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Specialty Update   |    
What's New in Orthopaedic Trauma
Peter A. Cole, MD1; Mohit Bhandari, MD2
1 Department of Orthopaedic Surgery, Regions Hospital, 640 Jackson Street, St. Paul, MN 55101. E-mail address: peter.a.cole@healthpartners.com
2 Orthopaedic Trauma Service, Hamilton General Hospital, 7 North, Suite 727, Barton Street East, Hamilton, ON L8L 2X2, Canada. E-mail address: bhandari@mcmaster.ca
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Zimmer, Synthes, Smith & Nephew, DePuy, AO) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Nov 01;88(11):2545-2561. doi: 10.2106/JBJS.F.01118
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This Specialty Update in orthopaedic trauma will summarize and review the most relevant clinical articles published between May 2005 and May 2006. We will continue the process of placing cited articles in an evidence-based context for the reader, with the given assumption that the "level of evidence" for a single study is not the same as a recommendation for a specific treatment or diagnostic strategy. Furthermore, we are instituting an important upgrade in this edition, which is information for the reader as to whether the reviewed studies were funded, and by whom. This documentation, which can be found in the electronic Appendix, may serve as appropriate recognition for sponsors of such projects but also will allow the reader to have another shade of context when interpreting findings.
Given the scope of the literature and the broad overview of trauma, we have focused our search to include journals that we believed to be most relevant to orthopaedic trauma. Specifically, we searched the Cochrane Database, seven orthopaedic journals, one general trauma journal, and four high-impact medical journals. Of the 9932 abstracts that we identified, 465 were determined to be potentially eligible studies and were reviewed by one of us (P.A.C.), who ultimately chose seventy-four papers to summarize. The present report summarizes the salient findings of seventeen Level-I studies, fifteen Level-II studies, eight Level-III studies, thirty-two Level-IV studies, and two Level-V studies. Of these studies, fifty-seven represented studies of therapy, twelve involved prognosis, four evaluated diagnostic tests, and one involved economic evaluation (see Appendix). Nineteen of the seventy-four studies included in this review received funding. Of the nineteen studies that were funded, five were funded by a government grant and eight were funded by a foundation grant (see Appendix). It is shocking that, of the seventy-four studies, only five were funded by an industry grant, and one was funded by an industry and government grant.

From Osteoporosis and Thromboembolism to Limb Salvage and the Psychopathology of Road Crash Victims

There are substantial efforts on the part of organized orthopaedic leadership at the level of the American Academy of Orthopaedic Surgeons and the American Orthopaedic Association to "own the bone," thus promoting a greater sense of responsibility by the orthopaedic surgeon and community for the totality of orthopaedic care of a patient. The most salient example at this time is the opportunity for and responsibility of orthopaedic surgeons to influence the care of patients with osteoporosis. Insofar as it is established that a low-energy fracture in a middle-aged or elderly adult is a good predictor of future fractures, the responsibility to act seems obvious. The norm is still to treat the fracture and to ignore the condition. Why is this? The first two articles provide a "must read" to understand the issues at hand.
Skedros et al. studied the knowledge and opinions of orthopaedic surgeons with regard to their opportunities for initiating the medical treatment of patients with an osteoporotic fracture1. A twenty-two-question voluntary survey was administered to 171 orthopaedic surgeons in Utah, Idaho, and Wyoming, generating a response rate of 63% (107 surveys). Sixty-eight percent of orthopaedic surgeons agreed or strongly agreed about the appropriateness of expanding their orthopaedic practice to include prescribing pharmacological treatments for osteoporosis. However, 47% were concerned enough about adverse events related to pharmacological treatments that they would rather avoid prescribing them. Fifty-one percent considered an apparent osteoporotic fracture and several other clinical risk factors for osteoporosis as sufficient evidence for the initiation of pharmacological treatment, whereas 72% thought that a bone-density scan should be performed before initiating treatment. Although 32% thought that all nonoperative treatment should be the responsibility of a primary-care provider, 63% thought that the orthopaedic surgeon should initiate a workup to look for secondary causes of the osteoporosis and should begin medical treatment of patients with an osteoporotic fracture before referring them. Although the survey was unvalidated and was only regional, the results underscore the problem.
Although at face value there seem to be large disparities of opinion on this subject, there is also enough commonality upon which to build. The desire either exists or could be generated. What is lacking is education and leadership. With all of the implications involved, logistically it would seem difficult to harmonize the medical "system" for appropriate diagnosis, treatment, and follow-up care.
Bogoch et al. were the authors of an excellent article that gives the reader a good idea of what it takes to institute such a program2. The Osteoporosis Exemplary Care Program at St. Michael's Hospital in Toronto, Canada, was established to identify, educate, evaluate, refer, and treat patients who are considered to be at risk for osteoporosis because of a typical fragility fracture. Three hundred and forty-nine patients with a fragility fracture who met the inclusion criteria and an additional eighty-one patients with a fracture who did not meet the inclusion criteria but were suspected by their orthopaedic surgeons of having underlying osteoporosis were enrolled in the study. Ninety-six percent of these 430 patients received approprite attention for osteoporosis, including diagnosis, treatment, referral, and follow-up. To accomplish this, a dedicated coordinator and the full cooperation of orthopaedic surgeons and residents, orthopaedic technologists, allied health-care professionals, and administrative staff were required. Certainly the next step is to determine the effects of this program on bone health and health care.
Before instituting such extensive programs to treat osteoporosis, it certainly would be advantageous to build a convincing argument regarding the efficacy of treatment. The Women's Health Initiative Investigators presented a study, published in the New England Journal of Medicine, in which 36,282 postmenopausal women were randomly assigned to receive 1000 mg of calcium carbonate with 400 IU of vitamin D3 daily or a placebo3. After an average duration of follow-up of seven years, hip bone density was 1.06% higher in the calcium-plus-vitamin-D group than in the placebo group (p < 0.01). The risk of renal calculi increased in association with calcium plus vitamin D, but there was no other measurable adverse affect on any other major organ system. For patients who were adherent to at least 80% of their prescription regimen, there was a 29% reduction in the rate of hip fractures. At the end of the trial, 59% of the enrollees were taking at least 80% of their prescribed regimen.
Moving from low-energy to high-energy injury, the Lower Extremity Assessment Project (LEAP) study group once again gleaned important information from this large effort regarding the longer-term outcomes of amputation and limb salvage4. The results are sobering. Three hundred and ninety-seven patients who had undergone amputation or reconstruction of the lower extremity were interviewed by telephone, and, on the average, physical functioning deteriorated between twenty-four and eighty-four months after the injury. Half of the patients had a physical Sickness Impact Profile sub-score of >9 points, which is indicative of substantial disability, and only 34.5% had a score typical of a general population of similar age and gender. Compared with patients who were managed with reconstruction for the treatment of a tibial shaft fracture, those with only a severe soft-tissue injury of the leg were 3.1 times more likely to have a physical Sickness Impact Profile subscore of 5 points and those managed with a through-the-knee amputation were 11.5 times more likely to have a physical subscore of 5 points. Given these findings, priority should be given to efforts to improve post-acute-care services that address these secondary conditions.
Another offshoot LEAP study was designed to determine the long-term outcomes following the treatment of severe lower extremity injuries in patients who had had absent plantar sensation at the time of initial presentation5. The results are fascinating and are likely to affect the treatment of the mangled extremity. Patients were divided into two groups: an insensate amputation group (twenty-six patients) and an insensate salvage group (twenty-nine patients). An additional control group was constructed from the parent cohort so that the patients in the study groups could be compared with patients in whom plantar sensation was present in a reconstructed limb. Patients in the insensate salvage group did not report or demonstrate significantly worse outcomes at twelve or twenty-four months after the injury compared with subjects in the insensate amputation or sensate control groups. In fact, among the patients in the insensate salvage and sensate control groups, an equal proportion (55%) had normal plan-tar sensation at two years after the injury, and only one patient in the insensate salvage group reported totally absent sensation at two years. Thus, it does not appear that plantar sensation should be a prognostic factor for determining long-term functional outcomes in patients managed with limb salvage.
As with all of the LEAP studies, conclusions should be interpreted with the understanding that all of the study subjects were managed at level-I trauma centers by specialists with expertise in, and with use of systems designed for, the treatment of such patients. Such a treatment context for trauma acknowledges and applies the newest techniques, particularly in the case of open fractures, for which techniques have changed and improved over the past fifteen years. One of the standards that has evolved includes the regular lavage of fractures (after débridement of devitalized tissue) with copious antibiotic solution. In vitro and animal studies have suggested that irrigation with detergent solution is more effective than irrigation with a solution containing antibiotic additives. Anglen, in a prospective, randomized study of 458 fractures in 400 patients, compared the efficacy of bacitracin with that of castile soap solution for open fractures6. After a mean duration of follow-up of 500 days, the results for 199 patients in each group revealed no significant differences in the rates of infection (18% compared with 13%, respectively; p = 0.2) or bone-healing (25% compared with 23%, respectively; p = 0.72). The rate of wound-healing problems, however, was significantly higher in the bacitracin group than in the soap group (9.5% compared with 4%; p = 0.03). Because the differences were slight between the two groups, a cost analysis would be warranted to further aid the surgeon in choosing appropriate solutions for irrigation.
Neurobehavioral and psychopathological disorders were evaluated in a study in which road-crash victims with isolated brain injury were compared with polytrauma patients without brain damage7. Twenty-five patients in each group were tested with the Neurobehavioral Scale, the SCL 90-R, and the State/Trait Anxiety Scale. The patients with severe brain injury (as indicated by a Glasgow Coma Score of <8 at the time of presentation) suffered from significantly more disorders of self-appraisal, flexible thinking, withdrawal, mood swings, irritability, disinhibition, excitement, attention, slower motor responses, mental fatigue, articulatory problems, and problems of oral expression and comprehension as well as exaggerated somatic concerns and a higher level of obsessive symptoms, whereas there was no significant difference between the two groups on the State/Trait Anxiety Scale. Polytrauma patients suffered from memory troubles (prevalence, 60%), concept disorganization (32%), loss of initiative (36%), irritability (52%), unusual thought content (40%), mood swings (40%), attention difficulties (24%), suspiciousness (48%), and feelings of guilt (36%). This study underscores the need for therapeutic intervention and the need to inform health-care workers about the most appropriate patient counseling.
Another area in which it is difficult for orthopaedic surgeons to reach a consensus is thromboembolic prophylaxis. An Arthroflow device (Ormed, Freiburg, Germany) is a bilateral continuous passive motion machine for the ankles that has been purported to increase venous flow volumes. In a prospective, randomized study of 227 trauma patients with fractures of the spine, pelvis, and/or lower extremity, patients were managed with low-molecular-weight heparin with and without an Arthroflow device8. With use of a rigorous methodology (including venography) for diagnostic work-up, the prevalence of deep-vein thrombosis was found to be 25% in the group managed with low-molecular-weight heparin only, compared with 3.6% in the group that received additional treatment with the Arthroflow device (p < 0.001). Studies comparing this improvement in prophylaxis with that associated with other mechanical modalities are indicated, including a comparison of compliance.

