrospective review of twenty-five patients with twenty-six talar neck fractures who were followed for a minimum of four years⁷⁰. After surgical intervention, sixteen fractures had an anatomic reduction, five had a nearly anatomic reduction, and five had a poor reduction. All eight noncomminuted fractures were anatomically reduced. The overall rate of union was 88%. All closed, displaced talar neck fractures healed. Posttraumatic arthritis of the subtalar joint was seen in all patients. Osteonecrosis was seen after thirteen of the twenty-six fractures overall, including six of seven open fractures. Patients with a displaced fracture of the talus should be counseled that posttraumatic arthritis and chronic pain are expected outcomes, even after anatomic reduction and stable fixation, particularly in the case of open fractures.

Smith et al. reported on one of the most devastating foot injuries: the extruded talus⁷¹. Eight of the twenty-seven patients in that series had a pure talar extrusion without a fracture, and the other nineteen had a talar extrusion combined with a talar fracture. Remarkably, only one patient had a deep infection. Clinical and radiographic follow-up of at least one year was available for a subset of seventeen patients. The findings suggested that, with principled management, saving the talus is worthwhile, if for no other reason than to restore normal anatomical alignment for future reconstructive procedures.

Advancements in surgical technique have led to improvements in the operative treatment of fractures of the calcaneus. However, current research has focused on defining specific populations of patients and subsets of fracture patterns that will benefit specifically from operative treatment. For instance, advanced age has been offered as a relative contraindication for formal open reduction and internal fixation. However, Herscovici et al., in a retrospective review of forty-four operatively treated calcaneal fractures in elderly individuals, reported encouraging results⁷². A 97% rate of union was achieved, with quite acceptable functional outcomes, after a mean duration of follow-up of forty-five months. Major complications included three cases of osteomyelitis, all of which resolved with surgical débridement and antibiotics. Thus, it appears that age did not play a role in the development of soft-tissue complications as has been suggested by other authors.

	Overview and Future

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
Some trends that seemed apparent as we scoured the trauma literature from May 2004 to May 2005 included evidence of greater collaboration among institutions and even nations. Take for example the twelve 2004 projects highlighted by the Orthopaedic Trauma Association this year; seven of these studies represented multi-institutional efforts, and four were multinational endeavors. Another trend that does not seem to be trailing off yet is the number of projects supported by industry grants, which again represented a large percentage (38%) of the OTA highlight papers chosen this past year. Obviously, disclosure of conflicts of interest in medicine has become a major focus in recent years at nearly all levels. These approaches are no less germane to reporting the year's evidence to you via this Subspecialty Update. Accordingly, beginning with next year's review, we will also begin identifying the disclosures of authors for all articles reviewed, hopefully giving the reader an easy way in which to interpret more accurately the data presented.

We would like to conclude with a challenge to the orthopaedic profession at large.

An acknowledged historical shortcoming of this and other Subspecialty Updates is the omission of basic-science literature from review and discussion. Most certainly, there are highly relevant, high-quality basic-science publications from the past year, some of which are sure to steer the trends of clinical medicine. Furthermore, there is an ever-increasing blur between basic-science and clinical manuscripts, likely brought on by increased levels of sophistication in scientific investigation. Examples abound but may be characterized by an article in this update by Harwood et al.⁴⁶, in which alterations of the systemic inflammatory response (SIRS) were measured with use of multiple physiologic markers after certain aspects of the trauma care of a patient. Where is the "Level of Evidence Table" for basic-science studies? Why are we not applying the same evidence scrutiny to the ever-increasing body of basic-science literature? Is there not the same need for tools to aid the clinician in evaluating these investigations, and perhaps more so because we are clinicians? The gauntlet has been thrown! In subsequent Orthopaedic Trauma Subspecialty Updates, we will begin a new process of gleaning the appropriate investigations for review in this venue, with the hope of stimulating orthopaedics to maintain its preeminent leadership role in medicine with regard to the rigorous processes to establish clinical recommendations for our patients.

	Appendix

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 
Tables listing the number of published articles screened for review from each journal are available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

	References

Top Introduction General Topics in Fracture... Spine Shoulder Elbow Distal Part of the... Acetabulum Hip Femur Proximal Part of Tibia... Ankle and Foot Overview and Future Appendix References

 

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66. Caschman J, Blagg S, Bishay M. The efficacy of the A-V Impulse system in the treatment of posttraumatic swelling following ankle fracture: a prospective randomized controlled study. J Orthop Trauma. 2004;18:596 -601.[CrossRef][Medline]

67. Jones KB, Maiers-Yelden KA, Marsh JL, Zimmerman MB, Estin M, Saltzman CL. Ankle fractures in patients with diabetes mellitus. J Bone Joint Surg Br.2005; 87:489 -95.

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71. Smith CS, Nork SE, Sangeorzan BJ.The extruded talus: results of reimplantation . Presented at the Orthopaedic Trauma Association Annual Meeting; 2004 Oct 8-10; Hollywood, FL.

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This Article Extract Full Text (PDF) Free CME: Take the activities for this article: CME 4: October, November, December 2005 Adult Hip Reconstruction Test 18: Winter 2006 Hand Test 5: Winter 2006 Trauma Test 10: Winter 2006 [Supplementary Material] Letters to the Editor: Submit a response Letters to the Editor: View responses Alert me when this article is cited Alert me when Letters to the Editor are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Rights and Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cole, P. A. Articles by Bhandari, M. Search for Related Content PubMed PubMed Citation Articles by Cole, P. A. Articles by Bhandari, M. Related Collections Specialty Update Adult Hip Hand/Wrist Social Bookmarking                   What's this?

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Copyright © 2005 by The Journal of Bone and Joint Surgery, Inc. Online ISSN: 1535-1386.
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