Extract
This Specialty Update in orthopaedic trauma will emphasize the most
relevant clinical literature that was published between June 2006 and May
2007. Given the scope of the literature and the broad overview of trauma, we
have focused our search to include journals that we believe to be most
relevant to orthopaedic trauma. Our approach certainly is not exhaustive,
however. For example, we did not translate non-English-language articles, nor
did we cover hand and pediatric trauma, given that these topics will be
reviewed in their specific subspecialty sections. Specifically, we searched
the Cochrane Database, seven orthopaedic journals, and four high-impact
medical journals (see Appendix). This search identified 8469 articles, of
which 340 were selected for possible relevance. All of these abstracts were
then reviewed by one of us (P.A.C.). After the abstract review, sixty-eight
studies were chosen for this update, including nineteen Level-I studies,
fifteen Level-II studies, seven Level-III studies, and twenty-seven Level-IV
studies. A table in the Appendix summarizes each of the studies and classifies
them according to level of evidence and study type. Of the sixty-eight
clinical articles, forty-seven represented studies of therapy, sixteen
involved prognosis, and five evaluated diagnostic tests.
This Specialty Update in orthopaedic trauma will emphasize the most
relevant clinical literature that was published between June 2006 and May
2007. Given the scope of the literature and the broad overview of trauma, we
have focused our search to include journals that we believe to be most
relevant to orthopaedic trauma. Our approach certainly is not exhaustive,
however. For example, we did not translate non-English-language articles, nor
did we cover hand and pediatric trauma, given that these topics will be
reviewed in their specific subspecialty sections. Specifically, we searched
the Cochrane Database, seven orthopaedic journals, and four high-impact
medical journals (see Appendix). This search identified 8469 articles, of
which 340 were selected for possible relevance. All of these abstracts were
then reviewed by one of us (P.A.C.). After the abstract review, sixty-eight
studies were chosen for this update, including nineteen Level-I studies,
fifteen Level-II studies, seven Level-III studies, and twenty-seven Level-IV
studies. A table in the Appendix summarizes each of the studies and classifies
them according to level of evidence and study type. Of the sixty-eight
clinical articles, forty-seven represented studies of therapy, sixteen
involved prognosis, and five evaluated diagnostic tests.
This year, for the first time, we are pleased to complement this update
with new material in the area of basic science. Under the guidance of one of
us (T.M. III), a process has been established to hone in on important
basic-science works relevant to the field, with the goal of elucidating
information that we believe may be equally important to the clinical papers
typically reviewed in this update. This process is not straightforward,
however, as there is no level-of-evidence strategy to help to evaluate and
contextualize basic-science studies. Although many of the techniques and
strategies used in basic-science investigation are foreign to most clinicians,
it has become increasingly clear that clinical and basic-science material
often intersect and provide a great deal of relevance to the orthopaedic
clinician.
This basic-science material will be presented under the heading of General
Topics. Given the wide range of possible research fields that relate to
musculoskeletal trauma and repair, the task of selecting a handful of
published projects seemed daunting. However, fifteen recognized experts were
polled and were asked to identify the one or two most important trauma-related
research articles in their field. We then selected (perhaps arbitrarily) six
articles for review that address vital areas of cutting-edge research.
We trust that you will be enriched by this year's orthopaedic trauma survey
and hope that this overview will prompt you, and make it easier for you, to
dive deeper into selections and topics that otherwise may be much more
difficult.
Basic Science
Growth Factors
Musculoskeletal repair occurs through a series of events mediated by growth
factors. Bone morphogenetic proteins (BMPs) have been identified as key
factors that influence a variety of processes, including chemotaxis, cellular
proliferation and differentiation, new blood-vessel formation, chondrogenesis,
and osteogenesis.
The degree to which BMP-2 is required for fracture-healing was evaluated by
Tsuji et al.1. Those
investigators created transgenic mice lacking limb-specific expression of
Bmp-2 using a Prx1cre enhancer (Bmp2c/c; Prx1::cre), thereby
avoiding the embryonic lethality from complete loss of Bmp-2. While these mice
did not appear to have defects in skeletal patterning, they did have
development of dose-dependent deficits in bone mineral density relative to
their heterozygous and control littermates. When unilateral femoral fractures
were created in the mice lacking limb-specific BMP-2, the fractures failed to
heal by Day 20 compared with the heterozygous and the control littermates,
which healed by that time-frame. These differences manifested as delayed
periosteal activation as well as the absence of a bridging callus and
undifferentiated mesenchymal progenitor cells. Additionally, Bmp-4 and Bmp-7
transcripts were present at comparable levels in mice with and without BMP-2,
suggesting that these BMPs cannot compensate for the absence of BMP-2 in
fracture-healing. The authors concluded that BMP-2 is required for the
initiation of fracture repair.
Developmental Biology
Fracture repair occurs through intramembranous and endochondral
ossification. As many of the processes that govern bone development and repair
are shared, investigators have gained insight into adult fracture-healing
through their understanding of skeletogenesis. Chondrocyte hypertrophy is a
key process in bone formation as cartilage matures and then is replaced by
bone. Several factors, such as members of the Runt family of transcription
factors (Runx2, Runx3), have been shown to be required for chondrocyte
hypertrophy and osteoblast differentiation, but this past year, Nishio et al.
demonstrated that Osterix, a transcription factor that acts downstream of
Runx2, is also required for osteoblast differentiation and bone formation as
well2.
Arnold et al. further reported on the previously undescribed essential role
of myocyte enhancer factor 2C (MEF2C) in the process of chondrocyte
hypertrophy and bone
development3.
Although MEF2C is known to regulate muscle and cardiovascular development,
transgenic mice that have a genetic deletion of MEF2C in endochondral
cartilage have impaired chondrocyte hypertrophy, angiogenesis, ossification,
and longitudinal bone growth. Furthermore, effects in bone deficiency of the
MEF2C mutant mice can be rescued by a mutation in its co-repressor histone
deacetylase 4 (HDAC4). The authors concluded that MEF2C controls bone
development by activating the gene program for chondrocyte hypertrophy, which
shares mechanistic commonalities with muscle and cardiovascular
development.
The mechanical environment influences musculoskeletal development and
repair, including mesenchymal differentiation into cartilage or bone. However,
the mechanisms through which mechanotransduction occurs are poorly understood.
Cilia are microtubule-based organelles present on the majority of mammalian
cells that have various functions, including sensory perception and
mechanosensation. Cilia formation requires intraflagellar transport (IFT), and
mutations in intraflagellar transport result in the loss of cilia. Haycraft et
al. generated a new conditional allele of the Ift88 gene and, using the
Cre-lox system, disrupted cilia on different cell populations in the
developing limb
bud4. Disruption of
the intraflagellar transport in the mesenchyme in the conditional mutant mice
(prx1cre;Ift88) demonstrated multiple defects, including disorganization of
the perichondrium and abnormal chondrocyte differentiation, as well as
endochondral bone formation. Given that intraflagellar transport results in
impaired sonic hedgehog (SHH) signal transduction, and that indian hedgehog
(IHH) regulates chondrocyte proliferation, the investigators evaluated IHH
signaling in the prx1cre;Ift88 mutants and found it to be disrupted. In
addition, the endochondral bone phenotype in these mice had similarities with
other mouse models, suggesting multiple roles for intraflagellar transport and
cilia in endochondral bone formation. Future studies involving this type of
technology will shed additional light on the relationship between mechanical
stimuli and the cellular and molecular response.
Tissue Engineering and Nanotechnology
Although bone tissue has an intrinsic ability to repair itself with new
bone, critically sized defects require bone restorative procedures. Successful
approaches will require advances in mechanically and biologically compatible
scaffolds, inductive factors, and progenitor cell biology. Using a novel
dynamic oscillating culture technique, Weinand et al. studied the possibility
of developing bone tissue in
vitro5. A
three-dimensionally printed porous scaffold made of
ß-tricalcium-phosphate (ß-TCP) was suspended in different hydrogels
(collagen I, fibrin, alginate, and pluronic F127) and bone-marrow-derived
differentiated mesenchymal stem cells. Histological analyses were performed at
one, two, four, and six weeks, and radiographic, gene transcription, and
biomechanical analyses were performed at six weeks. The combination of the
scaffold, cells, and collagen I samples was the superior combination, with
increased histological bone-tissue formation, radiographic opacities,
expression of bone-specific genes, and improved mechanical strength under
dynamic oscillating conditions. The authors concluded that in vitro bone
tissue can be successfully formed with the proper combination of hydrogel
(collagen I), scaffold (ß-TCP), progenitor cell, and mechanical
stimulus.
One of the goals in developing biomaterials for use in tissue engineering
and integration is to design scaffolds made of the proper material and
configuration for adequate cell adhesion and biomechanical support.
Nanotechnological approaches have been used to create materials that improve
bone growth into materials. Popat et al. created a novel material with titania
interfaces fabricated with controlled nanoarchitecture with use of
anodization6. They
studied the in vitro osseointegration of rat marrow stromal cells on the
titania surfaces (nanotubular and flat) at different time-points. The cells
cultured on the nanotubular surfaces showed greater cell adhesion and
proliferation, alkaline phosphatase activity, and bone matrix deposition
compared with those grown on the flat titanium surfaces. These different
implanting surfaces were then implanted subcutaneously in rats and were
evaluated histologically for an inflammatory response. No fibrosis or
inflammation was seen surrounding the implants; therefore, the authors
surmised that materials with nanotubular surfaces promote osseointegration,
without an inflammatory reaction. Nanotopography is a highly promising field
for improved cell-material interactions.
