Extract
Technological advancements present intriguing new options for the care of orthopaedic trauma patients. These new methods continue to be tested against older, time-tested options. Some of these time-tested methods have been reevaluated with modern scientific vigor. The results of such studies over the last year present insights regarding which new ideas should be adopted and which older methods should be abandoned. This update presents a synopsis of the most clinically relevant high-quality studies related to orthopaedic trauma from the past twelve months. Key methods (♦), results (➢), and take-home points (★) for these studies are presented.
Technological advancements present intriguing new options for the care of orthopaedic trauma patients. These new methods continue to be tested against older, time-tested options. Some of these time-tested methods have been reevaluated with modern scientific vigor. The results of such studies over the last year present insights regarding which new ideas should be adopted and which older methods should be abandoned. This update presents a synopsis of the most clinically relevant high-quality studies related to orthopaedic trauma from the past twelve months. Key methods (♦), results (➢), and take-home points (★) for these studies are presented.
The plethora of reasonable treatment options for fractures of the proximal part of the humerus demonstrates the lack of clear superiority of any one method. Head-to-head comparisons illuminated the relative benefits of various treatments options. Another study investigated whether the introduction of locked plating corresponded with increases in surgery for the treatment of proximal humeral fractures. The potential benefits of open reduction and internal fixation (ORIF) for the treatment of clavicular fractures and the anatomic structures at risk were similarly investigated. The controversy regarding optimum positioning of the shoulder after glenohumeral dislocations inspired further investigation.
Proximal Humeral Fracture: Intramedullary Nail Versus Locked Plate
♦A prospective randomized study included patients in China who were managed with either a locked intramedullary nail (n = 25) or a locking plate (n = 26) for the treatment of a two-part proximal humeral fracture1.➢All fractures healed with no infections. More complications (primarily screw penetration through the humeral head) were seen in the locking plate group (rate of complications, 31%) than the intramedullary nail group (rate of complications, 4%), but outcomes were better for the locking plate group at one year. Outcome scores continued to improve from one to three years postoperatively in both groups.★Locked plating and locked intramedullary nailing are both reasonable treatment options for two-part humeral fractures. If locked plating is chosen, the risk of screw penetration should be minimized.
Proximal Humeral Fracture: Polyaxial Locked Plate Versus Fixed-Angle Locked Plate
♦A prospective randomized study compared the results of polyaxial locked plating (n = 25) with those of standard fixed-angle locked plating (n = 31) for the treatment of three and four-part proximal humeral fractures2.➢Functional outcomes and complications were similar between the groups.★This study showed no verifiable advantage of polyaxial locked plating over standard fixed-angle locked plating for the treatment of proximal humeral fractures.
Proximal Humeral Fracture: Nonoperative Treatment Versus Locked Plate
♦Sixty Swedish patients with a three-part proximal humeral fracture were randomized to either nonoperative treatment or treatment with a locked plate and were followed for two years3.➢Range of motion and function were better in the locked plate group, but 13% of the patients in that group had a complication requiring a major reoperation and 17% had a minor reoperation.★In the absence of complications, locked plating provides better results than nonoperative treatment for three-part proximal humeral fractures.
Proximal Humeral Fracture: Nonoperative Treatment Versus Locked Plate
♦A prospective randomized study conducted in Norway compared nonoperative treatment (n = 25) with angle stable plating (with use of cerclage) (n = 25) for the treatment of three and four-part proximal humeral fractures4.➢Radiographic but not clinical outcomes were better in the operative treatment group at one year. There was electromyographic (EMG) evidence of deltoid injury in both groups. Screw penetration occurred in seven patients in the operative treatment group, and nonunion occurred in two patients in the nonoperative treatment group.★Nonoperative treatment is associated with similar functional results compared with plate fixation for the treatment of three and four-part proximal humeral fractures.
Proximal Humeral Fracture: Treatment Variations
♦A sample of the Medicare database from 1998 to 2000 was compared with a sample from 2004 to 2005 to determine changes in the incidence, treatment, rate of revision, and geographic variation of proximal humeral fracture5. These dates were thought to correspond to time periods before and after the introduction of locking plates.➢The incidence of proximal humeral fracture was unchanged (approximately 2.5 per 1000 beneficiaries), the relative rate of surgically treated fractures rose 25.6% (from 12.5% to 15.7%), the rates increased for both ORIF (28.5%) and hemiarthroplasty (19.6%), there was large geographic variation, and the rates of revision surgery increased (odds ratio = 1.47).★These data indicate that the surgical indications as well as the optimum treatment of proximal humeral fracture would benefit from further refinement.