Spine

McHenry and colleagues performed a retrospective cohort study at Harborview Medical Center in Seattle, Washington, to identify risk factors for respiratory failure in patients with surgically treated thoracic and lumbar spine fractures9. In that study, the trauma database was cross-referenced with the Adult Respiratory Distress Syndrome Registry to identify patients with spine fracture who also had respiratory failure. Respiratory failure occurred in 140 of the 1032 patients in the study cohort. Multivariate analysis identified five independent risk factors for respiratory failure, including an age of more than thirty-five years, an Injury Severity Score of >25 points, a Glasgow Coma Score of =12 points, blunt chest injury, and surgical stabilization performed more than two days after admission. It is noteworthy that the only risk factor that can be controlled by the surgeon (the timing of surgical stabilization) may decrease the risk of respiratory failure substantially in multiply injured patients with spine fractures.
Because of the potential for severe complications in association with the use of pedicle screws in the thoracic spine, many surgeons have shunned their use despite distinct biomechanical advantages. Bransford et al. conducted a retrospective review of 245 consecutive patients with thoracic spine fractures that required pedicle screw fixation at a level-I trauma center10. Following the insertion of 1533 pedicle screws between T1 and T10 in these patients, there were no major complications related to screw placement; however, three patients required a secondary procedure for prophylactic revision of four malpositioned screws that were detected on postoperative computed tomography scans. The key elements of success were preoperative imaging evaluation, the use of standard posterior element landmarks, and intraoperative fluoroscopy-guided placement of all screws.
The maintenance of reduction following posterior instrumentation for the treatment of spinal fractures is difficult, particularly in patients with two-level fusions. Li et al. performed a retrospective analysis of patients who had undergone two-segment fixation for the treatment of a single-level burst fracture between T11 and L2 to study the efficacy of transpedicle spacers for the prevention of kyphotic deformation postoperatively11. The patients in the control group (n = 45) were managed with short-segment posterior instrumentation alone, whereas those in the augmented group (n = 75) were managed with a titanium block designed for transpedicular positioning into the body. The rate of follow-up was 88%, with similar mean durations of follow-up in each group (range, twenty-four to seventy months). The immediate postoperative kyphotic angle was not significantly different between the groups, but the final kyphotic angle was less in the augmented group than in the control group (mean, 7° compared with 20°, p < 0.001). Furthermore, the control group had more failures (p < 0.001) and the augmented group had better results according to the Denis pain scale (p < 0.009). Although the results were encouraging, a criticism acknowledged by the authors is that the control group was made up of patients who were managed in the early part of the study.
The last two studies on the spine covered the treatment of intractable pain due to spinal compression fractures that were treated with vertebroplasty. In the first study, fifty-one patients with fifty-eight vertebral compression fractures were followed for a minimum of two years12. Thirty-nine patients (Group 1) presented without an intravertebral cleft, and twelve patients (Group 2) presented with an intravertebral cleft. The Oswestry disability index and visual analog scale scores in both groups decreased after treatment, but the mean scores in Group 2 were higher than those in Group 1 (p = 0.02 for the Oswestry disability index score and p = 0.02 for the visual analog scale score). There was no significant difference between the groups with regard to the loss of correction, although leakage of cement occurred with great frequency in Group 2, likely through the cortical defects in these patients. The authors concluded that although no infection or major complications occurred, physicians performing vertebroplasty for the treatment of intravertebral clefts should be cautioned. The second study was the first vertebroplasty study involving the use of validated instruments to measure outcome13. Fifty patients who presented with more than four months of intractable pain due to one or more osteoporotic compression fractures were managed with vertebroplasty by a radiologist. Thirty-one women and nineteen men (mean age, 68.6 years) with 103 fractures were followed prospectively for one year. The visual analog scale showed the greatest improvement between the baseline score (mean, 7.76) and the score at one month (mean, 2.9), and the score remained improved at one year (mean, 2.9). The Oswestry and Roland-Morris questionnaires demonstrated significant functional improvement between the baseline and one-month scores (p < 0.0001). The authors provided a compelling conclusion that the improvement in terms of pain and functional capabilities at one month was maintained through the first year, perhaps throwing the strongest argument to date behind this technique.

Acetabulum

Acetabular fractures are one of the most challenging fractures to treat in terms of conceptualization of the osseous injury and selection of surgical approach. Furthermore, each approach and each injury has its own associated challenges and complications. The next four papers to be discussed are valuable in that they convey a sense of the nuances or complications related to different approaches and injuries.
In the study by Karunakar et al., 169 consecutive patients in whom an acetabular fracture was treated with open reduction and internal fixation at a level-I trauma center were stratified into four classes according to body mass index: normal (<25), overweight (=25 but <30), obese (=30 but <40), and morbidly obese (=40)14. Odds-ratio analysis revealed that obese patients were 2.1 times more likely than normal-weight patients to have an estimated blood loss of >750 mL and were 2.6 times more likely to have a deep venous thrombosis. Morbidly obese patients were five times more likely to have a wound infection. Neurapraxia and heterotopic ossification were not associated with body mass index. Analysis according to fracture type or surgical approach was not recorded, presumably because the study was underpowered for meaningful analysis of these variables.
The study by Matta, which described a single surgeon's ten-year experience with use of the ilioinguinal surgical approach for the treatment of 119 acetabular fractures, yielded important information regarding surgical indications, observations, risks, and benefits15. According to radiographic examination, anatomic reduction (with a <1-mm step-off) was achieved in 74% of the patients and satisfactory reduction (with a 2 to 3-mm step-off) was achieved in 16%. Complications of surgery included surgical wound infection (prevalence, 3%), iatrogenic nerve palsy (2%), substantial ectopic bone (1%), and death from pulmonary embolus (1%). Although the clinical results after an average duration of follow-up of three years were excellent in 37% of the patients, good in 47%, fair in 14%, and poor in 2%, the methodology for assessment was not well documented. Two patients required total hip arthroplasty for the treatment of posttraumatic arthritis.
The study by Griffin et al., which described the experience of another single surgeon, served the same purpose of documenting the surgical and perioperative findings following the use of extended iliofemoral approach for the treatment of associated fracture patterns16. One hundred and six patients with a minimum duration of follow-up of two years (mean, 6.3 years) were prospectively followed. A both-column fracture was the most common indication in the series. Operative treatment was performed less than twenty-one days after the injury in seventy-one patients (67%), certainly yielding a late mean time to surgery. The reduction criteria were the same as those in the report by Matta (described above), and functional outcome was measured. The reduction was graded as anatomical in seventy-six patients (72%). Sixty-eight patients (64%) had a good or excellent result, and thirty-eight (36%) had a fair or poor result. Function was significantly correlated with the accuracy of the reduction (p < 0.009). Moderate to severe heterotopic ossification developed in thirty-two patients (30%), with 8.5% of the patients requiring an operation for excision. Heterotopic ossification was associated with a worse mean clinical score, indicating a clear role for heterotopic ossification prophylaxis.
A Kocher-Langenbeck approach combined with an osteotomy of the greater trochanter with remaining attachments of the gluteus medius and vastus lateralis muscles can yield greater access to the posterosuperior and superior ace-tabular wall area. Siebenrock et al. followed ten consecutive acetabular fractures (six transverse posterior wall fractures, three posterior wall fractures, and one T-type posterior wall fracture) that were treated with this approach; in two cases, a supplemental anterior approach was used17. In eight patients, an anatomic reduction was achieved; in the remaining two patients, both of whom had severe comminution, the reduction was within 1 to 3 mm. All trochanteric osteotomy sites that were fixed with two 3.5-mm screws healed in an anatomic position within six to eight weeks. Abductor strength was symmetric in eight patients and was mildly reduced in two. Heterotopic ossification was limited to Brooker classes 1 and 2 without functional impairment after an average duration of follow-up of twenty months. No femoral head necrosis was observed.
Patient outcomes following hip dislocation are quite variable, suggesting that certain injury characteristics may be missed on plain radiographs, even after a congruent reduction of the hip. In the study by Mullis and Dahners, thirty-six patients who had sustained a hip dislocation underwent arthros-copy at a single institution with the combined use of traction with use of a femoral distractor18. Loose bodies were found in thirty-three hips (92%), including seven of nine cases in which pelvic radiographs and computed tomography scans demonstrated no loose bodies and a concentric reduction. Hip arthroscopy may be indicated for loose-body removal when open treatment is not otherwise necessary, and outcome studies are warranted in order to determine the ability to adequately evacuate contents and also to compare differences in symptoms between control and study groups.