Growth Factors
This section reviews three studies involving the application of a growth
factor on a bovine collagen sponge to a site of tibial pathology. Two studies
involved bone morphogenetic protein-2 (BMP-2) (Infuse; Medtronic Sofamor
Danek, Memphis, Tennessee), and one involved bone morphogenetic protein-7
(BMP-7) (Osigraft; Stryker Biotech, Limerick, Ireland). To date, the gold
standard for the treatment of long-bone defects and nonunions has been
autogenous bone-grafting. Donor-site morbidity and the limited supply of
suitable bone graft make this solution problematic in some cases. In a
randomized controlled study of thirty adult patients who had an open
diaphyseal tibial fracture with a bone defect, autogenous bone graft was
compared with allograft combined with recombinant human BMP-2 (rhBMP-2) on a
collagen sponge (1.5
mg/mL)7. Fifteen
patients were enrolled in each group. The mean length of the defect was not
significantly different between the groups, and other variables such as
smoking, age, comorbidities, and fracture type were equivalent between the
groups. Ten patients in the autograft group and thirteen patients in the
rhBMP-2/allograft group had healing (as determined on the basis of a blinded
radiographic assessment) without further intervention, although an
insufficient volume of autograft had been harvested in the cases of three
patients in the autograft group. The mean estimated blood loss was
significantly less in the rhBMP-2/allograft group. There was no significant
difference in functional outcome according to the Short Musculoskeletal
Function Assessment score. Only one patient had development of transient
antibodies to bovine type-I collagen. The authors of the study concluded that
rhBMP-2/allograft is safe and is as effective as traditional autogenous
bone-grafting for the treatment of tibial fractures associated with diaphyseal
bone loss.
A subgroup analysis of the combined data from two prospective clinical
studies on the use of rhBMP-2 for the treatment of open tibial shaft fractures
formed the basis for the second
investigation8. Five
hundred and ten patients with open tibial fractures were prospectively
randomized to receive the control treatment (intramedullary nail fixation and
routine soft-tissue management) or the control treatment combined with the use
of an absorbable collagen sponge impregnated with one of two concentrations of
rhBMP-2, which was placed over the fracture at the time of definitive wound
closure. Only the control treatment and the Food and Drug
Administration-approved concentration of rhBMP-2 (1.50 mg/mL) were compared in
the subgroup analysis. Fifty-nine trauma centers in twelve countries
participated, and patients were followed for twelve months postoperatively.
Analysis of the subgroup of 131 patients with a Gustilo-Anderson type-IIIA or
IIIB open tibial fracture revealed a lower rate of bone-grafting procedures
(2% compared with 20%; p = 0.0005), a lower rate of invasive secondary
interventions (9% compared with 28%; p = 0.0065), and a lower rate of
infection (21% compared with 40%; p = 0.0234) in the rhBMP-2 group relative to
the control group. On the other hand, analysis of the subgroup of 113 patients
who were managed with reamed intramedullary nailing revealed no significant
difference between the rhBMP-2 group and the control group. This population of
patients was less severely injured, with a higher percentage of Gustilo and
Anderson open type-I and type-II fractures, and the authors pointed out that
this group was not sufficiently powered to show significant differences,
although a statistical trend favored the rhBMP-2 group. Overall, the data in
these two studies favored the use of rhBMP-2 for the treatment of severe open
tibial fractures.
The third growth-factor study investigated a more heterogenous group of
patients with distal tibial fractures (including open and closed fractures as
well as intra-articular and extra-articular fractures) that were treated with
a ring hybrid external
fixator9. Twenty
patients with distal tibial fractures that had been treated with external
fixation as well as growth factor (rhBMP-7)-soaked bovine collagen were
compared with twenty matched patients who had received similar treatment
without rhBMP-7. Significantly more fractures had healed by sixteen (p =
0.039) and twenty weeks (p = 0.022) in the BMP group as compared with the
matched group, despite a higher percentage of smokers, high-energy-fracture
variants, and larger bone defects in the former group; the evaluations were
not blinded. The mean time to union (p = 0.002), the duration of absence from
work (p = 0.018), and the time for which external fixation was required (p =
0.037) were significantly shorter in the BMP group than in the matched group.
Furthermore, the BMP group had fewer secondary interventions, leading the
authors to conclude that rhBMP-7 can enhance the union of distal tibial
fractures treated with external fixation.
Geriatric Orthopaedics—Risk Factors
It is difficult to sort out the relative effects of different risk factors
for fragility fractures in the elderly as there are so many variables at work
in this population. More large-scale clinical trials are being conducted to
answer these questions. Interestingly, this year, additional insight has been
gained regarding frequently hypothesized fracture risk factors such as a
previous fracture or dementia, but new risk factors have emerged as well.
In the British Medical Journal earlier this year, a metaanalysis
was published to present the evidence for strategies to prevent fragility
fractures in residents of care homes and hospitals and to investigate the risk
factors of dementia and cognitive
impairment10. Of
the 1207 references that were identified, forty-three studies (including
sixteen randomized controlled trials) met inclusion criteria based on quality
grading. When multifaceted interventions were employed in hospitals, the
authors reported a rate ratio of 0.82 (95% confidence interval, 0.68 to 0.997)
for falls but observed no significant effect on the number of fallers or
fractures. When hip protectors were employed in care homes, the rate ratio for
hip fractures was 0.67 (95% confidence interval, 0.46 to 0.98), but there was
no significant effect on falls and there were not enough data on fallers. The
authors concluded that there needs to be more research on the effectiveness of
different single interventions in hospitals and care homes in order to
understand which combination of interventions would have the greatest positive
effect.
An Australian prospective study that was published in the Journal of
the American Medical Association answered the broader question of
refracture risk in the population at
large11. Although
the study population consisted of an all-white cohort (based on regional
demographics), this longitudinal study (from 1989 to 2005) investigated
community dwellers, including 2245 women and 1760 men over the age of sixty
years, who were followed for a median of sixteen years. Of the 905 women and
337 men with an initial fracture, 253 women and seventy-one men experienced
another fragility fracture, making the relative risk of refracture 1.95 (95%
confidence interval, 1.70 to 2.25) in women and 3.47 (95% confidence interval,
2.68 to 4.48) in men. The estimated rate of loss to follow-up was only 5.3%.
Additionally, the absolute risk of subsequent fracture was similar for men and
women, and this increased risk occurred for virtually all age-groups and for
all clinical fractures and persisted for as long as ten years. Approximately
50% had a refracture by ten years, but the majority of those fractures
occurred within the first five years. Femoral neck bone mineral density, age,
and smoking were the best predictors of subsequent fracture in women, and
femoral neck bone mineral density, physical activity, and calcium intake were
predictors in men.
The optimal duration of treatment with alendronate for women with
postmenopausal osteoporosis is unknown. A randomized, double-blind trial was
conducted at ten clinical centers in the United
States12. One
thousand ninety-nine postmenopausal women who had been managed with
alendronate for the treatment of low femoral neck bone mineral density
(<0.68 g/cm3) and other high risk factors for five years were
randomized to treatment with alendronate at a dosage of 5 mg/d (n = 329) or 10
mg/d (n = 333) or with placebo (n = 437) for five more years (from 1998 to
2003). Women who discontinued the drug for five years showed a moderate
decline in bone mineral density and a gradual rise in biochemical markers for
bone turnover, but no higher fracture risk other than for clinical (not
morphometric) vertebral fractures, in comparison with those who continued to
receive alendronate. The authors concluded that discontinuation of alendronate
for up to five years (after treatment for five years) should be considered
except for women with a very high risk of clinical vertebral fractures.
It has been postulated that proton pump inhibitors that are used to
suppress stomach acid production may interfere with calcium absorption and
thus inhibit proper osteoclastic function, which could in turn affect fracture
risk. One study investigated a cohort consisting of users of proton pump
inhibitor therapy and nonusers of acid-suppression drugs who were older than
fifty years of
age13. In that
study, 13,556 patients with a hip fracture and 135,386 controls were culled
from a large database of general practices in the United Kingdom. The adjusted
odds ratio for hip fracture associated with more than one year of proton pump
inhibitor therapy was 1.44 (95% confidence interval, 1.30 to 1.59), and
interestingly, the strength of the association increased with increasing
duration of proton pump inhibitor therapy (adjusted odds ratio, 1.22 [95%
confidence interval, 1.15 to 1.30] for one year; 1.41 [95% confidence
interval, 1.28 to 1.56] for two years; 1.54 [95% confidence interval, 1.37 to
1.73] for three years; and 1.59 [95% confidence interval, 1.39 to 1.80] for
four years). The data were analyzed while controlling for a multitude of
possible confounding variables, demonstrating that proton pump inhibitor
therapy is strongly associated with an increased risk of hip fracture.
Because it is well known that malnutrition is common among the elderly, the
authors of a meta-analysis published by the Cochrane Collaboration sought to
answer the question of whether nutrition supplementation protocols affect
mortality after
fracture14.
Twenty-one randomized trials involving 1727 participants were included,
although the authors acknowledged the relatively poor quality ratings of the
trials. Eight trials evaluated oral multinutrient feeding, four trials
examined nasogastric multinutrient feeding, four trials tested increased
protein intake in an oral feed, and two trials tested intravenous
administration of vitamin B1 and other water-soluble vitamins (one trial) or
1-alpha-hydroxycholecalciferol (one trial), with all of the trials showing no
statistical evidence for decreased mortality. There was some weak evidence to
suggest that protein supplementation may have reduced the number of long-term
medical complications. One trial evaluating the role of dietetic assistants to
help with feeding showed a trend toward a reduction in mortality (relative
risk, 0.57; 99% confidence interval, 0.29 to 1.11). The conclusion of the
review was that adequately sized trials are required to overcome
methodological defects of the reviewed studies, and perhaps special attention
should be placed on the role of dietetic assistants.
Beyond the broad systematic review on the effects of nutrition
supplementation on post-fracture mortality, one recently published prospective
randomized trial on the effect of a dietary intervention on postoperative
morbidity among patients with hip fractures may give us cause for hope with
dietary action15.
In a nicely controlled study of eighty patients with intracapsular or
trochanteric hip fractures, including only communicative, otherwise healthy,
consentable individuals with no cognitive defects or comorbidities, the effect
of a nutrition program was evaluated with regard to the morbidity outcomes.