Clavicular Fracture: Nonoperative Treatment Versus Internal Fixation
♦A prospective nonrandomized cohort study in India included forty-five patients who were managed operatively and twenty-eight who were managed nonoperatively6.➢In the operative treatment group, there were no nonunions and two symptomatic malunions (prevalence, 4%). Both of the malunions were delayed unions that were associated with implant deformation, and both were treated with bone marrow injection. In the nonoperative treatment group, there were eight nonunions (prevalence, 29%), all of which were treated with operative repair, and ten symptomatic malunions (prevalence, 36%) (p < 0.05). Constant scores were better for the operative treatment group (p < 0.05).★Operative treatment of displaced clavicular fractures resulted in better healing and functional outcomes than nonoperative treatment did.
Anatomic Relationship of Structures at Risk During Plating of Clavicular Fractures
♦A cadaveric study examined the location of the subclavian vein and brachial plexus in relation to screws placed through the superior and anteroinferior clavicular plates7.➢Both superior and anteroinferior plate locations resulted in screw tip contact with a major neurovascular structure. Shoulder abduction to 90° increased the distance of the neurovascular structures from the clavicle.★Neurovascular structures are at risk during both superior and anteroinferior clavicular plating. Shoulder abduction may provide added safety.
Shoulder Dislocations
♦One hundred and eighty-eight patients were randomized to immobilization of the shoulder in either internal or external rotation after acute anterior glenohumeral dislocation8.➢There was no difference in the rate of recurrence between the internal rotation group (24.7%) and the external rotation group (30.8%).★The position of immobilization after shoulder dislocation does not appear to affect the recurrence of glenohumeral dislocation.
Classic teaching is that the functional range of elbow motion is 30° to 130° and 50° of both pronation and supination9. This concept was revisited with use of modern measurement techniques and with the inclusion of modern daily tasks. The concept of a 20-mL diagnostic arthrocentesis to identify an elbow arthrotomy was tested with use of a cadaveric model. Also, in a biomechanical comparison study, the compression across an olecranon fracture generated by a tension band construct and a compression plate construct were measured and compared both statically and dynamically with use of a cadaveric model.
Functional Elbow Motion Redefined
♦Twenty-five patients performed daily tasks consisting of six positional tasks, traditional everyday tasks, and modern-day tasks (typing on a computer, using a mouse, and using a cellular phone)10. Movements were measured to determine the functional range of motion of the elbow.➢The positional tasks required approximately 27° to 149° of motion in the frontal plane, 20° of pronation, and 104° of supination. Functional tasks required approximately 23° to 142° of motion in the frontal plane, 65° of pronation, and 77° of supination.★When assessed with use of modern measurement techniques and with the inclusion of contemporary functional tasks, the functional elbow range of motion may be greater than previously thought.
Saline Solution Load Test to Identify Traumatic Arthrotomy of the Elbow
♦A posterior arthrotomy was created in thirty-six cadaveric elbows, and a load test using 20 mL of saline solution was performed11-13. If the saline solution load test with range of motion was negative, the injection was continued until extravasation of fluid was achieved.➢With use of the traditional standard of 20 mL, twenty-six (72%) of thirty-six elbows had a positive result. With the addition of range of motion, five additional positive results were obtained (for a total rate of 86%). In order to achieve a 95% sensitivity, 40 mL of fluid was required.★In order to achieve 95% sensitivity for the detection of an arthrotomy of the elbow, 40 mL of fluid may be needed. The addition of ranging of the elbow may help to increase the sensitivity.
Olecranon Fracture: Tension Band Versus Compression Plate
♦A biomechanical study compared compression forces generated by a tension band (n = 10) and a compression plate (n = 10) for a transverse olecranon fracture14.➢Compression plating achieved a mean static compression of 819 N across the fracture, whereas the tension band generated 77 N. The mean compression at the articular surface was 343 N for the compression plate and 1 N for the tension band. During dynamic testing, the mean compression was reduced by a mean of 14 N for the tension band and 174 N for the compression plate. The tension band construct provided no compression at the articular surface during dynamic testing.★A compression plate construct is able to achieve much greater compression forces across an olecranon fracture when compared with a tension band construct. It is especially interesting that a small amount of compression at the articular surface and the loss of any articular compression during dynamic testing occurred, which is contrary to the tension band principles. Plating may provide superior compression for olecranon fractures.
