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Scientific Articles:
Andrew N. Pollak, Melissa L. McCarthy, R. Shay Bess, Julie Agel, and Marc F. Swiontkowski
Outcomes After Treatment of High-Energy Tibial Plafond Fractures
J Bone Joint Surg Am 2003; 85: 1893-1900 [Abstract] [Full text] [PDF]
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[Read Letter to the Editor] Dr Pollak and colleagues respond
Andrew N. Pollak, M.D., Melissa L. McCarthy, MS., ScD., Mark F. Swiontkowski, M.D., Julie Agel, ATC   (29 December 2003)

Dr Pollak and colleagues respond 29 December 2003
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Andrew N. Pollak, M.D.,
Orthopaedist
University of Maryland School of Medicine, 22 South Greene Street, Suite T3R54, Baltimore, MD 21201,
Melissa L. McCarthy, MS., ScD., Mark F. Swiontkowski, M.D., Julie Agel, ATC

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Re: Dr Pollak and colleagues respond

apollak{at}umoa.umm.edu Andrew N. Pollak, M.D., et al.

To The Editor:

The letter by Dr James J. Hutson regarding our recent article, "Outcomes after Treatment of High Energy Tibial Plafond Fractures", correctly recognizes a trend toward greater injury severity in the group of injuries treated with external fixation. This increase in injury severity is measurable only by the increase in the number of open injuries and the increase in the number of type-C injuries in the external fixation group.

We did not attempt to further classify these injuries into the C 1 -3 groups because of a demonstrated lack of reliability of the AO/OTA classification system at that level of specificity(1). Nonetheless, we agree that an ability to more specifically categorize severity of injury in a reliable fashion would be a useful way to better compare treatment groups in this situation. This was but one of many limitations of our retrospective study methodology. The discussion section of our manuscript included an appropriate discussion of those limitations.

The regression modeling used was intended to specifically correct for differences in treatment groups by correcting for multiple variables simultaneously. Thus, to the degree that our data demonstrated that severity of injury in the external fixation group was greater than that in the internal fixation group, the regression modeling considered the differences and we believe that the conclusions remain valid.

A more specific classification of injury severity would necessarily have increased our ability to control for that variable. Nonetheless, we believe that, in the context of the clearly described limitations of the current study, the statements linking the use of external fixation to poorer results are supported and should remain in the paper.

While we agree with Dr Hutson that the more specific data about injury severity that could be obtained in a prospective study might allow us to better assess any more subtle differences between the treatment groups, the overall poor results seen in both treatment groups within the current study strongly suggest that obtaining good results following this type of injury will require a different treatment approach than either of the two modalities employed in the current population.

We further agree with other authors who have determined that an “eclectic” approach to these injuries is of critical importance. Understanding the “personality” of these fractures is, we believe, important to developing a treatment approach that will minimize complications and provide the best result possible in the context of the overall poor prognosis for these injuries.

Andrew N. Pollak, MD Melissa L. McCarthy MS, ScD Marc F. Swiontkowski, MD Julie Agel, ATC

1. Martin JS, Marsh JL, Bonar SK, DeCoster TA, Found EM, Brandser EA. Assessment of the AO/ASIF fracture classification for the distal tibia. J Orthop Trauma. 1997;11:477-83.