The patients were randomized to either the control group (comprising forty
patients who received ordinary hospital food and beverage) or the intervention
group (comprising forty patients who received a 1000-kcal daily intravenous
supplement for three days, followed by a 400-kcal oral nutritional supplement
for seven days). The results of the study revealed that the control group
received only 54% and 64% of optimal energy and fluid intake, respectively,
whereas the intervention group had close to optimal nutritional intake (p <
0.001 and p < 0.0001). The risk of fracture-related complications was
greater in the control group than in the intervention group (70% compared with
15%; p < 0.0001). In addition, four patients in the control group, and none
in the intervention group, died within 120 days postoperatively (p = 0.04),
proving the efficacy of this nutritional program when used for healthy
patients with a hip fracture.
The Mangled Extremity
The Lower Extremity Assessment Project (LEAP) study and its scientific
offspring continue to pay dividends. The purpose of a study this year by the
Evidence-Based Orthopaedic Trauma Working Group was to perform a systematic
review of the literature in an effort to aid clinicians in decision-making
regarding limb salvage as opposed to primary amputation for the mangled
extremity16. Nine
observational studies formed the basis of the review. While the length of
hospital stay was similar for limb salvage and primary amputation, the length
of rehabilitation and total costs were higher for limb salvage. Furthermore,
patients managed with limb salvage required more procedures and were more
likely to undergo rehospitalization.
Long-term functional outcomes (as long as seven years after the injury)
were equivalent between the limb salvage and primary amputation groups, and
the rates of self-reported disability and pain were similar as well.
Functional outcomes worsened over time in both groups, and only about half of
the patients in both groups returned to competitive employment two years after
the injury. Clinical and psychosocial factors, including smoking, nonwhite
race, uninsured status, having less than a high-school education, an income
status below the poverty line, and low self-efficacy were all associated with
poorer functional outcomes. Additionally, whereas it is common at the time of
injury for patients to prefer limb salvage, the majority of patients with a
failed limb salvage stated that they would opt for early amputation if they
could decide again. These findings certainly indicate that strict patient
selection judgment should be exercised in determining appropriate candidates
for limb salvage.
Spine
The first two features in this section on the spine involved diagnostic
studies, both of which attempted to provide a guide for prognosis and the need
for surgery. The first, a retrospective study from the University of
Massachusetts involving twenty-six consecutive unilateral facet fractures that
did not initially meet surgical criteria (mechanical instability or unstable
neurological deficit), was performed to determine computed tomographic
features that lead to the failure of conservative
treatment17. When
patients who were successfully managed nonoperatively were compared with those
who required operative decompression and stabilization, those with unilateral
cervical facet fractures involving >40% of the absolute height of the
intact lateral mass or an absolute height of >1 cm were at increased risk
for the failure of nonoperative treatment (p = 0.0002 and p = 0.008,
respectively), whereas no patient with a fracture involving <40% of the
height of the lateral mass or an absolute height of <1 cm had failure of
nonoperative treatment. The limitations of the study were its small sample
size and the lack of a clear protocol for surgical indications; however, it
may serve as a clinical guide and as a good basis for a prospective study.
Although little correlation has been shown between the degree of collapse
of a vertebral body and the level of pain in patients with fragility
fractures, previous studies have only been based on supine or standing lateral
thoracolumbar radiographs. Toyone et al. studied 100 consecutively managed
patients (median age, seventy-five years; range, sixty to eighty-nine years)
who had back pain after a lower thoracic or upper wedge compression fracture
resulting from low-energy
trauma18. Supine
and standing lateral radiographs that were made one month after injury were
used to determine correlations between the change in vertebral wedge height
and pain. The median visual analog scale scores for back pain (possible range,
0 to 100 points, with 0 indicating no pain) with the patient in a supine
position, in a standing position, and when standing erect were 13, 33, and 41,
respectively, whereas the median change in wedge height from the supine to
standing radiographs was 8% (p < 0.001), suggesting that changes in
vertebral wedge height between these positions may yield important clinical
information regarding the pathogenesis of pain resulting from fragility
fractures of the spine.
The first systematic review to compare the efficacy and safety of balloon
kyphoplasty and vertebroplasty for the treatment of vertebral compression
fractures was published last
year19. That review
included three nonrandomized studies in which balloon kyphoplasty was compared
with conventional medical therapy, thirteen case series of balloon
kyphoplasty, one nonrandomized study in which vertebroplasty was compared with
conventional medical care, and fifty-seven cases series of vertebroplasty.
There were no randomized trials, and there was only one comparison study of
the two techniques. The findings suggested that vertebroplasty and balloon
kyphoplasty provide similar gains in pain relief, whereas for balloon
kyphoplasty there is better documentation of gains in patient functionality.
Regarding procedure safety, the level of cement leakage and the number of
reported adverse events were significantly lower for balloon kyphoplasty than
for vertebroplasty, although there was a good ratio of benefit to harm for
both procedures. This Level-III evidence should be interpreted with caution
and needs to be supplemented with randomized controlled trials.
With respect to burst fractures, we reviewed two randomized controlled
trials, one of which compared two surgical procedures (fusion and nonfusion)
and the other of which compared fusion with conservative management; these
studies yielded insight but did not answer the question of best treatment. The
first prospective trial was conducted to compare the results of posterior
short-segment stabilization with and without fusion for surgically treated
burst fractures of the thoracolumbar and lumbar spine in fifty-eight
patients20. The
inclusion criteria were a kyphotic angle of =20°, a decrease of
vertebral body height of =50%, or a canal compromise of =50%. The
operative treatment included posterior reduction and instrumentation, with the
fusion group (n = 30) receiving autogenous bone graft. After a mean duration
of follow-up of forty-one months, neither the average loss of kyphotic angle
nor the back pain scores were significantly different between the treatment
groups. The radiographic parameters, however, were significantly different,
with a lost correction of vertebral body height of 3.6% in the nonfusion group
as compared with 8.3% in the fusion group (p < 0.002). The nonfusion group
maintained segmental motion of 4.8°, compared with 1.0° for the fusion
group (p < 0.001). Additionally, there was significantly less blood loss
(303 compared with 572 mL) and operative time (162 compared with 224 minutes)
in the nonfusion group. It would therefore appear that, over the short run,
the advantages of instrumentation without fusion are the elimination of
donor-site complications, the saving of motion segments, and the reduction in
blood loss and operative time.
In a randomized trial from The Netherlands, spinal compression fractures
without a neurological deficit were evaluated after a mean duration of
follow-up of 4.3
years21. Eighteen
patients received bisegmental posterior stabilization, and sixteen were
managed with a conservative protocol. The patients in both groups were placed
in a hyperextension brace for three months, and hardware was removed from the
operatively managed patients between nine and twelve months postoperatively.
The rate of follow-up was 94%. Both local and regional kyphotic deformity were
significantly less in the operatively treated group (p < 0.0001). All
functional outcome scores, including visual analog spine and pain scores,
showed significantly better results in the operative treatment group (p = 0.02
to 0.03). There were no significant differences between the groups in terms of
the rate of complications. The percentage of patients returning to their
original jobs was significantly higher in the operative treatment group (85%
compared with 38%), suggesting a benefit for surgery in this group of
patients.
Pelvis
Morbidity after severe pelvic injury is often long-lasting, as shown in the
two articles described in this section. A longitudinal single-cohort study of
thirty-two operatively managed patients with unstable sacral fractures was
performed to describe associated injuries and residual impairment in this
severely injured population, providing insight into complications that are
rarely well documented after pelvic
surgery22. The mean
Injury Severity Score was 27 (range, 9 to 57), and additional injuries
occurred in 84% of the patients, with twenty-three of these injuries
considered to be severe. After a minimum duration of follow-up of one year,
91% of the patients had sensory impairment, 63% had gait impairment, 38% had
sexual impairment, and 21% had bowel or bladder dysfunction. Late impairments
correlated with the severity of the injury and the presence of associated
injuries, but not fracture characteristics. The surgical procedures were too
varied to assess their affect on outcome.
Sacral decompression and lumbopelvic fixation in patients with spinopelvic
dissociation is gaining a foothold in the treatment of unstable pelvic
fractures. In a retrospective review of nineteen patients with highly
displaced, comminuted, irreducible sacral fractures associated with neurologic
deficits, eighteen patients met the criteria for a minimum one-year
follow-up23. All
patients were managed with open reduction, sacral decompression, and
lumbopelvic fixation. Sacral fractures healed in all eighteen patients without
loss of reduction, and radiographic evaluation demonstrated the average sacral
kyphosis improved from 43° to 21°. Fifteen patients (83%) had full or
partial recovery of bowel and bladder deficits, although only ten patients
(56%) had improved Gibbons neurologic scores. The average Gibbons score
improved from 4 to 2.8 at a mean duration of follow-up of thirty-one months.
Complete recovery of cauda equina function was more likely in patients with
continuity of all sacral roots (86% compared with 0%; p = 0.00037) and
incomplete deficits (100% compared with 20%; p = 0.024). As the wound
infection rate of 16% reflected the most common complication, the
benefit-to-harm ratio would appear to support lumbopelvic fixation for this
severe condition.
Acetabulum
This section on the acetabulum is robust with outcome studies in which the
authors attempted to present data on prognostic factors for these complex
injuries, but the section begins with a study that aids diagnosis and ends
with an efficacy study on heterotopic bone prevention.
In the study by Patel et al., the computed tomography scans and the
anteroposterior and Judet radiographs of thirty patients were reviewed by six
orthopaedic surgeons to help to determine a method of diagnosis that has good
interobserver and intraobserver agreement in terms of the Letournel
classification and important prognostic
modifiers24. There
were eight yes-or-no questions regarding features on the pelvic radiographs
and simple yes-or-no questions regarding the presence of prognostic modifiers
(articular displacement, marginal impaction, incongruity, intra-articular
fragments, and osteochondral injuries to the femoral head). This simple binary
approach to the classification yielded an interobserver and intraobserver
agreement that ranged from moderate to near-perfect (kappa = 0.49 to 0.88 and
kappa = 0.57 to 0.88, respectively), which is a departure from similar
assessments of other published fracture-classification systems. On the other
hand, the prognostic modifiers yielded only slight to moderate interobserver
and intraobserver agreement.
The first two articles covering the prognostic factors for acetabular
fractures, both published in the British volume of The Journal of Bone and
Joint Surgery, aimed to identify key features of posterior wall
acetabular fractures and their treatment that correlate with outcome. The
studies demonstrated both differences and striking similarities.
