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