Pelvis

Bellabarba et al. evaluated the use of a two-pin supra-acetabular external fixator followed by immediate weight-bearing for the treatment of displaced vertically stable lateral compression pelvic fractures in a study of fourteen consecutive patients19. A symmetric reduction of both hemipelves was consistently achieved, and the mean time to healing was 8.2 weeks. None of the fractures displaced significantly after the initial reduction. The average duration of surgery was thirty-seven minutes, with an estimated blood loss of <50 mL. Patients were allowed to bear full weight immediately and were able to do so without assistive devices within an average of twelve days. Complications consisted of three minor pin-track infections, one temporary lateral femoral cutaneous nerve palsy, one pin-track abscess, and one case of chronic low-back pain, leading the authors to conclude that this treatment of displaced lateral compression pelvic fractures is safe and effective.
Griffin et al. conducted a retrospective review of sixty-two consecutive patients with vertically unstable pelvic fractures in whom the posterior injury was treated with closed reduction and percutaneous iliosacral screw fixation20. radiographs that were made immediately postoperatively and after a minimum of twelve months of follow-up were examined to assess displacement. Failure was defined as at least 1 cm of difference in combined vertical displacement between the postoperative and most recent follow-up radiographs. Thirty-two patients had a dislocation of the sacroiliac joint, and thirty had a sacral fracture. Fixation failed in four patients, all of whom had a sacral fracture with vertical instability, and all of these failures occurred in the first three weeks after surgery. A vertical sacral fracture pattern was associated with a significantly greater rate of failure (p = 0.04), perhaps suggesting a role for different or supplemental fixation in certain fracture variants.
To address the challenge of the vertically unstable sacral fracture, Schildhauer et al. performed a retrospective analysis of thirty-four patients who were managed with triangular osteosynthesis at a level-I trauma center21. The mean age of the patients was thirty-five years, and the average time from the injury to surgery was thirteen days. A combination of a vertical vertebropelvic distraction osteosynthesis (with use of a pedicle screw system) and transverse fixation of the sacral fracture with either iliosacral screws or trans-sacral plating was used. Nineteen patients were managed with early progressive weight-bearing and advanced to full weight-bearing at a mean of twenty-three days. Three of the thirty-four patients experienced loosening of hardware, including two patients who required secondary intervention. Given the degree of injury and the aggressiveness of the rehabilitation protocol, it seems that this treatment method carries substantial promise.
A relatively rare injury, for which there is scarce literature regarding treatment or outcomes, is the unstable pelvic fracture in the skeletally immature patient. Smith et al. performed a retrospective review of twenty-three patients from two level-I trauma centers, all of whom had an open triradiate cartilage and an unstable pelvic (Tile type-B or C) fracture22. The Short Musculoskeletal Function Assessment Questionnaire (SMFA) was used to assess the difference between patients who had been treated operatively and those who had been treated nonoperatively. Twenty patients were followed for a mean of 6.5 years. The four patients with a type-B fracture had a mean of 1.4 cm of pelvic asymmetry at the time of union and at the time of the most recent follow-up, whereas the sixteen patients with a type-C fracture had a mean of 1.5 cm of pelvic asymmetry at those times. Pelvic asymmetry did not remodel, even in the younger patients. Eighteen patients were managed operatively with external fixation, internal fixation, or a combination of both, and pelvic asymmetry of 1 cm was achieved in ten. These patients had no lumbar or sacroiliac pain, no or mild sacroiliac tenderness, no Trendelenburg sign, no lumbar scoliosis, and lower (better) bother and dys-function scores on the SMFA as compared with patients with more pelvic asymmetry. All patients with >1 cm of pelvic asymmetry had three or more of the following: nonstructural scoliosis, lumbar pain, a Trendelenburg sign, or sacroiliac joint tenderness and pain. These results indicate the importance of achieving an accurate reduction rather than using an approach of benign neglect with the expectation for remodeling of the deformity.

Shoulder

Scapular fractures are starting to gain the attention of fracture surgeons seeking a better understanding of the implications of this injury. Weening et al. performed a comparative observational study of multiply injured patients in an attempt to determine rates of associated injuries and mortality23. Ninety-four of 2538 patients who sustained trauma in a motor-vehicle accident were found to have sustained a scapular fracture. Not surprisingly, these patients, when compared with those without a scapular fracture, had a greater proportion of flail chest injuries, clavicular fractures, rib fractures, spine fractures, tibial and fibular fractures, and injuries to the spleen and liver. Surprisingly, however, the presence of a scapular fracture reduced the risk of mortality by 44%. It may be that the surrounding fractures of the forequarter and chest absorb energy and cushion the blow to critical organs.
Controversy still exists among orthopaedic surgeons with regard to the optimal treatment of displaced midshaft clavicular fractures. In an effort to better define optimal treatment, Zlowodzki et al. performed a systematic review of different treatment options24. Twenty-four studies met the inclusion criteria. Of the 2144 clavicular fractures that were identified, 97% occurred in the middle part of the shaft. Of these, 53% were treated nonoperatively, 30% were treated with a plate, and 17% were fixed with intramedullary pins. Among the nonoperatively treated midshaft clavicular fractures, the nonunion rate was 5.9% for nondisplaced fractures and 15.1% for displaced fractures. There was a relative risk reduction of 57% for nonunion favoring plate fixation over nonoperative treatment. Anterior-inferior plate placement was associated with fewer symptoms when compared with superior plate placement. Finally, conflicting evidence was found with regard to the nonunion rates associated with intramedullary fixation as opposed to nonoperative treatment. The authors cautioned that decisive conclusions could not be made because eighteen studies were retrospective and fifteen had no control group; nevertheless, mounting evidence seems to indicate that not all of those fractures predictably do well with nonoperative treatment.
In order to better describe the natural history of clavicular fracture-healing and to identify risk factors associated with poor outcomes, Nowak et al. performed a prospective study of 222 patients who were managed nonoperatively25. Nonunion was observed in 7% of the patients, and 42% of the patients still had some residual sequelae (pain at rest or with activity, strength reduction, cosmetic defects, and/or paresthesias) at six months. Displacement of more than one bone width was the strongest radiographic risk factor for sequelae. In addition, comminuted fractures and older age were associated with increased risk of symptoms at six months. There was no association of shortening or fracture location with outcome.
The previous two studies clearly underscore that there are questions regarding the amount of disability that is present following the nonoperative treatment of displaced midshaft clavicular fractures. McKee et al. added to the argument in a study in which patient-oriented outcome measures were used for the evaluation of thirty-two patients who had a displaced midshaft clavicular fracture that was treated nonoperatively26. The DASH (Disabilities of the Arm, Shoulder and Hand) patient questionnaire as well as an objective shoulder muscle-strength test with use of the Baltimore Therapeutic Equipment Work Simulator, with the uninjured arm serving as a control, were administered. Shoulder strength was reduced to 81% of the control value for maximum flexion, 82% for maximum abduction, 81% for maximum external rotation, and 85% for maximum internal rotation. Endurance was reduced to 75% for forward flexion, 67% for abduction, 82% for external rotation, and 78% for internal rotation (p < 0.05 for all values). In addition, the mean Constant score was 71 points, and the mean DASH score was 24.6 points, indicating substantial residual disability. These results seem to contradict the findings of previous studies; however, the authors believed that they were able to detect residual strength deficits that occur following the nonoperative treatment of midshaft clavicular fractures because they used patient-based outcomes and a more reliable form of strength-testing.
With regard to proximal humeral fractures, traditional forms of fixation (such as T plates, Kirschner wires, and intramedullary devices) have been associated with high rates of complications (e.g., osteonecrosis, nonunion, rotator cuff impairment, loss of fixation). Locking plates may be changing the landscape. Koukakis et al. performed a prospective study in which the results of treatment with the PHILOS plate (Synthes, Stratec Medical, Mezzovico, Switzerland) were compared with the results of treatment with conventional methods of surgical fixation27. Twenty patients with proximal humeral fractures who were managed with this system were followed for a mean of 16.2 months. The mean Constant score was 76.1%, and all fractures united. The one reported complication was a prominent plate, which was treated with plate removal. The authors found that the locked plates were not accompanied by hardware failure or impingement syndrome as observed with older forms of fixation.
Also in an attempt to address the high complication rates associated with the treatment of proximal humeral fractures, Martin et al. performed a retrospective evaluation of sixty-two patients who were managed with external fixation with use of the Hoffmann II External Fixation System (Stryker Orthopaedics, Mahwah, New Jersey)28. The mean duration of follow-up was 1.5 years and, again, all fractures healed and the authors recorded no instances of osteonecrosis with collapse. Satisfactory results were observed in forty-nine of the sixty-two patients. In fifty patients, the reduction was considered to be good, with <5 mm of displacement between the fragments and <10° of angulation. Thus, it seems that stable fixation of these fractures can yield promising results.
Although the advance of newer techniques is promising, salvage options must be considered, particularly for elderly patients in whom fixation has either failed or is not possible. Boileau et al. described a series of 203 patients with sequelae of proximal humeral fractures that were treated with a nonconstrained modular and adaptable shoulder prosthesis (Aequalis; Tornier, Stafford, Texas)29. Patients who were treated for impacted fractures associated with humeral head collapse, humeral head necrosis, or an unreducible dislocation had predictably good results. However, patients who were treated for sequelae of surgical neck nonunion or tuberosity malunion had poor functional results. The authors attributed these poor results to the need for a greater tuberosity osteotomy in order to insert the nonconstrained prosthesis properly in this group and believed that such patients may be better served with a reverse shoulder arthroplasty.
Whether to use plate fixation or an intramedullary nail for the treatment of a humeral shaft fracture remains controversial. In an effort to detect specific advantages of one method over another, Bhandari et al. conducted a systematic review and meta-analysis of three randomized trials analyzing these methods30. Plate fixation was associated with a lower relative risk of reoperation than intramedullary nailing was, translating to a risk reduction of 74% for reoperation with plates. Plate fixation also reduced the risk of shoulder problems in comparison with intramedullary nails. Despite this cumulative evidence, the data are inconclusive, and the authors recommended a large, randomized trial to confirm these findings.