Bhandari et al. used a prospective database to identify 109 patients with
an acetabular fracture associated with a posterior hip dislocation, all of
whom were managed operatively within three weeks after the injury and were
followed for at least two
years25. There were
38% simple patterns (32% of which were posterior wall patterns) and 61.5%
associated patterns (41% of which were transverse plus posterior wall
patterns). The mean age was forty-two years, and 72% of the patients were
male. With use of multivariate analysis, the quality of reduction of the
fracture was identified as the only significant predictor of radiographic
grade, clinical function (as assessed with the Merle d'Aubigné score),
and the development of posttraumatic arthritis (p < 0.001). All patients
who lacked anatomical reduction (i.e., those who had a >1-mm step or gap
detected on any one of three radiographic views of the pelvis) had development
of radiographic signs of arthritis, whereas only 25.5% (twenty-four) of those
with an anatomical reduction did so (p = 0.05). With use of univariable
regression analysis, an interval of more than sixteen hours before relocation
(p = 0.05) and the presence of femoral head damage (p = 0.03) were also
associated with arthritis. No patient with an imperfect reduction had a good
or excellent result at the time of the latest follow-up, whereas 70% of the
patients with an anatomical reduction had a good or excellent result beyond
twelve years postoperatively. Only nine patients (8%) required total hip
arthroplasty.
In the second retrospective review, from Toronto, 128 patients who had been
managed operatively for a fracture involving the posterior wall of the
acetabulum were studied for the same
reason26. The mean
age in this group was 41.6 years, and the fracture types included forty-four
simple and eighty-four associated patterns. The Musculoskeletal Functional
Assessment and Short Form-36 scores, the presence of radiographic signs of
arthritis, and complications were assessed as a function of injury. The
authors concluded that the patients had profound functional deficits compared
with the normal population and that anatomical reduction alone was not
sufficient to restore function. A posterior wall with more than three
fragments (p = 0.005), marginal impaction (p = 0.01), and residual
displacement of >2 mm (p = 0.001) were associated with the development of
arthritis, which was related to poor function and the need for hip
replacement. Hip replacement was required in 12.5% of the patients within 2.9
years after the injury.
Possible explanations for the discrepancy in findings between the studies
include issues related to surgical technique, the determination of
anatomicity, the use of different outcome instruments (with the latter study
involving the use of validated tools), the number of patients with inadequate
follow-up (forty-five in the first study, compared with forty-four in the
second study), and the 17% prevalence of complete sciatic nerve palsy as well
as the high number of associated bodily injuries (mean Injury Severity Score,
23.4) in the Toronto study. Collectively, however, they give us insight into
some of the subtle and salient factors that determine prognosis.
In another retrospective report, Madhu et al. sought to determine the
effect on outcome and arthritis that a delay to surgery might
cause27. In a study
of 237 patients with displaced fractures of the acetabulum, surgical reduction
was assessed, fractures were classified into elementary and associated
patterns according to the Letournel system, and the time to surgery was
documented. When the time to surgery was analyzed as a categorical variable
(zero to five, six to ten, eleven to fifteen, sixteen to twenty, and more than
twenty days), an anatomical reduction was found to be more likely when surgery
was performed within fifteen days for elementary fracture patterns (p = 0.04)
and five days for associated fracture patterns (p = 0.008). Significance in
terms of functional outcome was first reached at fifteen days after surgery
for elementary fracture patterns (p = 0.02) and at ten days for associated
patterns (p < 0.0001). The authors pointed out that the organization of
regional trauma services must be capable of satisfying these time-dependent
requirements.
Borrelli et al. attempted to determine the correlation between muscular
strength and patient function for fifteen patients in whom a displaced
acetabular fracture was treated through an anterior ilioinguinal approach and
then compared these results with those for a group of patients who were
managed with a Kocher-Langenbeck posterior
approach28. After a
mean duration of follow-up of forty-four months, the ilioinguinal group had an
overall muscle strength deficit of 9% and an average Musculoskeletal
Functional Assessment score of 17. After a mean duration of follow-up of
twenty-four months, the Kocher-Langenbeck group had an overall strength
deficit of 8% and an average Musculoskeletal Functional Assessment score of
22. Although the numbers in that study were very small, the authors found that
the Musculoskeletal Functional Assessment scores did not differ significantly
according to the surgical approach, the fracture pattern, gender, age,
articular reduction, the radiographic grade, or the presence of heterotopic
ossification. However, there was a correlation between hip extension/flexion
work and maximum torque as well as between hip adduction work and maximum
torque and the Musculoskeletal Functional Assessment score, leading the
authors to conclude that an emphasis should be placed on hip muscle strength
after the operative treatment of a displaced acetabular fracture in order to
maximize outcome.
In the prospective, randomized trial by Karunakar et al., the effect of
indomethacin was compared with that of a placebo for reducing the prevalence
of heterotopic
ossification29.A
total of 121 patients with a displaced fracture of the acetabulum that was
treated through a posterior Kocher-Langenbeck approach were randomized to
receive either indomethacin (75 mg sustained release) or a placebo once daily
for six weeks. At three months postoperatively, Brooker grade-III or IV
ossification had occurred in nine (15.2%) of fifty-nine patients in the
indomethacin group and twelve (19.4%) of sixty-two patents in the placebo
group; this difference was not significant. These results must be interpreted
with caution, however, as the treatment groups differed significantly in terms
of one important variable, hip dislocation, with 21% more hip dislocations in
the placebo group. Furthermore, patient compliance with indomethacin was poor,
with 43% of those who agreed to be tested having no detectable serum levels of
indomethacin.
Upper Extremity
Shoulder and Proximal Part of the Humerus
While surgical treatment of most clavicular fractures was considered heresy
only a decade ago, four articles that were published during the past year
featured the surgical treatment of clavicular fractures. The most compelling
work in this area has come from Toronto, with a compelling, prospective,
randomized trial in which operative treatment was compared with nonoperative
treatment for clavicular shaft
fractures30. In a
well-controlled trial, 132 patients with a displaced midshaft clavicular
fracture (with no cortical contact) who were seen at eight different centers
were randomized to either sling treatment or a superior plating procedure.
Constant scores and Disabilities of the Arm, Shoulder and Hand (DASH) scores
were significantly improved in the operative fixation group at all time-points
between six and forty-eight weeks (p < 0.01). The mean time to radiographic
union was 28.4 weeks in the nonoperative treatment group and 16.4 weeks in the
operative treatment group (p = 0.001). The nonoperative treatment group had
more nonunions (seven compared with two, p = 0.042) and symptomatic malunions
(nine compared with zero, p = 0.001). Complications in the operative treatment
group included local irritation or prominence of the hardware (five patients),
wound infection (three), and failure (one). One year postoperatively, the
patients in the operative treatment group were more likely to be satisfied
with the appearance of the shoulder (p = 0.001) and with the shoulder in
general (p = 0.002) than were those who had been managed with a sling. This
study presented solid evidence in support of operative management, but,
because it did not stratify injury characteristics, it is impossible to know
if there are subgroups that either do or do not benefit from surgery.
Despite the fact that the clavicle is such a superficial bone, open
clavicular fractures are rare injuries, representing only 1.4% (twenty-four)
of 1740 clavicular fractures that were collected in a prospective database at
Harborview Medical Center (Seattle, Washington) over a thirteen-year
period31. Twenty
nonballistic fractures were evaluated with respect to injury characteristics
and associations. The rate of head injury was 65%, and the rate of significant
facial trauma was 55%. The rate of pneumothorax was 50%, and the rate of
bilateral pneumothorax was 35%. The rate of cervical or thoracic spine
injuries was 35%. The rate of scapular fractures was 40%, and the rate of
additional ipsilateral upper extremity fractures was 30%. Interestingly,
neurovascular complications were rare. All patients underwent
débridement and irrigation, and fourteen of the twenty patients
underwent open reduction and internal fixation. Of the fifteen patients with
adequate follow-up, all had union.
In a study that seemed to corroborate the surgical outcomes found in the
Canadian Trauma Group Clavicle Study described above, Collinge et al. reported
on a series of eighty consecutive patients with a middle-third clavicular
fracture or a painful nonunion of the clavicle that was treated with open
reduction and internal
fixation32. In
contradistinction to the Canadian trial, which involved the use of a superior
clavicular plating technique, this study highlighted the advantages of
anteroinferior plating. Among the fifty-eight patients who had sufficient
records and at least two years of follow-up, there was only a single nonunion.
The mean healing time was 9.5 weeks for the patients who had had fracture
fixations and 10.5 weeks for those who had had nonunion reconstructions.
Except for the patients with neurologic injury trauma, the functional results
were excellent and were comparable with normative data from age-matched
controls. Complications included three infections, all of which resolved while
the plate was left intact. In addition, two patients desired and underwent
hardware removal. Five patients complained of minor irritation, and none
complained of tenderness under bras or backpacks. The authors purported
multiple advantages of the anteroinferior plate location, including the fact
that drills are directed away from the important infraclavicular structures
and that there is less likelihood of implant prominence.
A more challenging fracture with a track record for treatment failure is
the unstable lateral clavicular fracture (Neer type II). The largest published
series to date on the use of the clavicular hook plate (Stratec Medical,
Oberdorf, Switzerland) for the treatment of this injury was a retrospective
study of sixty-three patients from
Finland33. The
Oxford score, the subjective part of the Constant score, and the subjective
shoulder value were assessed for fifty-eight patients after a mean duration of
follow-up of 3.6 years. The mean Oxford score was 15, indicating good
function. The mean score for the subjective part of the Constant score was 32,
compared with 34 on the control side (p = 0.003). The mean subjective shoulder
value was 86%. Fifty-nine fractures united uneventfully. There was one delayed
union, and there were three nonunions (two of which were thought to be the
result of premature plate removal at two and three months); however, only one
of these four complications required surgery. Additionally, there was one
infection, one frozen shoulder, and three cases of late fracture medial to the
plate after falls. The authors concluded that the hook plate provided a safe
and effective solution for an otherwise difficult problem, but they emphasized
the need for plate removal in all cases after healing.