There is no clear consensus on the optimum treatment of distal radial fractures. A prospective randomized study evaluated the outcome after either volar locked plating or nonoperative care. The utility of formal postoperative occupational therapy was also evaluated for patients managed with operative fixation of distal radial fractures.
Distal Radial Fracture: Treatment in the Elderly
♦A prospective randomized study compared the functional outcomes for patients over the age of sixty-five years who were managed operatively with volar locked plating (n = 36) or nonoperatively with casting (n = 37) for the treatment of a displaced distal radial fracture15.➢Wrist motion was comparable between the groups throughout the study period. The operative treatment group had improved grip strength and alignment when compared with the casting group. The functional scores were better in the operative treatment group in the early period but were similar at the six-month and one-year time points. Complications were more common in the operative treatment group.★Patients over the age of sixty-five years with displaced, unstable distal radial fractures have similar outcomes when treated operatively or nonoperatively. Anatomical reduction did not affect the activities of daily living or ultimate wrist motion.
Distal Radial Fracture: Occupational Therapy Following Operative Fixation
♦A prospective randomized study evaluated the utility of occupational therapy after volar locked plating for the treatment of unstable distal radial fractures. Ninety-four patients were randomized to receive occupational therapy (n = 46) or assigned independent exercises (n = 48)16.➢At three months, patients in the independent exercise group had superior results with regard to pinch strength, mean grip strength, and the Gartland and Werley score. At six months, the independent exercise group had improved wrist extension, ulnar deviation, supination, grip strength, and Mayo scores. Differences in arm-specific disability (as measured with the Disabilities of the Arm, Shoulder and Hand [DASH] score) were similar between both groups at both time points.★Formal occupational therapy does not improve the disability score or improve wrist motion following volar locked plate fixation of a distal radial fracture.
Hip and femoral fractures, while very common, continue to provide questions for surgeons as more detailed treatments in the operative and perioperative phases evolve. Functional consequences of the femoral nail entry point, the utility of multispecialty in-hospital hip fracture care, and hip fracture study citation were critically evaluated. Also, revision arthroplasty was compared with ORIF for the treatment of periprosthetic fractures about femoral stems.
Femoral Intramedullary Nail Entry Points
♦One hundred and ten patients were enrolled in a prospective, randomized trial comparing piriformis fossa and greater trochanteric entry portals for intramedullary nailing for the treatment of femoral shaft fractures17.➢There were slight functional differences at six months and no functional differences at one year. Operative and fluoroscopy time, incision length, and heterotopic ossification rates favored trochanteric entry.★The function of patients with femoral fractures did not vary with the intramedullary nail entry point, but trochanteric entry decreased heterotopic ossification and had operative advantages.♦Seventeen patients were evaluated in a retrospective cohort study of piriformis fossa and greater trochanteric entry for the treatment of subtrochanteric fracture18.➢Piriformis fossa entry was associated with Trendelenburg gait, reinnervation in the superior gluteal distribution, and decreased strength.★Trochanteric entry was associated with less soft-tissue injury and less functional deficit at the hip compared with piriformis fossa entry.
Hip Fracture: Multispecialty Care
♦A retrospective cohort study evaluated 306 patients with a hip fracture who were managed before and after the institution of multidisciplinary inpatient care19.➢New-onset arrhythmia, urinary tract infection, and inpatient complications were decreased with the new service. Readmission rates decreased from 18% to 4% in patients with an ASA (American Society of Anesthesiologists) score of 1 or 2.★Multispecialty inpatient care after hip fracture reduced inpatient complications and, in healthier patients, decreased the rehospitalization rate.♦A prospective cohort study evaluated the effect of multispecialty inpatient care on the treatment of osteoporosis in 137 patients with a hip fracture20.➢Vitamin D, calcium, and bisphosphonate use increased after discharge compared with preadmission and historical controls; 39.4% of the patients kept an appointment with an endocrinologist.★Automating osteoporosis treatment at the time of discharge after hip fracture was effective for increasing treatment rates.