Elbow

Olecranon osteotomy provides improved visualization of the distal humeral articular surface to facilitate fracture reduction. Unfortunately, complications have been reported in association with this approach, including delayed union, nonunion, and symptomatic olecranon hardware. Coles et al. performed a retrospective review of seventy patients in whom a chevron olecranon osteotomy had been performed31. Osteotomy-site repair was performed with use of an intramedullary screw and supplemental dorsal ulnar wiring or with plate stabilization. Sixty-seven patients had adequate follow-up. All osteotomy sites united, with one delayed union. Of note, two patients required early revision osteosynthesis secondary to loss of reduction. While the authors could not determine from the records how many patients had subsequent removal of the osteotomy-site implants, they concluded that olecranon osteotomy is a useful technique for the visualization of complex articular injuries of the distal part of the humerus and that, when this procedure is performed, the site should be repaired with secure stabilization.
Supracondylar or intercondylar distal humeral fractures are commonly treated with 3.5-mm implants to achieve rigid fixation, thereby allowing early range of motion. One disadvantage of 3.5-mm implants is their inability to achieve sufficient fixation of low columnar fractures. Mini-fragment implants can overcome this problem because a greater number of screws can be placed into the distal fragments secondary to their decreased size. However, because of their size, legitimate concern exists regarding the ultimate strength of such a construct and whether or not it is safe to engage in early motion following this type of fracture fixation. To answer this question, Russell et al. performed a retrospective study on twenty-four patients who had undergone open reduction and internal fixation of supracondylar or intercondylar distal humeral fractures with use of 2.7-mm reconstruction plates (Synthes, Paoli, Pennsylvania) placed on the medial column and 2.7-mm dynamic compression plates placed on the lateral column32. The average duration of follow-up was 48.5 weeks. All patients but one began active range-of-motion exercises on the first postoperative day. No patient had hardware failure, required subsequent bone-grafting, or had loss of fracture reduction. The authors concluded that mini-fragment implants were able to maintain stability until the time of fracture union in patients with supracondylar or intercondylar distal humeral fractures.
Limited information is available regarding the functional outcome for patients managed with open reduction and internal fixation of capitellar and trochlear fractures. Dubberley et al. conducted a retrospective review of twenty-eight patients33. The average Mayo Elbow Performance Index score (91 ± 11) and the average quality-of-life scores (46 on the physical component and 50 on the mental component of the Short Form-36) suggested overall good results. The average range of motion was from 19° to 138°. Two cases of nonunion were observed in patients who had sustained comminuted fractures, both of whom required conversion to a total elbow arthroplasty. The authors also proposed a classification system for these fractures to assist with the determination of surgical management and prognosis. Overall, the findings of the study demonstrated that patients with more complex fractures required more extensive surgery, had more complications resulting in secondary procedures, and had poorer outcomes.
Radial head resection has been the accepted technique for the treatment of comminuted radial head fractures for some time. However, with the advent of improved forms of mini-fixation, such as self-tapping Herbert screws and low-profile mini-plates, some surgeons have attempted to reconstruct such fractures. In order to build evidence for the validation of this approach, Ikeda et al. performed a study in which the results of radial head resection were compared with those of open reduction and internal fixation34. Twenty-eight patients were enrolled in the study, with fifteen undergoing radial head resection and thirteen undergoing open reduction and internal fixation with cannulated Herbert screws alone or in combination with a low-profile mini-plate. The average duration of follow-up was ten years for the radial head resection group and three years for the open reduction and internal fixation group. The findings of the study demonstrated that the average elbow motion was from 15.5° to 131.4° in the resection group and from 7.1° to 133.8° in the open reduction and internal fixation group. Patients who underwent radial head resection demonstrated a loss of strength in extension, pronation, and supination compared with those who underwent open reduction and internal fixation. In addition, the Broberg and Morrey functional rating score averaged 81.4 points for patients managed with resection, compared with 90.7 points for those managed with open reduction and internal fixation (p = 0.0034). Finally, the average score on the American Shoulder and Elbow Surgeons elbow assessment form was 87.3 points for the radial head resection group and 94.6 points for the open reduction and internal fixation group (p = 0.0031). In a future study, it would be interesting to see how patients who are managed with radial head resection and prosthetic replacement compare with those who are managed with open reduction and internal fixation as described in this paper.

Distal Part of the Radius

The best method for the treatment of comminuted metaphyseal distal radial fractures with a congruous articular surface is not known. Kreder et al. performed a prospective, randomized, controlled trial in which closed reduction and casting was compared with spanning external fixation and optional percutaneous Kirschner wires35. The study included 113 adults. Patients were randomized to receive treatment with either casting (n = 59) or spanning external fixation with use of a small AO fixator and optional percutaneous Kirschner wires (n = 54). All patients had improvement over the two-year course of the study. There were trends toward better function and better length and palmar tilt restoration in patients managed with external fixation; however, these differences did not reach significance. The authors decided that a definitive conclusion regarding the superiority of one of these two forms of treatment could not be reached on the basis of this study.
Moving to intra-articular fractures, Kreder et al. also performed a randomized, controlled trial in which open reduction and internal fixation was compared with indirect reduction and percutaneous fixation for the treatment of distal radial fractures36. A total of 179 adults with a displaced intraarticular fracture of the distal part of the radius were randomized to treatment with indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). There was no significant difference between the groups in terms of the radiographic restoration of anatomical features or the range of movement. However, during the two-year follow-up period, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than did those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimized initially. The authors concluded that open reduction should be preceded by an attempt at minimally invasive percutaneous reduction.
Higher-energy intra-articular distal radial fracture variants present even greater challenges, and the two following papers presented markedly different strategies for treatment. Hanel et al. presented a retrospective chart review of sixty-two patients who were managed with bridge plating of the distal part of the radius37. Fifty-two patients were managed with a 2.4-mm titanium mandibular reconstruction plate, and ten patients were managed with a 2.4-mm stainless steel plate specifically designed for this purpose. All plates were placed along the floor of the second dorsal wrist compartment and were secured to the second metacarpal distally and to the dorsal part of the radius proximally. Accessory incisions and additional Kirschner wires and plates were used as needed to obtain an acceptable articular reduction. Digital range-of-motion exercises were started within twenty-four hours, and load-bearing through the forearm and elbow was allowed immediately with a platform crutch. The results were good, with fracture union and acceptable reduction being achieved in all patients. The authors concluded that the use of bridge plates for the treatment of high-energy distal radial fractures is effective and avoids the complications associated with external fixators, particularly pin-track irritation.
In patients with distal radial fractures, metaphyseal comminution can leave very little support for the articular fragments, placing the majority of the load of the articular reduction on the implants. With such fractures, neither external fixation nor a single volar or dorsal implant is sufficient to provide adequate stability. Ring et al. recently described a surgical technique to overcome this problem38. The authors combined dorsal and volar plate fixation to treat twenty-five such fractures. The patients were evaluated at an average of twenty-six months after the injury. A good or excellent functional result was achieved in 96% of the patients according to the rating system of Gartland and Werley and in 40% of the patients according to the more stringent modified system of Green and O'Brien. Range of motion was somewhat limited in all directions, and grip strength in the involved limb was an average of 78% of that in the contralateral limb. The authors concluded that combined dorsal and volar plate fixation of the distal part of the radius is indicated for fractures with complex comminution of the articular surface and metaphysis for which a single dorsal or volar plate would not be sufficient.
With regard to the fragility fracture end of the spectrum for the distal part of the radius, Hung et al. performed a prospective study to determine if volumetric bone mineral density at the distal part of the radius was a risk factor for Colles fracture39. Peripheral quantitative computed tomography was used to measure volumetric bone mineral density of a non-fractured distal part of the radius, and dual-energy x-ray absorptiometry was used to measure areal bone mineral density at the spine and hip in forty-five premenopausal women and thirty-nine postmenopausal women with a Colles fracture. These patients were then compared with ninety-five premenopausal and ninety postmenopausal age-matched controls. The results of the study demonstrated lower bone mineral density at all measurement sites in the patients who had a Colles fracture as compared both with patients who had a high-energy fracture and with control subjects. More patients with a bone mineral density of less than -2.5 standard deviations (Z-score) were found in the premenopausal group than in the post-menopausal group. The authors concluded that low bone-mineral density at the distal part of the radius in premenopausal women is an important risk factor for low-energy Colles fracture.