In a prospective cohort study of 252 patients ranging from fifteen to
thirty-five years of age who had an anterior glenohumeral dislocation that was
treated with sling immobilization followed by a physical therapy regimen,
instability developed in 55.7% of the shoulders within the first two years and
in 66.8% by the fifth
year34. Patients
with atraumatic instability, hyperlaxity with an atraumatic mechanism, and no
Bankart lesion on magnetic resonance arthrography were excluded. A measurable
degree of functional impairment was present at two years after the initial
dislocation in most patients, and a significant risk for redislocation was
noted among younger patients as well as among male patients (p < 0.01). Of
the 134 patients who had a redislocation, 110 agreed to an operation, and of
the twenty-four who declined, sixteen had another dislocation. The authors
concluded that recurrent instability and functional deficits are common after
primary nonoperative treatment of a traumatic anterior shoulder dislocation
and that this injury warrants operative treatment in high-risk young male
patients.
To evaluate the radiographic and clinical outcome (including the prevalence
of recurrence) for displaced greater tuberosity fractures associated with
traumatic anterior shoulder dislocation, Dimakopoulos et al. retrospectively
studied thirty-four patients after a mean duration of follow-up of 4.8 years
to assess the fixation of the tuberosity and the repair of any rotator cuff
tear35. The union
rate was 97%. The result was excellent for twenty-five patients, very good for
six, good for two, and poor for one. The average Constant score was 88.4,
despite a 19.4% rate of neurologic injuries. All but one of the neurological
injuries resolved after a mean of 3.5 months. No case of recurrence of
dislocation was noted in any patient. Partial absorption of the tuberosity
(with no clinical relevance) was detected in four cases. The authors reported
that this treatment allows for early joint motion and yields excellent results
in about three quarters of the patients.
Humeral Shaft and Elbow
Although orthopaedic surgeons have found more frequent indications for the
operative treatment of humeral shaft fractures in the past decade, the results
of three studies that were published during the past year generally supported
nonoperative treatment, but with a couple of caveats. Two retrospective
studies, one from Boston and one from Sweden, yielded similar
conclusions36,37.
Both studies employed functional brace treatment until fracture-healing, and
both identified a nonunion rate of 10%.
In the Swedish study, which included seventy-eight patients, the authors
identified a trend toward more frequent nonunions in association with simple
(Orthopaedic Trauma Association type-A)
fractures36. The
nonunions that were operatively treated had an 88% union rate. Fifty patients
completed long-term outcome examinations, and half reported full recovery
after nonoperative treatment. However, none of the patients with a healed
nonunion had full recovery after revision surgery. The authors warned that the
acute simple fracture pattern in the proximal and middle thirds of the humerus
may represent an indication for surgery.
In the Boston study, the main risk factor was the proximal one-third
fracture, with four (29%) of fourteen such fractures having failed to
heal37.
Interestingly, all of the proximal one-third fractures that did not heal were
long spiral oblique fractures. There was no more than a 15° loss of
shoulder or elbow motion among the patients who had healing of the fracture,
and it is notable that angular deformity of >20° of varus occurred in
three patients but was not thought to cause a functional problem.
Extending the theme of the previous two studies, Jawa et al. reported on
fifty-one consecutive patients with a closed, extra-articular fracture of the
distal one-third of the humeral diaphysis who were identified from an
orthopaedic trauma database at two
centers38. Forty
patients were followed for at least six months or until healing of the
fracture; of these, nineteen had been managed with plate fixation and
twenty-one had been managed with functional bracing. Among the operatively
managed patients, one had loss of fixation and one had development of an
infection. Three iatrogenic postoperative radial nerve palsies developed, one
of which had not resolved at the time of follow-up three months after surgery.
All operatively treated fractures healed with <10° of angular
deformity, and only one patient lost 20° of shoulder or elbow motion.
Among the nonoperatively managed patients, two had conversion to plate
fixation because of concern with alignment, leaving only one patient with
>30° of malalignment in any plane. Two patients lost >20° of
elbow or shoulder motion, and two patients had development of skin breakdown
during brace treatment. The authors concluded that operative treatment
achieves more predictable alignment and a potentially quicker return of
function but risks iatrogenic nerve injury and infection, whereas functional
bracing can be associated with skin problems and varying degrees of angular
deformity but usually is associated with excellent function and range of
motion.
With the increased availability and improved technique of computed
tomography, Doornberg et al. hypothesized that three-dimensional computed
tomography reconstructions would improve diagnostic acumen with regard to our
understanding and classification of distal humeral
fractures39. The
computed tomography technique included imaging slices with <1.25-mm
intervals, with the radius and ulna being subtracted from the image. Five
observers evaluated thirty intraarticular fractures with respect to specific
fracture characteristics and then classified the fractures according to two
common schemes. Three-dimensional computed tomography improved both the
intraobserver and interobserver reliability of classification and also
improved the level of intraobserver agreement for all fracture characteristics
from moderate to substantial, leading the authors to recommend its routine use
for operative decision-making.
The second study on distal humeral articular fractures involved only
partial articular fractures. In that study, seventy-nine patients with a mean
age of forty-seven years were assessed
retrospectively40.
This injury was found to occur most commonly in osteoporotic individuals,
although there was a striking bimodal distribution in terms of age (more than
eighty years and less than twenty years). The incidence among female patients
over the age of sixty years was twice that among female patients under the age
of sixty years. The mean age was 55.1 years for female patients, compared with
27.5 years for male patients. When the fracture occurred in young male
patients, it was a more complex pattern from a higher energy mechanism. An
associated radial head fracture occurred in 24% of the cases. Corroborating
the findings of the previous study, preoperative classification from plain
radiographs often underestimated the extent of the injury.
An anteromedial coronoid facet fracture, which results from a varus
posteromedial rotational injury force, was treated in eighteen patients over a
six-year period41.
Twelve patients received treatment for the acute fracture, and six required
revision after initial treatment elsewhere. All but three patients (two with a
concomitant fracture of the olecranon and one with a second fracture at the
base of the coronoid) had an avulsion of the origin of the lateral collateral
ligament complex from the lateral epicondyle. Fracture patterns were
characterized and instability was documented, with varus subluxation being
observed in thirteen patients and posterior dislocation being noted in five
patients. The initial treatment was operative in fifteen patients and
nonoperative in three. The coronoid fracture was secured with various methods
in eleven patients but was not repaired in the remaining seven patients. At
the time of the latest follow-up, six patients had malalignment of the
anteromedial facet of the coronoid with varus subluxation of the elbow, which
was due to the fact that the fracture had not been fixed (four patients) or to
the loss of fracture fixation (two patients). All six patients had a fair or
poor result. The remaining twelve patients had good or excellent elbow
function. The authors surmised that anteromedial fractures of the coronoid are
associated with subluxation or complete dislocation of the elbow in most
patients, making it imperative to stably fix the coronoid fracture.
Radial head replacement has become popular in recent years when the
proximal part of the radius is "not reconstructable."
Interpretation of this phrase in many circles seems to have included any and
all comminuted radial head fractures, yet some have argued that successful
execution of an anatomic and stable reduction of the native proximal part of
the radius renders optimal results. In a prospective study from Cologne,
Germany, the radiographic and clinical outcomes for twenty-three patients with
a complex radial head fracture were evaluated at a median of two years after
treatment of the injury with use of a new fixation device (Fragment Fixation
System [FFS]; Orthofix, Bussolengo,
Italy)42. The
fixation device includes threaded wires that are self-drilling and
self-tapping as well as a proximal shoulder that applies compression. Fourteen
Mason type-III and eleven Mason type-IV fractures underwent open reduction and
internal fixation. Seven patients had joint instability after repair, for
which an articulating elbow fixator was used. All fractures united and, at the
time of the latest follow-up, the functional elbow score was excellent for
eight and good for four patients with a Mason type-III fracture and was
excellent for five, good for three, and fair for three patients with a Mason
type-IV fracture. Two patients had been lost to follow-up. Good elbow motion
was achieved, leading to the conclusion that successful fixation of severe
radial head fractures is possible and can lead to satisfactory functional
results while preserving the native anatomy.
A retrospective review of sixty-three Monteggia fractures in adults was
conducted to determine the prognosis of Bado and Jupiter classification
variants on the basis of the mean 8.4-year follow-up of forty-seven patients
who were managed
operatively43.
Overall, the mean Broberg and Morrey score was 87.2 and the mean DASH score
was 17.4. There was a significant correlation between the two scores (p =
0.01); however, twelve patients (26%) needed a second operation within twelve
months. The salient finding of this study was that Bado type-II Monteggia
fractures, and within this group, Jupiter type-IIa fractures, are frequently
associated with fractures of the radial head and the coronoid process. These
fractures were poor prognostic indicators, and these patients should be
counseled accordingly regarding the possible need for further surgery.
Distal Part of the Radius
The Massachusetts General Hospital upper extremity group conducted a study
of distal radial fractures to investigate the added value of the
three-dimensional computed tomography scan in
diagnosis44. Four
independent observers evaluated computed tomography and plain radiographic
images of thirty intra-articular fractures of the distal part of the radius
for the presence of a fracture line in the coronal plane, impacted central
articular fragments, the presence of comminution, and the number of fracture
fragments. These observations were then compared against intraoperative
findings. Three-dimensional computed tomography significantly improved
intraobserver agreement, but not interobserver agreement, regarding the
presence of coronal plane fracture lines and central articular fragment
depression. It improved both intraobserver agreement regarding the presence of
articular comminution and interobserver agreement for determining the number
of articular fracture fragments. Perhaps most importantly, the addition of
three-dimensional computed tomography influenced treatment recommendations,
resulting in a significantly greater number of decisions for an open approach
and a combined dorsal and volar exposure. The authors concluded that
three-dimensional computed tomography improves both the reliability and the
accuracy of radiographic characterization of articular fractures of the distal
part of the radius and influences treatment decisions.
Mackenney et al. tried to identify the predictors of fracture instability
and to construct a method of predicting the radiographic outcome (instability)
by analyzing data on 4000 distal radial fractures that had been collected over
a five-year
period45.