Periprosthetic Fractures: Revision Arthroplasty Versus ORIF
♦In a retrospective analysis of German patients with a periprosthetic femoral fracture, the results for twenty-three patients who were managed with ORIF between 1992 and 2001 were compared with the results for twenty-nine patients who were managed with revision arthroplasty with a modular prosthesis nail between 2001 and 200821.➢The patients who were managed with the modular prosthesis nail, who were allowed immediate full weight-bearing, had decreased total and six-month mortality. Subgroup analysis of Vancouver type-B1 fractures showed a decrease in total mortality but not in six-month mortality.★The immediate weight-bearing associated with revision arthroplasty may be responsible for improved survival; however, improvements in medical and critical care between the two time frames were not accounted for.
Recent studies examined techniques to ensure a proper start site for a tibial nail, attempted to shed light on the phenomenon of anterior knee pain following intramedullary nailing of the tibia, and examined the efficacy of pulsed electromagnetic field stimulators for tibial healing. The utility of computed tomography (CT) scans to help to diagnose occult ankle fractures associated with distal-third tibial fractures was also examined. Other studies included a comparison of intramedullary nailing and plating techniques for the treatment of distal extra-articular tibial fractures and a study evaluating the risk of infection with overlap of the external fixation pin site and the definitive plate construct.
Tibial Intramedullary Nail Start Point
♦A radiographic study of twelve cadaveric tibiae investigated how rotation of the tibia can affect the accuracy of the ideal start site for intramedullary nail insertion22.➢An adequate anteroposterior image of the tibia could be obtained through a 30° arc. Rotation resulted in as much as 15 mm of translation of the starting point. Use of an image in which the fibular head was bisected by the tibial condyle resulted in a start site that was either correct or slightly lateral to the ideal starting point.★The ideal insertion site for a tibial intramedullary nail can be greatly affected by the rotation of the tibia during imaging. With use of a fibular bisector line, a consistent image of the tibia can be obtained to achieve an acceptable start site.
Correlation of Anterior Knee Pain and Fracture Union After Tibial Nailing
♦A retrospective review of prospectively collected data on 428 patients with 443 tibial fractures evaluated the association of anterior knee pain and fracture union23.➢Decreasing anterior knee pain correlated with progressive fracture union. Increasing time from surgery did not correlate with decreasing knee pain.★Decreasing anterior knee pain may be a sign of osseous union following intramedullary nailing of a tibial fracture.
Electromagnetic Field Stimulation for Acute Tibial Fractures
♦In a double-blinded randomized trial, 259 patients with an acute tibial fracture were randomly assigned to treatment with activated and inactivated pulsed electromagnetic field devices. Patients were evaluated for the need for a secondary procedure due to delayed union or nonunion24.★There was no difference in radiographic union or functional outcomes between the groups. Thirty-one patients (29%) in the activated group and thirty patients (27%) in the inactivated group required a secondary procedure within twelve months after the injury.★Pulsed electromagnetic field stimulation of acute tibial fractures demonstrated no reduction in the need for secondary procedures due to delayed union or nonunion.
Ankle Fracture Associated with Distal Tibial Shaft Fractures
♦Sixty-seven distal-third tibial shaft fractures were evaluated for intra-articular fracture extension with use of a CT protocol to assess the ankle25.➢Twenty-nine tibial fractures (43%) were associated with intra-articular fractures: twenty-three posterior malleolar fractures, three anterolateral fractures, and three medial malleolar fractures. Seventeen intra-articular fractures (59%), including four intra-articular fractures (14%) that were not recognized on radiographs, required operative fixation.★Distal-third tibial shaft fractures are associated with a high incidence of ankle fractures that are not readily identified on radiographs. A protocol including an ankle CT scan for distal-third tibial shaft fractures can identify fractures that are missed during the initial evaluation.
Distal Tibial Shaft Fractures: Plate Versus Intramedullary Nail
♦A prospective randomized study compared intramedullary nailing and plating for the treatment of distal extra-articular tibial shaft fractures26.➢There were three infections in both groups, with most infections (83%) occurring after an open fracture. Four patients in the intramedullary nail group and two patients in the plate group had development of a nonunion, with a trend toward nonunion in patients who had fibular fixation. All nonunions were associated with an open fracture. Malalignment of >5° occurred in thirteen patients (23%) in the intramedullary nail group and four patients (8.3%) in the plate group. The rate of secondary procedures was equal in both groups, and all secondary procedures were related to prominent implants.★Distal extra-articular tibial shaft fractures can be successfully treated with both intramedullary nailing and plating. Both treatment groups had similar rates of infection, nonunion, and secondary procedures. Intramedullary nailing was associated with more malalignment than plating was.