Proximal Part of the Femur

It is difficult to find consensus on the treatment of hip fractures, particularly displaced femoral neck fractures. In a survey mailed to members of the Orthopaedic Trauma Association and European-AO International-affiliated trauma centers with a 67% response rate, 89% of the respondents believed that internal fixation was the procedure of choice for patients less than sixty years old with a displaced Garden type-III fracture40. This percentage decreased to 25% for the treatment of this type of fracture in patients between the ages of sixty and eighty years. For patients over the age of eighty years, almost all surgeons preferred arthroplasty. Many surgeons believed that there was no difference between arthroplasty and internal fixation when mortality, infection rates, and quality of life were considered. These results yield a good starting point for consensus-building and education.
Zlowodzki et al. evaluated the demographic and radiographic variables associated with fixation failure in an observational study of eighty patients with femoral neck fractures that were treated with cannulated screws41. The overall failure rate was 30%, mimicking failure rates reported in the literature. Forty-nine patients were managed with three cannulated screws. Four variables were associated with fixation failure, the most novel of which was the lack of use of washers. The other three variables were imperfect quality of reduction, an age of more than seventy-five years, and a displaced fracture type. A striking finding was that neither the distance of the most inferior screw to the inferior neck nor the sum of the tip apex distances was found to be a significant factor. Perhaps the enhanced compression afforded by washers against the lateral wall of the femur has been overlooked in teaching the best techniques for fixing this fracture.
Recent prospective, randomized trials may have begun a process of consensus-building on the treatment of displaced femoral neck fractures in the elderly in that they seem to distinguish total hip arthroplasty as a treatment of choice. Blomfeldt et al., in a follow-up of a previous outcome study with two years of follow-up, reported on the same cohort after four years of follow-up42. One hundred and two patients who had an acute displaced femoral neck fracture were randomly allocated to treatment with total hip replacement or internal fixation. The inclusion criteria were an age of at least seventy years, the absence of severe cognitive dysfunction, an independent living status, and the ability to walk independently. After forty-eight months of follow-up, the rate of hip complications was 4% in the total hip replacement group and 42% in the internal fixation group (p < 0.001) and the rates of reoperation were 4% and 47%, respectively (p < 0.001). The arthroplasty group had no additional hip complications or reoperations between the twenty-four and forty-eight-month follow-up visits. In the fixation group, the percentage of hip complications increased from 36% to 42% and the percentage of reoperations increased from 42% to 47% during the same period. Ninety-seven percent of the patients in the arthroplasty group and 57% of the patients in the fixation group who were available for follow-up at forty-eight months had no hip complications (p < 0.001). Remaining concerns about this and other studies are related to methods and techniques of fixation as well as to the absence of a rigorous comparison of patients who had successful healing of the femoral neck fractures with those who underwent joint replacement. Importantly, although the standard of fixation of femoral neck fractures includes the use of three cannulated screws, only two screws were used in this study.
Until now, no similar prospective, randomized study has been performed on unstable intertrochanteric fractures, although their treatment track record is not much better than that of femoral neck fractures. Unstable intertrochanteric fractures in elderly patients are associated with a high rate of complications. In the study by Kim et al., fifty-eight elderly patients with an AO-OTA type-31-A2 fracture (an unstable three-part intertrochanteric fracture) were randomized into two treatment groups and were followed for a minimum of two years43. Twenty-nine patients were managed with a long-stem cementless calcar-replacement prosthesis (Group I), and twenty-nine patients were managed with a proximal femoral nail (Group II). Although there were no significant differences between the groups in terms of functional outcomes, hospital stay, time to weight-bearing, or general complications, the patients who were managed with internal fixation had a shorter operative time, less blood loss, fewer units of blood transfused, a lower mortality rate, and lower hospital costs compared with those who were managed with the long-stem cementless calcar-replacement prosthesis.
Maybe there is more that could be done with internal fixation of unstable intertrochanteric fractures, as discovered by Mattsson et al.44. This group performed a prospective, randomized, multicenter study of 112 such fractures in order to evaluate whether internal fixation with a sliding-screw device combined with augmentation with calcium-phosphate degradable cement could improve the clinical, functional, and radiographic outcome when compared with the use of a sliding-screw device alone. The results were rather compelling, even for this relatively small study group. Six weeks after surgery, the patients in the augmented group had significantly lower global and functional pain scores, less pain after walking fifty feet (15.2 m), and a better return to activities of daily living. After six weeks and six months of follow-up, patients in the augmented group demonstrated significant improvement compared with those in the control group in terms of the SF-36 score as well. No other significant differences were found between the groups, and no complications were discovered in relation to the use of the cement (Norian; Synthes).
At times, it seems that an undercurrent of debate will always persist regarding whether cephalomedullary implants are better than sliding hip screws for the treatment of intertrochanteric hip fractures. The Cochrane Collaboration performed an updated systematic review of this subject45. Thirty-two trials met the inclusion criteria. Twenty trials involving 3646 patients compared the Gamma nail with any number of sliding hip screw (also known as compression hip screw) designs. The Gamma nail was associated with an increased risk of operative and later fractures of the femur and an increased reoperation rate. There were no major differences between implants in terms of the rates of infection, mortality, or medical complications. In five trials involving 623 patients, the intramedullary hip screw (IMHS; Smith and Nephew Richards, Memphis, Tennessee) was compared with a sliding hip screw. Fracture fixation complications were more common in the IMHS group, and all cases of operative and later fractures of the femur occurred in this group. Postoperative complications, mortality, and functional outcomes were similar in the two groups. Two trials involving 314 patients showed no difference between the proximal femoral nail (PFN; Synthes) and the sliding hip screw in terms of the rate of fracture-fixation complications, the rate of reoperation, the rate of wound infection, or the length of hospital stay. Importantly, two trials involving sixty-five patients with reverse and transverse fractures at the level of the lesser trochanter demonstrated that intramedullary nails (the Gamma nail or the PFN) were associated with better intraoperative results and fewer fracture-fixation complications in comparison with extra-medullary implants (a 90° blade-plate or a dynamic condylar plate). The authors of the review concluded that a sliding hip screw appears to be superior for most trochanteric femoral fractures but cautioned that additional studies are required to determine if different types of intramedullary nails produce similar results and to confirm that intramedullary nails have advantages for the treatment of reverse oblique and transverse fractures in the peritrochanteric region.
Ideally, the medical community would embrace strategies to prevent fragility hip fractures altogether. Unfortunately, what seemed like a good idea in this regard has not panned out so well. An extensive meta-analysis was published this year analyzing all (fourteen) randomized and quasi-randomized trials in which the prevalence of hip fractures, pelvic fractures, and other fractures in elderly people who were offered hip protectors was compared with the prevalence of these complications in a control group that was not offered hip protectors46. Pooling of data from eleven trials carried out in nursing or residential care settings revealed that there was evidence of a marginal but significant reduction in the prevalence of hip fracture (relative risk, 0.77; 95% confidence interval, 0.62 to 0.97). However, pooling of data from three individually randomized trials of 5135 community-dwelling participants showed no reduction in the prevalence of hip, pelvic, or other type of fracture in individuals for whom the use of such protectors had been prescribed. Compliance was poor as well, thus establishing the ineffectiveness of this modality outside of an institutional setting.