Predictors of early and late instability and malunion differed according to
the displacement of the fracture at the time of presentation. Patient age,
metaphyseal comminution, and ulnar variance were the most consistent
predictors of radiographic outcome, and dorsal angular deformity was not found
to be a significant predictor. Interestingly, the classification of a patient
as independent (that is, able to go shopping alone) was predictive of malunion
in displaced fractures. A formula that stratifies the risk of each variable
was presented to allow for the prediction of loss of reduction and malunion in
an effort to aid the surgeon's decision-making regarding the primary treatment
of distal radial fractures.
The purpose of a Swedish randomized trial was to compare wrist-bridging and
non-wrist-bridging external fixation for displaced distal radial fractures in
the elderly46.
Thirty-eight patients (mean age, seventy-one years) were randomized to
treatment with a bridging external fixator or a nonbridging external fixator.
At the time of follow-up, there was no significant difference in DASH or
visual analog pain scores. There was also no significant difference in terms
of range of motion, grip strength, or patient satisfaction. Although volar
tilt and radial inclination were the same in both groups, the nonbridging
group maintained a significantly better radial length at one year. The authors
concluded that there was no clinically relevant benefit to nonbridging
external fixation in this group of patients, but there should be caution with
interpretation given the small numbers.
Twenty patients with a fracture of the dorsal articular margin of the
distal part of the radius with dorsal radiocarpal subluxation (a reverse
Barton fracture) were evaluated at a mean of thirty months after open
reduction and internal
fixation47.
Surgical findings included major volar injuries, including two torn volar
ligaments, ten rotated volar marginal lip fractures, and six volar articular
impactions. Fourteen of the twenty patients also had impacted central
articular fragments. Eighteen patients underwent surgical reconstruction of
the articular surface and application of a dorsal buttress plate. Nineteen
fractures healed without substantial loss of alignment. The final average
wrist and forearm motion was 59° of flexion, 56° of extension, 87°
of pronation, and 85° of supination. The mean grip strength was 85% of
that of the contralateral, uninjured hand. The final functional result
according to the system of Gartland and Werley was rated as excellent or good
for eighteen patients and fair for two. The average modified Mayo wrist score
was 75 and the average DASH score was 15 points, leading to the conclusion
that despite the complexity of these injuries, satisfactory wrist function can
be achieved with operative treatment in most patients.
In a surgical technique article, twenty-three skeletally mature patients
were evaluated at a mean thirty-eight months after an intra-articular
osteotomy for the treatment of a malunion of the distal part of the
radius48. The
indications for the osteotomy included dorsal or volar subluxation of the
radiocarpal joint in fourteen patients and articular incongruity of =2 mm
as measured on a posteroanterior radiograph in seventeen patients. Six
patients had a combined intra-articular and extra-articular malunion, and the
mean step-off or gap of the articular surface prior to the operation was 4 mm.
The average interval from the injury to the osteotomy was six months. With
regard to reoperations, one patient had partial wrist arthrodesis because of
radiocarpal arthrosis, three patients had additional surgery because of
dysfunction of the distal radioulnar joint, and one patient had tendon
transfer because of a rupture of the extensor pollicis longus. After healing
of the osteotomy site, the mean articular incongruity averaged 0.4 mm.
Clinical results included a final grip strength that averaged 85% of that on
the contralateral side. The rate of excellent or good results was 83%
according to the rating system of Fernandez and that of Gartland and Werley.
The authors pointed to the comparable results with extra-articular osteotomies
of the distal part of the radius and noted that an intra-articular osteotomy
may limit the need for a salvage procedure such as arthrodesis.
Lower Extremity
Proximal Part of the Femur
Perhaps one of the most significant movements in fracture care over the
past decade has been the trend away from internal fixation of femoral neck
fractures in the elderly. This trend seems to have resulted not from the
relative performances of a healed fracture with a well-perfused femoral head
and a hemiarthroplasty or total hip arthroplasty but from the occurrence of
complications such as nonunion and osteonecrosis in >30% of patients. A
Cochrane review of all randomized controlled trials that have compared
internal fixation with arthroplasty for the treatment of intracapsular femoral
fractures in adults did not lend clear-cut evidence for this modern trend away
from internal
fixation49. After
screening for trial quality, seventeen randomized, controlled trials involving
2694 participants were included. The results of the review demonstrated
significant decreases in the duration of surgery, the amount of blood loss,
the need for blood transfusion, and the rate of deep wound infection for
internal fixation relative to arthroplasty; however, arthroplasty had a lower
reoperation rate in comparison with fixation. There were no clear differences
in terms of the length of hospital stay, mortality, or return to residence
status. There was a suggestion from some studies that arthroplasty was
associated with lower rates of pain and higher function. The authors concluded
that future trials need to focus better on measuring functional outcome to
decipher appropriate patient selection for each procedure.
The complexity of this debate on the best method for the treatment of
intracapsular hip fractures is underscored by diverging conclusions of a
meta-analysis from Sweden in which fourteen randomized controlled trials
involving 2289 patients between 1966 and 2004 showed that primary arthroplasty
leads to significantly fewer major complications of surgery, including
infection, and fewer
reoperations50. As
in the previous review, however, there was no significant difference in
mortality at thirty days or one year between the two groups. The authors
stated that most of the studies demonstrated better function and less pain
after primary arthroplasty.
The debate has shifted during the past couple of years to whether either a
hemiarthroplasty or total hip arthroplasty provides a superior treatment
option. In one prospective randomized study comparing these treatment options,
eighty-one patients who had been mobile and had lived independently before
sustaining a displaced fracture of the femoral neck were randomized to each of
these two treatment
groups51. The mean
age of the patients was seventy-five years, and the mean duration of follow-up
was three years. Total hip arthroplasty conferred superior short-term clinical
results as demonstrated by greater walking distance (3.6 compared with 1.9 km;
p = 0.039) and a lower Oxford hip score (p = 0.033). Furthermore, twenty of
thirty-two living patients in the hemiarthroplasty group had radiographic
evidence of acetabular erosion at the time of the final follow-up. Two
patients required revision to a total hip arthroplasty, and three additional
hips had acetabular erosion severe enough to warrant revision. In contrast,
there were three dislocations in the total hip arthroplasty group and none in
the hemiarthroplasty group. Overall, the authors concluded that a total hip
arthroplasty conferred a better functional outcome with fewer short-term
complications.
Another meta-analysis focused attention on the use of cement (as opposed to
press-fit fixation) in the treatment of femoral neck fractures with
arthroplasty52.
Seventeen trials involving 1920 patients were included, although there were
few direct comparisons in trials in which the components were a controlled
variable. In comparison with uncemented prostheses, cemented prostheses were
associated with less pain at one year or later and demonstrated a tendency
toward better mobility. No significant difference in surgical complications
was found. In two trials involving 232 patients, hemiarthroplasty without
cement was compared with total hip replacement. Both studies demonstrated
increased pain for the uncemented prosthesis, and one study demonstrated
better mobility and a lower long-term revision rate for patients managed with
total hip arthroplasty. In two trials involving 214 participants,
hemiarthroplasty with cement was compared with total hip replacement. Both
trials demonstrated little difference between prostheses except a slightly
longer surgical time and a tendency toward better function in the total hip
arthroplasty group. The authors of that meta-analysis concluded that cementing
a prosthesis in place may reduce postoperative pain and lead to better
mobility.
In summary, arthroplasty with cement seems to have emerged as the preferred
solution for the treatment of femoral neck fractures in the elderly. It is
important to realize, however, that these studies ultimately are comparing any
type of internal fixation with any type of arthroplasty (over four decades) as
well as the myriad of surgical techniques and approaches associated with such
operations. These variables leave plenty of room for speculation as to whether
a native hip with a well-fixed fracture without complications would
out-perform an arthroplasty over the long term. Indeed, future studies need to
focus on this remaining question to sort out appropriate roles for these
various techniques.
There has been no debate on the use of arthroplasty as opposed to internal
fixation for the treatment of extracapsular hip fractures; rather, the debate
has centered around types of internal fixation. In a randomized controlled
trial from Nepal, published in the British volume of The Journal of Bone
and Joint Surgery, the sliding hip screw was compared with three months
of external fixation for the treatment of intertrochanteric hip fractures in
sixty-seven patients with a mean age of sixty-six
years53. With the
two groups being matched according to age and gender, the results revealed
that the time to surgery, the duration of surgery, the amount of blood loss,
the length of hospital stay, and the cost of treatment were all significantly
higher in the sliding hip screw group. There was no significant difference at
six months with regard to the time to union, the range of hip motion, the mean
Harris hip score, or the quality of reduction of the fracture. Although
pin-track infections occurred in 60% of the patients with external fixators,
there was no difference in the rate of deep infection. Interestingly, all
patients managed with external fixation had local anesthesia during the
operation, whereas all patients in the internal fixation group underwent
regional anesthesia. These results may support the idea that external fixation
could be the most viable option in societies in which resources are scarce.
These results also corroborate previous evidence on the viability of external
fixation for the treatment of intertrochanteric hip fractures and collectively
seem to indicate that a quest for some internal fixation device that maintains
femoral neck length and neck-shaft angle may indeed be the goal.
Although the sliding hip screw has remained the gold standard for the
treatment of intertrochanteric fractures, there has been greater recognition
of poor outcomes in the elderly population. A greater understanding of the
variables that portend a poor prognosis is therefore critical. In the third
study in as many years to point to the integrity of the lateral cortex of the
proximal part of the femur as being the critical variable in surgical outcome,
214 consecutive patients with an intertrochanteric fracture that was treated
in Denmark with a 135° sliding compression hip screw with a four-hole
side-plate were
studied54. Only
five (3%) of 168 patients with an intact lateral femoral wall postoperatively
underwent a reoperation within six months, whereas ten (22%) of forty-six
patients with a fractured lateral femoral wall underwent reoperation (an eight
times higher risk). Furthermore, 74% of the detected fractures of the lateral
femoral wall occurred during the operative procedure itself, with such a
fracture occurring in 31% of the ninety-nine patients with a fracture of the
lesser or greater trochanter. It is notable that the implant position (tip
apex distance) was also found to have an effect (although lesser) on the
reoperation rate but a fractured lesser trochanter did not.