Risk of Infection at the Overlap of External Fixation Pin Sites and Plates
♦The risk of infection was evaluated in a retrospective review of seventy-nine tibial plateau fractures that were initially treated with spanning external fixation followed by delayed ORIF27.➢Six patients (7.6%) had development of a deep infection that required secondary surgical procedures and intravenous antibiotics. Three of these patients initially had open fractures, and three had closed injuries. Of the six patients with infections, two had overlap of the plate and pin sites. The distance from the end of the plate to the pin site did not correlate with a higher infection rate, nor did a history of an open fracture, time in the external fixator, fracture classification, patient sex, age, or healing outcome of the fracture.★There does not appear to be an increased risk for infection related to pin site and plate overlap. The concern of overlap of the external fixation and the anticipated zone of fixation should not supersede placement of a stable external fixation construct.
The accuracy of intraoperative syndesmotic stress tests has come into question recently. In addition, many risk factors for complications following ankle fracture treatment are not under surgeon control, but achieving smoking cessation immediately before or after ankle fracture surgery may substantially decrease the rate of deep infection. The Hawkins classification of talar neck fractures was devised on the basis of the risk of osteonecrosis, although recent series have demonstrated far lower osteonecrosis rates than originally reported. Highly sensitive imaging techniques evaluating the blood supply of the talus provide a potential explanation for the lower osteonecrosis rates. Finally, pilon fractures can be devastating injuries, and, although anatomic fracture reduction may be an important factor for achieving a good outcome, other factors, such as articular cartilage injury, may play a more important role.
Ankle Fractures: Intraoperative Testing of the Syndesmosis
♦Surgeon-performed hook and external rotation tests were compared prospectively with a standardized external rotation test (control) for the ability to accurately diagnose syndesmotic injury after fixation of supination-external rotation ankle fractures28.➢Seventeen percent of patients had syndesmotic instability on the basis of the standard. The sensitivity and specificity of the hook test were 0.25 and 0.98, respectively, and the corresponding values for the external rotation test were 0.58 and 0.96, respectively.★Traditional intraoperative syndesmotic stress tests have low sensitivity, and additional tests may be necessary to accurately diagnose syndesmotic injuries. These may include standardized sagittal plane stress tests. The clinical relevance of the spectrum of injury and repair of the syndesmosis remains poorly understood.
Ankle Fractures: Risk Factors for Complications
♦A consecutive series of 906 operatively treated ankle fractures were retrospectively analyzed to determine risk factors for postoperative complications29.➢In the group of patients who smoked (n = 185), the rates of all complications (30%) and deep wound infections (5%) were significantly increased compared with those in nonsmokers.★As with many fractures and soft-tissue injuries, smoking increases the complication rate substantially. Preoperative and immediate postoperative smoking cessation counseling is paramount in these cases.
Talus Vascularity
♦Gadolinium-enhanced magnetic resonance imaging (MRI) and gross dissection after latex injection were used to study the vascularity of the talus30.➢The peroneal artery contributed 17% of the talar blood supply, the anterior tibial artery contributed 36%, and the posterior tibial artery contributed 47%. Additionally, a rich intraosseous anastomotic vascular network was identified.★A large proportion of talar vascularity arises from posterior vessels. This may explain the lower rate of osteonecrosis seen following talar neck fractures with use of modern treatment principles as compared with historical reports.
Pilon Fractures: Chondrocyte Viability
♦Seven human ankle specimens were harvested immediately after amputation, and an impaction injury was applied to simulate a pilon fracture. Chondrocyte viability was assessed in various regions at various time points31.➢Chondrocyte death was greatest at the edges of the articular fracture. Additionally, chondrocyte death in the articular cartilage progressed faster over the subsequent forty-eight hours at the fracture-edge region.★Despite advances in osseous reconstruction in pilon fractures, chondrocyte death from impact as well as accelerated death from the moment of impact onward remain a substantial clinical problem and are a high-priority target for therapeutic intervention.
Controversy persists regarding many aspects of the surgical indications for and methods of the stabilization of pelvic ring injuries. Determining “instability” of a pelvic ring injury, i.e., one that is likely to displace without operative fixation, can be challenging. Radiographic features have been identified that help to predict displacement with nonoperative treatment and that may help to define surgical indications. A novel subcutaneous construct that provides a new option for anterior pelvic fixation was described. The accuracy of articular reduction in patients with displaced acetabular fractures is known to affect long-term joint function. Specific challenges in obese patients and the effect of patient positioning on obtaining accurate reductions were described.