Femoral Fractures

Recently, the theory and practice of damage-control orthopaedics has enjoyed front-stage attention. The theory is that a femoral fracture in a critically injured patient is better off being stabilized initially with an external fixator rather than an intramedullary nail in order to avoid the immunologic and inflammatory challenge associated with the embolic result of reamer and nail insertion. In this scenario, the external fixator is exchanged for a nail after resuscitation and stabilization of the patient. In a retrospective study of patients with femoral shaft fractures, Harwood et al. determined that there was no difference in the rate of infection between patients who were managed with primary nailing and those who were managed with primary external fixation followed by conversion to an intramedullary nail47. This finding was observed despite the fact that the patients who initially were managed with external fixation had a greater injury severity score and a greater number of Gustilo type-III open fractures. It is noteworthy that the mean interval between the application of the external fixator and intramedullary nailing was 14.1 days. Furthermore, it is important to note that a rigorous protocol of pin-track care at the time of exchange was performed. This protocol is described in the article.
Some femoral nails are now designed to have a trochanteric starting point. The jury is still out as to whether or not this technique is any easier or more effective. Starr et al. compared the piriformis fossa starting point with the trochanteric starting point in a study in which high-energy proximal femoral fractures were treated with cephalomedullary (reconstruction) nails48. This prospective, randomized study included thirty-four consecutive patients who had sustained a subtrochanteric, intertrochanteric, or ipsilateral femoral neck or shaft fracture. Direct fracture exposure was avoided, a reamed technique was used, and all nails were statically locked. There was no difference between the groups in terms of blood loss, incision length, duration of surgery, or intraoperative complications. The surgeon's assessment of ease of use did not differ. The rate of varus malunion did not differ between the two groups. All fractures healed without additional surgery, and there was no difference between the groups with regard to return to work status, Harris hip score, or the ranges of motion of the hip and knee.
Perhaps an important factor in the treatment of femoral fractures with use of the trochanteric starting point is the shape of the nail itself. The nail formerly designed to be placed through the piriformis fossa was not designed for insertion through the trochanter, and the practice of inserting such a nail into the femur through the trochanter commonly resulted in a varus reduction. In a prospective, clinical trial that was conducted at three trauma centers, sixty-one consecutive patients with a femoral diaphyseal fracture were managed with an antegrade nail designed for trochanteric entry49. All but one of the fractures united after the index procedure. No patient sustained iatrogenic fracture comminution, and there were no angular malunions. Of the forty-six patients who were seen at the time of follow-up, six reported slight pain and two reported moderate pain.

Periprosthetic Femoral Fractures

Periprosthetic femoral fractures seem to be occurring more frequently with the explosion in the number of geriatric patients attributable to the baby boom generation entering the high-risk categories for osteoporosis and the greater number of arthroplasties being performed in younger patients. The next two studies contrast the results from large series of periprosthetic fractures. In the study by Lindahl et al., 1049 periprosthetic fractures around total hip replacements that had been reported to the Swedish National Hip Arthroplasty Register between 1979 and 2000 were identified50. Of these fractures, 245 (23%) were treated with an additional operation after the failure of the initial treatment. It was found that the risk of failure was reduced for Vancouver type-B2 injuries if revision of the implant was undertaken or if revision and open reduction and internal fixation were performed. An increased risk of failure was associated with fractures that were classified as Vancouver type B1 (femoral fracture around a stable stem). The most common reasons for failure in this group were loosening of the femoral prosthesis, nonunion, and re-fracture. The authors speculated that many fractures that were classified as Vancouver type B1 (n = 304) were in reality type-B2 fractures (fractures around a loose stem) that were unrecognized and therefore undertreated, leading the authors to state that a stem should be considered loose until proven otherwise. In the study by Ricci et al., fifty consecutive patients with a femoral shaft fracture about a stable intramedullary implant (a Vancouver type-B1 fracture) were managed with a single approach involving the use of indirect reduction and internal fixation with a single lateral plate without bone-grafting51. It is important to note that although two patients received a blade-plate, none of the other patients received a fixed-angle (locking) plate. Four patients died in the early postoperative period, and five had inadequate follow-up. The remaining forty-one fractures healed in satisfactory alignment, without evidence of implant loosening or malalignment, at a mean of twelve weeks after the index procedure. Thirty of these forty-one patients returned to their baseline walking status, indicating improved results compared with previous reports. One key difference between this study51 and the former study50 is that, in the study by Ricci et al.51, biologic surgical techniques were emphasized, whereas in the study by Lindahl et al50., the patients were recruited as far back as 1979, prior to the onset of the philosophy of biologically friendly surgery.
The dubious track record for the treatment of periprosthetic fractures may in fact be improving with advances in plating technology. Locked plating has experienced increased clinical research interest since its introduction to the orthopaedic mainstream in 1997. Now studies revealing larger roles for locking plate and screw technology in more challenging clinical situations are beginning to emerge. Femoral fractures that occur after a knee or hip arthroplasty historically have been plagued with high complication rates. In a retrospective study that was conducted at two institutions, O'Toole et al. analyzed the results associated with the use of the Less Invasive Stabilization System (LISS) (Synthes) for the treatment of twenty-four periprosthetic femoral fractures in patients with a stable ipsilateral total knee prosthesis and/or hip prosthesis52. Ten patients had an ipsilateral hip replacement, nine had an ipsilateral total knee replacement, and five had both knee and hip replacements. Eighteen procedures involved the use of a minimally invasive technique, and the majority of the fixators were applied to overlap the hip and/or knee prosthesis, with fixation in the zone of the hip stem being augmented with cerclage wires in six of fifteen patients. Ten fractures had between 5° and 10° of malalignment postoperatively, and two had >10° of malalignment. Importantly, there were no complications related to the cement mantle in ten hips with a cemented stem and thirteen knees with a cemented femoral component. After a mean of forty-eight weeks of follow-up, eighteen of the nineteen fractures in the surviving patients with adequate follow-up had healed uneventfully. These results are very encouraging when compared with the historical track record for this difficult problem. In a variation on this same theme, Ricci et al. reported on twenty-four prospectively collected, consecutive, closed supracondylar femoral fractures proximal to a well-fixed total knee replacement that were treated with a Locking Condylar Plate (Synthes)53. Twenty-two patients were available for follow-up at a mean of fifteen months. Indirect reduction methods were used in all cases. Nineteen of the twenty-two fractures healed after the index procedure. All three patients with healing complications had insulin-dependent diabetes and were obese. There were two malreductions and two deep infected nonunions. Fracture of screws in the proximal fragment occurred in four patients, and a progressive coronal plane deformity occurred in three.