A relatively high rate of reoperation has been associated with Gamma
nailing of trochanteric fractures. In a study involving a consecutive series
of 554 patients, the outcomes for fifty-two patients who had a reoperation
because of the failure of a Gamma nail were compared with those for the
remaining 502 patients who had no
reoperation55. The
most common reasons for a reoperation were a new fracture around the implant
(seventeen), local pain after a healed fracture (eleven), nonunion (nine), and
cut-out (eight). A second reoperation was required in nine (17%) of the
fifty-two patients. The mortality was significantly lower at thirty days and
at one to five years in the patients who underwent a reoperation, and there
were no significant differences in independent walking ability or pain,
indicating that reoperation did not lead to a worse clinical outcome. As the
rate of loss to follow-up was 30% and the patients who had a reoperation were
still subjected to a second episode of perioperative morbidity and mortality,
these results must be interpreted with caution.
With the advent of treatments for osteoporosis comes a newly identified
fracture that is associated with the use of alendronate, the potent inhibitor
of bone resorption that is indicated for this condition. A retrospective
review of consecutive patients who presented with a low-energy subtrochanteric
fracture identified thirteen patients, all of whom were female and nine of
whom were receiving long-term alendronate
therapy56. The
minimum treatment period with the drug was 2.5 years, although six patients
had been treated for more than four years. The mean age at the time of
presentation was 66.9 years in the alendronate group, compared with 80.3 years
in the group of patients who were not managed with alendronate. The
characteristic "alendronate fracture" occurred at the femoral
metaphyseal-diaphyseal junction, and four occurred with no trauma at all; in
fact, five of the nine patients had had prodromal pain in the affected hip in
the months preceding the fall. Three patients had a stress reaction in the
cortex in the contralateral femur. That study suggested that prolonged
suppression of bone remodeling with alendronate may be associated with a new
form of insufficiency fracture of the femur, indicating a need for caution in
the long-term use of this drug and patient education around warning signs for
the fracture. More research is needed to determine the risk of a fracture in
patients managed with alendronate as well as the sequelae of cessation as
opposed to continuation of treatment.
As the average life span increases, operations in nonagenarians are
becoming commonplace. In one study, fifty patients with an age of more than
ninety-five years (mean age, 98.1 years) who underwent surgery for the
treatment of a fracture of the hip were compared prospectively with a control
group of 200 consecutive patients with an age of less than ninety-five years
(mean age, 81.3 years) who had a similar
operation57. The
mortality rate at twenty-eight and 120 days was higher in the group of
patients who were more than ninety-five years old and, in fact, 36% (eighteen)
of the patients in that group died within twenty-eight days after the
fracture. However, by one year, postoperative mortality was not significantly
different between the two groups, nor was it significantly different from the
standardized mortality rate for the age-matched population. Not surprisingly,
other predictors of mortality included the American Society of
Anesthesiologists (ASA) grade, the number of comorbid medical conditions, and
active medical problems at the time of admission. Of the patients in the study
group, 62% lived independently prior to admission. This rate had decreased to
12% at twelve months after surgery, compared with 46% in the control group
during the same time-period. Although the results of surgery are rather dire
in this age-group, it can be concluded that a palliative operation seems
warranted and that good results are still possible.
Femoral Shaft
A prospective cohort study of 108 patients that was conducted at four
Level-I trauma centers compared differences in the treatment of femoral shaft
fractures with use of two different antegrade intramedullary nail
designs58. One type
was designed for a piriformis entry, and one type was designed for a
trochanteric femoral entry. Thirty-seven of the thirty-eight fractures from
the trochanteric entry group and fifty-two of fifty-three fractures from the
piriformis entry group went on to union. There were no significant differences
in terms of alignment or functional outcome, but differences were identified
in terms of operative time and fluoroscopy time, with both being greater in
the piriformis entry group. Not surprisingly, the operative time was 30%
greater and the fluoroscopy time was 73% higher for patients who were
considered to be morbidly obese. Although the main limitation of the study
seems to be that it was nonrandomized, thus allowing for patient selection
bias, the results seem to support trochanteric femoral entry given new designs
that accommodate the anatomy of the proximal part of the femur.
In a study from Boston Medical Center, a protocol was developed and
instituted to decrease the prevalence of missed femoral neck fractures in
patients with a femoral shaft
fracture59. The
protocol consisted of a dedicated anteroposterior internal rotation
radiograph, a fine (2-mm)-cut computed tomographic scan through the femoral
neck, and an intraoperative fluoroscopic lateral radiograph prior to an
intramedullary nailing procedure. Postoperative anteroposterior and lateral
radiographs of the hip were made in the operating room before awakening the
patient. Two hundred and fifty-four of 268 patients were followed for at least
two months after the institution of the protocol, and sixteen were found to
have an associated ipsilateral femoral neck fracture. Thirteen associated
femoral neck fractures were identified before the patient entered surgery, and
twelve of those were identified with the fine-cut computed tomographic scan.
Five of the twelve fractures that were identified with computed tomography
could not be seen on the preoperative or intraoperative radiographs of the
hip. One fracture was identified intraoperatively before fixation of the
femoral shaft fracture. There was one iatrogenic fracture and one missed
femoral neck fracture, which, even in retrospect, were difficult to diagnose
with a review of the computed tomography scan. Overall, the protocol reduced
the delay in diagnosis by 91% in comparison with the experience at the same
institution in the year prior to the initiation of the protocol, thus
demonstrating the value of a rigorous protocol for the detection of this
potentially devastating injury.
Periprosthetic Femoral Fractures
This new section on the salvage of periprosthetic femoral fractures
features two articles on fractures around the femoral stem of a hip
arthroplasty and one that looked at periprosthetic fractures of the knee
and/or hip treated with locking plates.
The first study was an epidemiologic snapshot of periprosthetic hip
fractures from The Swedish National Hip Arthroplasty Register, which features
one database for primary arthroplasty and another for revision
arthroplasty60.
Three hundred and twenty-one periprosthetic fractures that were reported
between 1999 and 2000 provided the basis for this survey. Ninety-one patients
(mean age, 73.8 years) sustained a fracture after at least one revision
procedure, and 230 patients (mean age, 77.9 years) sustained a fracture after
a primary total hip arthroplasty. Surprisingly, a high percentage of patients
in both groups (66% in the primary replacement group and 51% in the revision
group) had a loose stem at the time of the fracture. The vast majority of the
fractures were Vancouver type-B2 fractures (fractures around the tip of a
loose stem). The authors concluded that high-risk patients should have routine
radiographic follow-up in an effort to preempt periprosthetic fractures with
an earlier diagnosis of loose implants.
In a study by Ricci et al., the application of indirect reduction with
lateral plate fixation and no bone-grafting or strut allografts was used for
fifty consecutive patients with a femoral shaft fracture about a stable
intramedullary implant (a Vancouver type-B1
fracture)61.
Forty-one of the forty-six survivors were available for follow-up at an
average of two years postoperatively. All fractures healed in satisfactory
alignment, although these data were not detailed, at an average of twelve
weeks. Follow-up revealed that one patient had a broken cable and two patients
had one fractured screw, but all of the fractures healed without evidence of
implant loosening. Thirty of the forty-one patients returned to their baseline
ambulatory status.
Further support for an indirect fracture reduction for this problem is
found in the second study, by O'Toole et al., in which the Less Invasive
Stabilization System was used for the treatment of twenty-four patients with
periprosthetic fractures around the hip or knee over a two-year
period62. All
patients were female, with an average age of 79.5 years, and there were no
loose arthroplasty components. Ten patients had an ipsilateral hip
arthroplasty, nine had a total knee arthroplasty, and five had both. At an
average of forty-eight weeks of follow-up, eighteen of nineteen fractures in
the surviving group healed uneventfully, for a complication rate of 5.2%. One
fracture was complicated by hardware pullout and was revised with a longer
device and healed. There was malalignment of >5° in twelve patients,
underscoring the challenges of indirect fracture reduction techniques.
Distal Part of the Femur, Knee, and Proximal Part of the Tibia
Moving to the treatment of acute fractures around the knee, a new twist in
locked plating designs emerged with the first published report of the use of
variable angled locked screws with these
plates63. That
study involved a heterogenous group of fifty-six fractures of the distal part
of the femur and proximal part of the tibia that were treated by five surgeons
with use of various techniques, with 27% of the patients being managed with
bone-grafting and 29% being managed with open (as opposed to percutaneous)
plating with use of the POLYAX Locked Plating System (DePuy Orthopaedics,
Warsaw, Indiana). After a minimum duration of follow-up of six months, the
authors reported a 94% union rate, a 6% infection rate, no mechanical
complications, and no evidence of varus collapse or screw cutout, results that
were similar to those associated with other fixed-trajectory locked plating
techniques.
The next several papers focused on mostly high-energy injuries to the
tibial plateau, emphasized different approaches to this clinical challenge,
and collectively seemed to indicate that progress has occurred with a fracture
that has a dubious history for wound complications. Rademakers et al. reported
the longest-term follow-up in a study of 202
patients64. All
patients were followed for at least one year; at that time, the rate of union
was 95% and the patients had recovered a mean knee range of motion of 130°
(range, 10° to 145°). One hundred and nine patients (54%) had
long-term follow-up (mean, fourteen years). Conventional open techniques and
nonlocked implants were used for treatment. Of the original 202 fractures,
sixty-nine percent of the fractures were monocondylar, and 31% were
bicondylar. We will focus on the long-term follow-up group in this report,
although importantly, ten patients were excluded from the analysis because of
the fact that they had had salvage procedures because of an undesirable
clinical result. The mean range of knee motion at the time of the most recent
follow-up was 135°. Functional results showed a mean Neer score of 88.6
points and a mean Hospital for Special Surgery score of 84.8 points, with
monocondylar fractures showing significantly better functional results in
comparison with bicondylar fractures. Secondary osteoarthritis had developed
in 31% of the patients, but it was well tolerated in most (64%) of these
cases. Patients with malalignment of >5° had development of a moderate
to severe grade of osteoarthritis relative to the well-aligned group, and age
did not appear to influence radiographic or clinical results.