Pelvic Ring Injuries: Displacement Risk
♦One hundred and seventeen minimally displaced high-energy lateral compression pelvic ring injuries with an associated sacral fracture were treated nonoperatively with immediate weight-bearing as tolerated and were followed until union. Injury-related factors that predicted subsequent displacement were retrospectively determined32.➢Overall, twenty-three fractures displaced. Complete sacral fractures (those that involved the ventral and dorsal cortex) in conjunction with bilateral ramus fractures displaced 68% of the time. Complete sacral fractures with unilateral ramus fractures displaced 33% of the time. Incomplete sacral fractures and those without ramus fractures did not displace.★Radiographic features allow for the prediction of displacement, and may alter the surgical treatment of lateral compression pelvic fractures. The functional implications of healed pelvic deformity remain to be fully determined.
Pelvic Ring Injuries: Anterior Internal Fixator
♦Twenty-four vertically and rotationally unstable pelvic fractures were treated with appropriate posterior fixation and a subcutaneous anterior internal fixator consisting of spinal pedicle screws in the anterior inferior iliac spine and a subcutaneous connecting rod. Complications and maintenance of reduction were prospectively recorded33.➢All fractures healed, and complications were minimal. The vast majority of patients were able to sit, stand, and roll on their side. Nursing care was much simplified. A majority of the anterior fixators were ultimately removed.★This novel technique is a potential advance in the surgical treatment of unstable pelvic ring injuries. This technique may be a viable option in lieu of definitive pelvic external fixation or anterior internal fixation. The role of this technique in the acute treatment of the unstable patient remains to be defined. Another CT-based study identified the proximity of critical soft tissues to these constructs34.
Acetabular Fractures: Effect of Patient Position
♦Sixty-six patients with transverse acetabular fractures were managed with a Kocher-Langenbeck approach in either the prone (n = 33) or lateral (n = 33) position. Reduction quality and perioperative variables were analyzed retrospectively to compare the two patient positions35.➢The average residual displacement was 1.3 mm in the prone group, compared with 2.1 mm in the lateral group (p = 0.08). There were no differences in operative time or blood loss.★Gravity forces of the proximal part of the femur on the caudal segment of transverse fractures can complicate reduction. Prone positioning may facilitate more accurate reductions than lateral positioning.
Acetabular Fractures: Effect of Obesity
♦Two hundred and forty-two patients with acute displaced acetabular fractures were managed surgically. Of these, 149 were obese and ninety-three were non-obese. Reduction quality was assessed with radiographs and CT scans to retrospectively compare the groups36.➢On CT scanning, anatomic reduction was achieved in 47% of non-obese patients and 44% of obese patients. Subgroup analysis demonstrated anatomic reduction in 31% of morbidly obese patients.★Similar reduction accuracy can be achieved in obese compared with non-obese patients. However, this is often technically more difficult given the larger soft-tissue envelope and difficulty obtaining windows for clamp and implant placement.
New data suggest that techniques allowing early weight-bearing after geriatric ankle fractures may decrease the morbidity associated with extended weight-bearing restrictions. Biological approaches to expedite healing of geriatric pelvic fractures appear to be promising. Percutaneous methods of implant placement may provide clinically important benefits in the treatment of hip fractures. Iatrogenic lateral trochanteric wall fractures have been recognized to be related to complications when a sliding hip screw implant is used.
Geriatric Ankle Fractures: Early Weight-Bearing
♦Thirty-six patients with an age of more than seventy years who had malleolar ankle fractures were managed with intramedullary wires and plates and screws augmented with methylmethacrylate and were allowed early weight-bearing at approximately two weeks postoperatively37.➢There was no loss of fracture reduction or displacement of the ankle mortise. All fractures were healed by six months in the surviving patients.★This technique of augmented geriatric ankle fracture fixation may allow for earlier weight-bearing return to function.