Knee Ligaments, Proximal Part of the Tibia, and Tibial Shaft

Schmidt et al. designed a prospective diagnostic protocol to determine the spectrum of knee injury in patients who presented to Allegheny General Hospital with a hip dislocation (or fracture-dislocation)54. They reasoned that coexistent injuries are most likely because it is usually the knee that absorbs the direct energy from the injury mechanism, with the hip injury resulting from indirect forces. Twenty-eight consecutive patients were evaluated with a standardized history, physical examination, and magnetic resonance imaging. Twenty-five of the twenty-eight knees had visible evidence of soft-tissue injury on inspection. Magnetic resonance imaging revealed evidence of some abnormality in twenty-five of twenty-seven knees, with effusion, bone bruise, and meniscal tear being the most common findings. The authors concluded that more liberal use of magnetic resonance imaging should be considered, and certainly more diagnostic vigilance should be paid to such patients. The authors acknowledged that their study did not address the possibly benign natural history of many of these lesions.
Bottomley et al., in a study from London, England, evaluated the relationship between the pattern of damage to the posterolateral corner of the knee and the position of the common peroneal nerve55. Fifty-four consecutive patients with posterolateral corner disruption requiring surgery were evaluated. Sixteen of the eighteen patients with a biceps avulsion or avulsion-fracture of the fibular head had a displaced common peroneal nerve, and eight of these sixteen had a nerve palsy. The nerve was pulled anteriorly with the biceps tendon in all cases. This phenomenon makes perfect sense as the common peroneal nerve is tethered to the posterior edge of the biceps femoris tendon at the proximal-lateral knee region. On the contrary, none of the thirty-four more proximal injuries resulted in an abnormal nerve position. This relationship will aid surgeons when performing open repairs of the posterolateral corner and suggests that the common peroneal nerve should be anticipated to be injured or displaced and thus should be identified more proximally first.
The first clinical report on the use of locked plating for the treatment of proximal tibial fractures was recently published, giving a glimpse into an encouraging future for these traditionally problematic fractures. This year, two more studies seemed to corroborate earlier findings of high union rates and low infection rates in association with the Less Invasive Stabilization System (LISS) (Synthes).
An Austrian group prospectively studied twenty-five patients with twenty-six proximal tibial fractures, including intraarticular and extra-articular variants (AO types A2, A3, C1, C2, and C3), that were treated with the Less Invasive Stabilization System56. The minimum duration of follow-up was three years. Similar to the findings in previous studies, there were no losses of reduction in patients with extra-articular fractures (at least four screws were used on each side of the fracture). Furthermore, varus malalignment occurred in association with only one fracture. The mean Knee Society and Hospital for Special Surgery scores steadily improved through the first postoperative year before patient function plateaued, although two patients had development of knee arthrosis requiring total knee replacement. There was one delayed union, and two patients desired or underwent implant removal. It is noteworthy that eight patients had an open fracture. The final range of knee flexion averaged 130° for the extra-articular variants and 117° for the intra-articular variants, again mimicking the results of previous studies involving the use of this technique.
The use of a single lateral plate for the treatment of bi-column fractures seemed to be adequate in the former study56 (in agreement with the findings of other published studies on the Less Invasive Stabilization System), with only one recorded minor loss of alignment. This success rate is challenged by a study from Germany in which sixty-eight patients with sixty-nine proximal tibial (AO/ASIF 41-C-type) fractures were treated with a single lateral plate57. After eleven to thirteen months of follow-up, malalignment in the frontal or sagittal plane of >5° was seen in thirteen patients (19%), including nine patients who had late loss of alignment of 5° to 10° (seven fractures collapsed into varus, and two fell into antecurvatum). These rates of malalignment and loss of reduction are higher than those that have been previously reported, possibly reflecting the early learning curves of a large group of forty-one surgeons in thirteen trauma centers or perhaps reflecting a deviation from the prescribed minimally invasive technique as thirteen patients underwent primary bone-grafting.
As noted previously, the low infection rates recorded in both of the previous two studies56,57 are much better than historically published infection rates for open reduction and internal fixation in the range of 10% to 88%.
Clearly, another treatment variable besides less invasive surgery that has changed in the past decade has been the more conservative timing of definitive surgery and the use of spanning external fixation across the injured knee during the delay to definitive fixation. Egol et al. described a staged protocol involving temporary spanning external fixation prior to formal definitive fixation in a study of fifty-seven high-energy proximal tibial fractures (OTA type 41), including sixteen open fractures58. These fractures were repaired with various plate-and-screw constructs or with conversion to a ring fixator (n = 6) at an average of fifteen days after the injury. Forty-nine fractures were followed for a mean of 15.7 months. The rates of deep infection and nonunion were only 5% and 4%, respectively. Although knee stiffness is a potential downside to spanning external fixation, the mean arc of knee motion at the time of the final follow-up was from 1° to 106° in this study. There were clearly many uncontrolled treatment variables in this study, but the authors recommended the routine use of spanning external fixators for the treatment of high-energy tibial plateau fractures on the basis of the low complication rate encountered.
Another high-energy, but rarely reported, tibial plateau fracture that does not fit into the Schatzker classification scheme—the posterior shearing tibial plateau fracture—was described this year by the orthopaedic trauma group at Brigham and Women's Hospital and Massachusetts General Hospital59. The authors reported on a retrospective series of thirteen patients in whom an inferiorly displaced posteromedial shear fracture with variable amounts of lateral condylar impaction was treated through a popliteal approach. There were only two complications, including one flexion contracture and one minor wound dehiscence. After a mean duration of follow-up of twenty months, the average Musculoskeletal Function Assessment dysfunction score was 19.5 of 100. The functional outcome score was significantly related to the quality of articular reduction, indicating a successful approach to a rare and difficult problem.
The AO Clinical Investigation and Documentation Center used multivariate regression analysis to illustrate associations of prognostic factors and to show the relative risks of delayed union or nonunion of tibial fractures that were treated operatively60. A prospective observational study was conducted on 416 patients with tibial shaft fractures that were treated operatively at one of forty-one Swiss trauma clinics. After a minimum duration of follow-up of six months, a 13% rate of delayed union or nonunion was encountered. Skin breakage (and the size of the open wound), diastasis of the fixed fracture, and fracture location were identified as the variables associated with the greatest risk for nonunion. Interestingly, the AO fracture classification did not correlate with the likelihood of nonunion, whereas the risk of healing problems was doubled for fractures of the distal part of the shaft and for fractures showing a postoperative diastasis. Associations between these prognostic factors were then illustrated in a path diagram that the Center developed.
The optimal treatment of unstable distal extra-articular tibial fractures is unknown. Zelle et al. performed a meta-analysis of the English-language literature to assess the complications and healing rates associated with the different technique used to treat this injury61. Sixteen studies met the inclusion criteria. Data were pooled for 521 patients who were managed nonoperatively, 489 who were managed with an intramedullary nail, and 115 who were managed with a plate and screws. The nailing group had a higher rate of open fractures (28.1%) than did the nonoperative group (1%) or the plating group (4.3%). The results of this review revealed that the nonoperative group had a nonunion rate of 1.3%, a mal-union rate of 15%, a secondary procedure rate of 4.3%, and an infection rate of 0%. The intramedullary nailing group had rates of 5.5%, 16.2%, 16.4%, and 4.3%, respectively, and the plating group had rates of 5.2%, 13.1%, 8.7%, and 2.6%, respectively. Another finding was that there have been no prospective, randomized trials on the treatment of this injury, which underscores the need for such a trial.
It is ironic, coming on the heels of the aforementioned meta-analysis, which demonstrated the highest complication rates in the intramedullary nailing group, that two studies that were published this past year focused on the intramedullary nailing of distal tibial fractures. The first study, by Nork et al., specifically focused on fractures located within 5 cm of the ankle joint62. Thirty-six fractures involving the distal 5 cm of the tibia were treated with reamed intramedullary nailing with use of either two or three distal interlocking screws. In contradistinction to the malunion rate of 16.2% found in the collective contemporary literature, Nork et al. reported an 8% rate of malunion (defined as >5° of angulation in any plane). No patient demonstrated loss of alignment during the follow-up period. Complications included one deep infection and one iatrogenic fracture. In the group of thirty patients who could be followed, the average time to union was 23.5 weeks, although three patients with associated traumatic bone loss underwent a staged autograft procedure prior to union. Perhaps the better results reflected in this series were related at least partly to the common use of multiple screws in the distal fragment and ipsilateral fibular plating. The second study, by Egol et al., focused specifically on this latter issue of whether or not plating of the fibula can make a difference when used as a supplement to intramedullary nailing of distal tibial fractures63. In this retrospective review that was conducted at three level-I trauma centers, two groups of fractures were studied. Group 1 consisted of twenty-five fractures that were treated with small-fragment plate fixation of the fibula and intramedullary nailing of the tibia, and Group 2 consisted of forty-seven fractures that were treated with intramedullary nailing of the tibia without fibular fixation. In multivariate adjusted analysis, plating of the fibular fracture was significantly associated with the maintenance of reduction, despite the more common use of plates for the more distal tibial fractures. Not surprisingly, the authors found that the use of at least two distal locking bolts also was protective against the loss of reduction.
In a prospective, randomized study comparing closed intramedullary nailing with open plate-and-screw fixation for the treatment of distal metaphyseal fractures of the tibia, sixty-four consecutive fractures were followed for a period of two years64. There was no significant difference between the groups in terms of the time to union, the rate of superficial or deep infection, functional outcome, or the rate of malunion. The articles discussed above speak collectively to the importance of obtaining and maintaining a reduction of distal tibial fractures with stable fixation allowing for early rehabilitation.