Along the same theme of satisfactory clinical results, a study by Barei et
al. showed the merit of anterolateral and posteromedial surgical approaches
for dual plating of comminuted bicondylar tibial plateau
fractures65.
Eighty-three of these fractures, of which 13% were open, were followed for a
mean of fifty-nine months. The authors found that a satisfactory articular
reduction was significantly associated with a better Musculoskeletal
Functional Assessment score. Rank-order fracture severity was also predictive
of the Musculoskeletal Functional Assessment score, but no association was
identified between rank-order severity and a satisfactory articular reduction.
The authors concluded that the combined medial and lateral approach yielded
acceptable results, that it allowed for an anatomic articular reduction about
half of the time, and that an anatomic reduction was associated with better
outcomes within the confines of the injury severity.
The following two studies, which demonstrated starkly different clinical
results at different centers, challenge the recent published track record for
plate fixation of tibial plateau fractures. In the first, a multicenter,
prospective, randomized trial, by the Canadian Orthopaedic Trauma group,
standard open reduction and internal fixation with use of medial and lateral
plates was compared with percutaneous or limited open fixation and application
of a circular fixator for the treatment of displaced bicondylar tibial plateau
fractures66.
Eighty-three fractures were randomized, and no significant differences were
found between the groups in terms of demographic characteristics or fracture
severity. Not surprisingly, the circular fixator group had significantly less
estimated blood loss and less inpatient hospital time. There was a statistical
trend for patients in the circular fixator group to have superior early
outcome in terms of Hospital for Special Surgery scores at six months and the
ability to return to preinjury activities at six and twelve months. The arc of
knee motion and functional outcome measures revealed no significant
differences between the two groups at two years postoperatively. There was an
18% rate of deep infection in the open reduction and internal fixation group
as well as more than twice the number of repeat unplanned surgical procedures
(thirty-seven compared with sixteen).
The second report, by Phisitkul et al., underscores the potential danger of
open reduction and internal fixation of tibial plateau fractures as well as
the pitfalls associated with the technique of minimally invasive
plating67. In that
study, only twelve (32%) of thirty-seven fractures healed without any
complications. This sobering report demonstrated a 22% rate of infection (with
five infections requiring hardware removal), a 22% rate of postoperative
malalignment, and an 8% rate of varus collapse. Nine additional complications
were noted in that retrospective review of bicondylar tibial plateau fractures
treated with a locked plate.
Tibial Shaft
Nork et al. previously described the successful treatment of distal-quarter
tibial shaft fractures with intramedullary nail fixation. During the past
year, they reported on the treatment of proximal-quarter tibial shaft
fractures using the same
technique68.
Thirty-five patients with thirty-seven fractures were managed primarily with
intramedullary nail fixation of proximal-quarter tibial fractures. The average
distance from the proximal articular surface to the fracture was 68 mm, but
the nail used in the study allowed for the placement of four proximal locking
screws within 4.5 cm of the proximal nail. Acceptable alignment was obtained
in thirty-four of thirty-seven fractures. Two patients with open fractures
underwent a planned, staged iliac crest autograft procedure postoperatively,
and four other minor secondary procedures were performed to achieve union.
Among the thirty-three fractures that were followed, there was a 100% union
rate, and no patient had any change in alignment at the time of the most
recent radiographic evaluation. There were two deep infections, both of which
resolved after treatment. The authors described a host of tricks and
techniques to accomplish reduction in patients with this difficult
fracture.
Kakar and Tornetta performed a prospective study of sixty-two consecutive
patients who had a segmental tibial fracture that was treated with an unreamed
tibial nail69.
Fifty-eight percent of the fractures were open (10% bifocally). Fractures that
were associated with >50% cortical bone loss were not included in this
analysis. Of the fifty-one fractures that could be followed, forty-six
achieved primary union. There were no deep infections or instances of nail or
screw breakage in the series, and knee pain occurred in fourteen patients
(27%). The authors described the execution and nuances of this operation,
providing an effective roadmap for the treatment of this difficult injury with
use of an unreamed nailing technique.
Two novel technologies have more recently gained attention in the
literature. The first was featured in a prospective randomized study of
fifty-three patients with diaphyseal tibial fractures, by a group from Tel
Aviv, Israel, who compared fracture fixation with use of either an
interlocking intramedullary nail (Mathys, Bettlach, Switzerland) or an
expandable tibial nail (Fixion DiscoTech Medical Technologies, Herzliya,
Israel)70. The
expandable nail is made by connecting four longitudinal stainless steel struts
interconnected with a stainless ribbon, which allows for expansion to fit the
medullary canal when inflated with saline solution to a pressure of 70 bar. It
avoids the need for interlocking screws. The minimum duration of follow-up in
the study was two years. Union was achieved after a mean of seventeen weeks in
the interlocking nail group and after a mean of 11.5 weeks in the expandable
nail group. Reoperation was required in nine patients in the interlocking nail
group and one patient in the expandable nailgroup. Although the expandable
nail hardware cost 30% more, there was a 39% reduction in overall surgical and
hospital expenses in association with its use. The authors recommended this
nailing system on the basis of the simplicity of its use, economic savings,
and possible clinical advantages, including biological advantages and less
need for hardware removal.
The second novel technology in tibial fracture care was assessed in a
retrospective, consecutive series of forty-nine patients with fifty Gustilo
and Anderson type-III open tibial shaft
fractures71.
Negative-pressure wound therapy technology (Wound Vacuum Assisted Closure
[V.A.C.] System; Kinetic Concepts, San Antonio, Texas) was used in each case
before definitive wound closure or flap coverage. The rate of deep infection
was 8.3% for type-IIIA open fractures, 45.8% for type-IIIB fractures, and 50%
for type-IIIC fractures, although twelve fractures needed free or local tissue
transfer for coverage. Twenty-four (48%) of fifty fractures required
subsequent surgery to facilitate fracture-healing, a rate similar to that of
historical controls. Patients were managed with a well-accepted protocol of
surgery and antibiotics during the initial treatment period, but the negative
pressure wound therapy did last for a mean 12.7 days, with the dressings being
changed every two to four days until the time of definitive closure. The
authors presented a candid sobering report that underscored the advice of many
in the field that while negative pressure wound therapy is a nice adjunct to
treatment, it is not a panacea, nor can it replace foundational principles in
the treatment of open fractures.
Foot and Ankle
During the past year, there was a relative paucity of material published on
foot and ankle trauma. DeAngelis et al. addressed the question as to whether
medial tenderness predicts deep deltoid ligament incompetence in
supination-external rotation-type ankle
fractures72. That
group prospectively enrolled fifty-five adult patients with a Weber B lateral
malleolar fracture that had a normal medial clear space. All fracture patterns
consistent with a supination-external rotation mechanism were included.
Tenderness in the region of the deltoid ligament was assessed, and an external
rotation stress mortise radiograph was then made. Thirteen patients (23.6%)
had medial tenderness and had a positive external rotation stress radiograph
(>4 mm medial clear space). Thirteen patients (23.6%) had medial tenderness
and had a negative external rotation stress radiograph. Nineteen patients
(34.5%) did not have medial tenderness and had a negative external rotation
stress radiograph. Ten patients (18.2%) did not have medial tenderness and had
a positive external rotation stress radiograph. Thus, there was a 25% chance
that a fracture with medial tenderness would have a positive external rotation
stress test and a 25% chance that a fracture with no medial tenderness would
have a positive stress test. Therefore, the clinician should not rely on
medial tenderness as a measure of deep deltoid ligament incompetence as this
test has very poor sensitivity and specificity as well as a poor positive and
negative predictive value.
Reported complications of open reduction and internal fixation of calcaneal
fractures have been frequent and sometimes devastating in the past, although
more recent studies have suggested that these can be mitigated with meticulous
and conservatively timed surgery in the well-chosen patient. To help to define
the spectrum of treatment, however, a group from the University of Iowa
reported outcomes after the nonoperative treatment of displaced
intra-articular calcaneal fractures that were followed at two intervals a
decade apart over a twenty-year
period73. In 1990,
nineteen patients with twenty-four calcaneal fractures (from an original group
of fifty-four fractures that met inclusion criteria) were assessed with a
computed tomographic scan, radiographs, and the 100-point Iowa calcaneal
score. In 2000, the Iowa calcaneal score was repeated. In 1990, fifteen of
twenty-four feet had a good or excellent result. However, in 2000, the mean
Iowa calcaneal score for the same group of patients had dropped 10 points
(from 74 to 64 points). Subtalar arthrosis seemed to be responsible for the
drop. In 1990, subtalar arthrosis on the computed tomography scan correlated
with a lower average score (64 compared with 82 points). Furthermore, among
patients in whom no or minimal arthrosis was detected on the computed
tomography scan in 1990, the scores remained stable over the second decade.
This likely indicates that articular malreduction of the calcaneus matters
both over the short term and over the long term as patients with grade-III and
IV arthrosis have increased pain and deterioration in function in the second
decade, whereas those without arthrosis can have good and stable outcomes at
more than twenty years.
More recently, there has been a resurgence of interest in percutaneous
techniques for the treatment of calcaneal fractures, although critics have
stated that optimal articular reductions are then sacrificed. Magnan et al.,
from Verona, Italy, combined such percutaneous techniques with the use of a
distractor-fixator device to help to obtain and maintain a better position for
the tuberosity of the calcaneus in a study of fifty-four consecutive closed
displaced
fractures74. The
clinical results at a mean of four years were excellent or good in forty-nine
cases (90.7%), fair in two, and poor in three according to the Maryland Foot
Score. Computed tomography scans demonstrated an excellent result in
twenty-four cases (44.4%), a good result in twenty-five (46.3%), a fair result
in three, and a poor result in two. The authors concluded that this technique
yields comparable results to open reduction and internal fixation, but a
side-by-side comparison is clearly needed to substantiate this claim.
Tables presenting the journals searched for this update and listing the
studies according to Level of Evidence are available with the electronic
versions of this article, on our web site at
(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).
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