Geriatric Pelvic Fractures: Benefits of Parathyroid Hormone
♦Sixty-five patients with osteoporosis who sustained a pelvic fracture were randomized to receive parathyroid hormone treatment (PTH 1-84) or no treatment. Fracture-healing was assessed with use of serial CT scans, and function was assessed with a visual analog scale (VAS) and the timed up-and-go (TUG) test38.➢At Week 8, 100% of fractures in the PTH group and 9% of fractures in the control group had healed. Both the VAS score and the TUG score were significantly better in the treatment group.★This study demonstrates the potentially powerful fracture-healing effects of intermittent parathyroid hormone in cases of fractures that may otherwise require prolonged healing times.
Geriatric Hip Fractures: Lateral Wall Fracture
♦Two hundred and forty-one patients with an intertrochanteric hip fracture were managed with either a standard screw-side plate device with a large lag screw or a percutaneous plate-screw device with a smaller-diameter femoral head implant. Lateral trochanteric wall fracture was assessed39.➢Twenty percent of patients who were managed with the large lag screw device developed a lateral trochanteric wall fracture, compared with 1.4% of those who were managed with the smaller device.★Intraoperative lateral trochanteric wall fracture can alter the mechanics of a sliding hip screw device, rendering the lateral buttress incompetent. This can lead to excessive shortening at the fracture site and should be avoided when possible.♦A prospective randomized study of sixty-six intertrochanteric hip fractures compared standard sliding hip screws with a percutaneously inserted device with two screws into the femoral head40.➢The percutaneous device allowed for shorter operative times (forty-eight compared with seventy-eight minutes) and less blood loss (40 compared with 100 mL), which led to fewer transfusions. Functional outcomes were at least equivalent compared with those associated with the standard technique and implant. The mortality rate was lower in the percutaneous group (15% compared with 27%), although this difference was not significant (p = 0.22).★Percutaneous fixation of geriatric intertrochanteric hip fractures may have subtle but clinically important benefits.
Animal studies investigated strategies to minimize infection associated with external fixation. Clinical studies compared methods to achieve docking-site union after distraction osteogenesis, the utility of bone morphogenetic protein-2 (BMP-2) used with reamed nailing of open tibial fractures, the optimal pressure for open fracture lavage, and the benefits of incisional negative-pressure wound therapy.
External Fixation Pin Sites
♦The antibacterial activity of nitric oxide (NO)-coated external fixation pins was tested in a rat model41.➢Bacterial colony counts of the NO-coated pins were significantly (five to tenfold) lower than controls.★External fixation pins coated with NO can inhibit bacterial colonization and may have the potential to reduce associated pin-site infection.
Docking-Site Healing After Distraction Osteogenesis
♦A retrospective study of forty-nine patients compared three methods for promoting docking-site healing after distraction osteogenesis of the tibia: compression, surgical debridement plus autologous bone-grafting, and surgical debridement plus bone marrow concentrate and demineralized bone matrix (DBM)42.➢Healing time was longer for compression than for bone marrow concentrate and DBM. No differences were found when the other groups were compared.★Bone marrow concentrate and DBM appear to be a viable alternative to autologous bone graft to promote docking-site healing.
BMP-2 in Open Fractures
♦A prospective randomized study compared reamed tibial nailing of open fractures with and without use of adjuvant BMP-243.➢There were no significant differences between the groups in terms of healing, the need for secondary procedures, or complications.★In contrast to previous studies of unreamed tibial nailing, healing of open tibial fractures after reamed nailing was not significantly improved by the addition of BMP-2.
Lavage for Open Fractures
♦A prospective randomized study compared wound treatment with either castile soap or normal saline solution delivered at either high or low pressure44.➢There were no significant differences in outcomes between groups; however, there was a trend toward advantage associated with low-pressure delivery.★This pilot study suggests that low-pressure lavage may be better than high-pressure lavage and that castile soap and saline solution are equally effective during irrigation of open fractures.
Incisional Negative-Pressure Wound Therapy
♦A prospective randomized study compared standard wound dressings with prophylactic negative-pressure dressings for patients with high-risk lower extremity fractures45.➢Negative-pressure dressings resulted in fewer infections than standard dressings.★Negative-pressure wound dressings should be considered for patients with high-risk lower extremity fractures.
Cognitive impairment after polytrauma and various aspects of compartment syndrome were investigated during the last year.
Cognitive Impairment after Polytrauma
♦A prospective cohort of 108 patients with polytrauma who were admitted to the intensive care unit underwent neuropsychological testing at one year46.➢Ventilation days, reamed intramedullary nailing, emergency department hematocrit, emergency department blood pressure, and twenty-four hour transfusion requirements were associated with cognitive impairment on bivariate analysis (p < 0.05). Logistic regression identified reamed intramedullary nailing as a “moderate” risk factor for cognitive impairment (p = 0.06) after controlling for confounders.★Additional research is warranted into the relationship of common and effective fracture treatments and cognitive function.