Ankle and Foot

In the article by Koval et al., entitled "Ankle Fractures in the Elderly: What You Get Depends on Where You Live and Who You See," the data on 20% of the Medicare Part-B claims from the years 1998 to 2000 were analyzed, specifically with regard to the claims attached to Current Procedural Terminology (CPT) codes for operative and nonoperative treatment of ankle fractures65. Of the 33,704 ankle fractures that were identified, 7.6% were isolated medial malleolar fractures, 50.8% were isolated lateral malleolar fractures, 27.4% were bimalleolar fractures, and 14.2% were trimalleolar fractures. The rate of ankle fractures varied substantially, from 1 per 1000 Medicare enrollees in San Francisco, California, to 8.3 per 1000 in Hickory, North Carolina. The rate was highest (5.8 per 1000) in white women and lowest (1.5 per 1000) in nonwhite men. The rates of operative fixation varied dramatically, ranging from 14% in Binghampton, New York, to 72% in Napa, California, with a mean rate of 33% for the United States. Because data from radiographs and patient charts were not accessible, the authors pointed out that it is not possible to tease apart the reasons for such wide variations. Beneficiaries living in areas in which a hospital was a member of the Council of Teaching Hospitals were less likely to receive surgical treatment. Perhaps counterintuitively, the concentration of orthopaedists in a region was not associated with the likelihood of having surgical treatment. On the basis of these interesting findings, the authors concluded that the significant variation in treatment likely reflects a lack of consensus on the indications for surgery (unlike the case for hip fractures, for which there is a strong consensus for operative treatment) and that perhaps the lower rates in areas with teaching hospitals may have something to do with greater consensus on surgical indications established by the faculty in such settings.
Perhaps some of the diversity in the treatment of ankle fractures has to do with confusion in interpreting the nature of the ligamentous injury or the morphology of the posterior malleolus in a trimalleolar ankle fracture. Two studies underscored the lack of diagnostic accuracy with use of currently accepted radiographs. In the first study, by Haraguchi et al., computed tomography was used to clarify the pathologic anatomy of the posterior malleolar fracture66. Fifty-seven consecutive patients with a posterior fracture fragment were reviewed, and three general patterns were found: the posterolateral-oblique type (67%), the medial-extension type (19%), and the small-shell type (14%). The average area of the fragment comprised 11.7% of the cross-sectional area of the tibial plafond for posterolateral-oblique fractures and 29.8% for medial-extension fractures. The angles between the bimalleolar axis and the major fracture line of the posterior malleolus ranged from 9° to 40°. Because of the great variability in the size of the fragment, the pattern of fracture, and, most importantly, the vector of this fracture line (which did not correspond properly with standard radiographic positions), the authors strongly recommended the use of computed tomography for surgical planning when the posterior malleolus is involved. In the second study, by Gardner et al., fifty-nine patients were evaluated with both standard ankle radiographs and a magnetic resonance imaging scan67. All plain radiographs were classified according to the Lauge-Hansen system by an experienced orthopaedic traumatologist, and magnetic resonance imaging studies were read by a musculoskeletal radiologist who was blinded to the radiographic examinations. The ligaments that were predicted to be ruptured on the basis of the Lauge-Hansen classification were then compared with the actual injured structures with use of magnetic resonance imaging. Of the fifty-nine ankle fractures, ten (17%) were not classifiable on the basis of the Lauge-Hansen system. Of the forty-nine fractures that fit into Lauge-Hansen categories, twenty-six (53%) had patterns of ligamentous injury and fracture morphology on magnetic resonance imaging that did not coincide with the Lauge-Hansen predictions. A common fracture pattern was observed in eight of the ten unclassifiable fractures: a high spiral fracture of the fibula, a vertical shear fracture of the medial malleolus, a posterior malleolar fracture, and complete tears of the anterior-inferior tibiofibular ligament and the interosseous membrane. In addition, >65% of the patients in this series had a complete ligamentous injury and a fracture of the malleolus to which the ligament attaches. Although the Lauge-Hansen classification clearly aids in understanding the injury mechanism and treatment, this system was established in the biomechanics laboratory on the basis of findings in cadavers and therefore does not always fit the reality of injuries in the clinical setting.
In the study by Egol et al., 232 patients who had sustained an ankle fracture were managed surgically and were followed prospectively for a minimum of one year to evaluate functional recovery68. Complete follow-up data were available for 198 patients. At one year, 174 (88%) of the patients had either no or mild ankle pain and 178 (90%) either had no limitations or had limitations only in recreational activities. One hundred and seventy-eight patients (90%) had >89% functional recovery on the basis of the American Orthopaedic Foot and Ankle Society score. An age of less than forty years was a predictor of recovery, as measured with the Short Musculoskeletal Function Assessment (SMFA) form, at six months. However, by one year, age was no longer a predictor of recovery. Men were more likely to recover function than women were. ASA Class 1 or 2 and an absence of diabetes were also predictors of better functional recovery at one year. Overall, SMFA subscores by one year were almost back to normal levels, providing quite encouraging prognostic information for patients.
Can the orthopaedic surgeon positively affect the rate of return to such functional recovery? Simanski et al. conducted a prospective functional outcome study to determine whether a postoperative protocol of immediate weight-bearing was better than the short-term use of an orthosis and delayed weight-bearing69. Forty-three patients who were managed surgically for the treatment of a Weber type-B or C fracture underwent early weight-bearing. Twenty-three patients in this group were matched to the same number of historic controls who were treated for six weeks in a cast. After a mean duration of follow-up of twenty months, the early-weight-bearing group had a shorter time to full weight-bearing and time until return to work. In both groups, the majority of patients eventually reached their preinjury level of activity. The authors concluded that potential candidates for early weight-bearing are patients with a stable osteosynthesis of their fractured ankles as judged by the surgeon, in a compliant and motivated patient.
The following two retrospective studies analyzed a similar treatment for the tibial pilon fracture, which until recently has had a poor track record with regard to complications of open reduction and internal fixation. In both studies, a posterolateral approach between the peroneal and flexor hallucis tendons was used and a staged protocol with a spanning ankle external fixator was used for variable amounts of time in all patients. The average duration of follow-up was fourteen months in the first study70 and thirteen months in the second study71. In the first study, by Sheerin et al., a 90° cannulated blade-plate and autogenous iliac crest bone graft was used for fifteen distal tibial fractures, thirteen of which were open70. All fifteen fractures were followed until union, which occurred at a mean of twenty weeks. The average American Orthopaedic Foot and Ankle Society score was 81 of a possible 100. There were no deep infections. There was one nonunion, which united after revision with a locked plate and bone graft. In the second study, by Bhattacharyya et al., despite the fact that only four of nineteen fractures were open, nine (47%) of nineteen patients had a total of fourteen major complications, including wound problems (six), aseptic nonunion (two), infected nonunion (two), tibiotalar fusion (three), and a 3-mm step-off (one), necessitating fourteen reoperations71. The authors recommended abandoning this treatment. There were two major differences between the two studies, which may help to explain the divergent results and sort out an appropriate role for this technique. The first study included only AO-OTA Type-43A3 and 43C1 fractures (extra-articular distal tibial fractures with a comminuted metaphysis or a single split into the plafond but with no metaphyseal comminution), whereas the second study included more complex intra-articular variants. It is likely that the greatest difference between the two studies is the timing of surgery, which was far more conservative (less acute) in the first study. The mean time to definitive treatment was twenty-two weeks (range, two to eighty-four weeks) in the first study, whereas it was thirteen days (range, two to thirty days) in the second study. As is commonly the case, patient selection for treatment may be the best indicator for a good outcome.
In a follow-up to their randomized, controlled trial of operative and nonoperative treatment of calcaneal fractures that was published in The Journal in 2002, Brauer et al.72 reported on a follow-up tangent on the cost-effectiveness of operative and nonoperative treatment for displaced calca-neal fractures based on the results and assumptions from the 2002 trial. A four-year time horizon was used to determine the effect on costs and health benefits. The complication rate, arthrodesis rate, survival data, health-outcome data, and indirect costs (time from work) were estimated. Operative treatment resulted in a lower rate of subtalar arthrodesis and a shorter time off from work compared with nonoperative treatment; thus, when indirect costs were considered, operative treatment was less costly (an average savings of 19,000 Canadian dollars per patient), making it the preferred treatment strategy from a purely economic perspective. The result was most sensitive to the estimates of the costs of time lost from work; in fact, when these costs were excluded, operative treatment increased the average cost per fracture by 2800 Canadian dollars per patient.
Perhaps one subgroup of patients that is not generally favored for operative treatment of calcaneal fractures is the elderly. In the study by Herscovici et al., thirty-seven fractures in patients who were at least sixty-five years of age were followed for a minimum of twenty-four months after surgery with functional outcome assessment73. All but one fracture healed at an average of 110 days. In general, the outcome scores were good. Posttraumatic subtalar arthritis developed in twelve patients, but only three patients desired an arthrodesis. There were four major complications (three cases of osteomyelitis and one nonunion), all of which were treated successfully, and four patients desired hardware removal. Herscovici et al. recommended that operative treatment should be considered for elderly patients with an active lifestyle.
There are relatively few published data on fractures distal to the calcaneus, so it is refreshing to read a well-designed prospective, randomized study comparing primary arthrodesis with open reduction and internal fixation for the treatment of primarily ligamentous Lisfranc joint injuries. Ly and Coetzee followed forty-one patients for an average of 42.5 months to determine functional outcomes74. Twenty patients were managed with open reduction and screw fixation, and twenty-one patients were managed with primary arthrodesis of the medial two or three rays. Anatomic initial reduction was obtained in eighteen of the twenty patients in the open-reduction group and twenty of the twenty-one patients in the arthrodesis group. After twenty-four months of follow-up, the mean AOFAS midfoot score was 68.6 points in the open-reduction group and 88 points in the arthrodesis group (p < 0.005) and five patients in the open-reduction group had persistent pain with the development of deformity or osteoarthrosis that was eventually treated with an arthrodesis. The patients who had been managed with a primary arthrodesis estimated that their postoperative level of activity was 92% of the preinjury level, whereas those in the open-reduction group estimated that their postoperative level was only 65% of the preoperative level, leading the authors to conclude that primary stable arthrodesis of the medial two or three rays yields a better short and intermediate-term outcome than does open reduction and internal fixation of ligamentous Lisfranc joint injuries.
Three tables summarizing the studies reported here are available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
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Simanski CJ, Maegele MG, Lefering R, Lehnen DM, Kawel N, Riess P, Yucel N, Tiling T, Bouillon B. Functional treatment and early weightbearing after an ankle fracture: a prospective study. J Orthop Trauma. 2006;20: 108-14.20108  2006  [PubMed][CrossRef]
 
Sheerin DV, Turen CH, Nascone JW. Reconstruction of distal tibia fractures using a posterolateral approach and a blade plate. J Orthop Trauma. 2006;20: 247-52.20247  2006  [PubMed][CrossRef]
 
Bhattacharyya T, Crichlow R, Gobezie R, Kim E, Vrahas MS. Complications associated with the posterolateral approach for pilon fractures. J Orthop Trauma. 2006;20: 104-7.20104  2006  [PubMed][CrossRef]
 
Brauer CA, Manns BJ, Ko M, Donaldson C, Buckley R. An economic evaluation of operative compared with nonoperative management of displaced intraarticular calcaneal fractures. J Bone Joint Surg Am. 2005;87: 2741-9.872741  2005  [CrossRef]
 
Herscovici D Jr, Widmaier J, Scaduto JM, Sanders RW, Walling A. Operative treatment of calcaneal fractures in elderly patients. J Bone Joint Surg Am. 2005;87: 1260-4.871260  2005  [PubMed][CrossRef]
 
Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006;88: 514-20.88514  2006  [PubMed][CrossRef]
 

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Sheerin DV, Turen CH, Nascone JW. Reconstruction of distal tibia fractures using a posterolateral approach and a blade plate. J Orthop Trauma. 2006;20: 247-52.20247  2006  [PubMed][CrossRef]
 
Bhattacharyya T, Crichlow R, Gobezie R, Kim E, Vrahas MS. Complications associated with the posterolateral approach for pilon fractures. J Orthop Trauma. 2006;20: 104-7.20104  2006  [PubMed][CrossRef]
 
Brauer CA, Manns BJ, Ko M, Donaldson C, Buckley R. An economic evaluation of operative compared with nonoperative management of displaced intraarticular calcaneal fractures. J Bone Joint Surg Am. 2005;87: 2741-9.872741  2005  [CrossRef]
 
Herscovici D Jr, Widmaier J, Scaduto JM, Sanders RW, Walling A. Operative treatment of calcaneal fractures in elderly patients. J Bone Joint Surg Am. 2005;87: 1260-4.871260  2005  [PubMed][CrossRef]
 
Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006;88: 514-20.88514  2006  [PubMed][CrossRef]
 
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