Compartment Syndrome
♦The relationship between compartment syndrome and utilization of hospital resources47, ballistic injuries48, and sports injuries49 were investigated retrospectively.➢Hospital length of stay tripled (three versus nine days) and charges doubled ($23,800 versus $49,700) for patients with compartment syndrome as compared with those with isolated and uncomplicated tibial fractures. Ballistic fractures were associated with a 2.8% rate of compartment syndrome, with increased rates of compartment syndrome seen in association with tibial (11.4%) and fibular (11.6%) fractures. Among tibial and fibular fractures, higher rates were found in association with proximal fractures. Only 3% of tibial fractures resulted from sports injuries, but sports injuries accounted for 24% of the injuries that were associated with the development of compartment syndrome.★Particular vigilance with injuries not commonly associated with compartment syndrome should be maintained, and increased costs can be expected.
Return to work after polytrauma and the long-term outcomes of ankle fractures were investigated.
Return to Work After Polytrauma
♦A prospective cohort study of 101 patients with an Injury Severity Score (ISS) of >15 was used to characterize return to work after polytrauma50.➢The rate of return to work at five years was 49%, with 23% of patients receiving full disability benefits. Predictors of return to work were higher education, coping style, and better function across Short Form-36 (SF-36) categories.★Rehabilitation designed to improve coping, in addition to physical and cognitive therapy, may increase return to work after polytrauma.
Very-Long-Term Follow-up After Ankle Fracture
♦Two retrospective cohort studies with more than seventeen years of follow-up of 148 supination-external rotation type-II, III, and IV ankle fractures51 and sixty pronation-external rotation type-III and IV52 ankle fractures that were treated on the basis of a radiographic instability protocol were performed.➢Good to excellent self-reported outcomes were found in association with 93% of supination-external rotation fractures and 90% of pronation-external rotation fractures. Radiographic arthritis did not correlate with outcome scores and was treated with arthrodesis very rarely (in only five ankles, all of which had supination-external rotation type-IV fractures).★Protocol-led decision-making based on radiographic evidence of instability results in good to excellent long-term outcomes after malleolar fractures.
There is increasing awareness that implants that are currently used for metaphyseal fractures, specifically, laterally based locked plates, may be too stiff to allow for adequate fracture-site motion and callus formation. Abundant recent research has focused on various aspects of this phenomenon, including the timing of dynamization for fractures and the vascular implications of increasing fracture-site instability. Finally, negative-pressure therapy (NPT) has increased in popularity for the temporary or definitive treatment of open wounds. This modality also may provide clinical benefits when used over closed wounds by decreasing hematoma and drainage and expediting wound-healing.
Fracture Fixation Stiffness
♦A rat femoral osteotomy external fixation model was used to study the effects of the timing of increasing fracture-site motion on healing53.➢Late fracture dynamization (at three or four weeks) led to enhanced fracture-healing compared with the constant flexible and constant rigid groups. Fracture-site flexibility early in the healing process appeared to be detrimental to healing, corroborating the findings of previous studies.★This study offers some insight into the ideal temporal mechanical environment for fracture-healing.♦A mouse tibial fracture model was used to compare tissue vascularization and hypoxia in stabilized and nonstabilized fractures in the early healing phase54.➢Mechanical stability did not affect oxygen levels at the fracture site. Nonstabilized fractures had a more robust angiogenic response as determined by means of histological analysis and stereology. However, gene microarray analysis did not show any differences in the major signaling pathways of angiogenesis.★Mechanical stability affects tissue vascularization, and it appears that some degree of instability promotes angiogenesis. The optimal stiffness level to promote angiogenesis and to provide enough stability to allow capillary bud formation remains to be determined.
Negative-Pressure Therapy for Closed Wounds
♦Fifty-six elliptical wounds were created on porcine skin. After primary closure, wounds were treated with either NPT for three days or with standard sterile dressings. Mechanical testing was then performed and the appearance of the wounds was evaluated55.➢Wounds treated with NPT were stronger, had less deep hematoma, and appeared healthier.★NPT has been studied extensively for the treatment of open wounds. This animal study provides evidence of the benefits of NPT after wound closure under tension.
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