The treatment of musculoskeletal trauma continues to evolve at a rapid pace, with ongoing advances in our understanding of the pathophysiology of trauma and the biology of fracture-healing and the soft-tissue response to injury, the continual introduction of new implants and surgical techniques, and clarification of the role of nonoperative treatment of certain injuries. The current emphasis on evidence-based management continues, with the orthopaedic literature containing an increasing number of randomized clinical trials, meta-analyses, and systematic reviews.
For the purpose of summarizing advances in orthopaedic traumatology within the past year, we reviewed all issues of The Journal of Bone and Joint Surgery (American Volume and British Volume), Journal of Orthopaedic Trauma, Journal of Trauma, Clinical Orthopaedics and Related Research, and Injury. Selected articles from other journals were also included. Finally, presentations from the annual meetings of the Orthopaedic Trauma Association (OTA) and the American Academy of Orthopaedic Surgeons (AAOS) were reviewed. All articles and presentations that represent Level-I and II evidence are reviewed herein, along with other articles of clinical importance (in the opinion of the authors).
The twenty-fifth Anniversary Annual Scientific Meeting of the Orthopaedic Trauma Association (OTA) will be held October 7 through 10, 2009, in San Diego, California. Please see the OTA web page () for more information about the meeting schedule and registration. The OTA meets at Specialty Day during the Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) and always plans an educational event suitable for all orthopaedic surgeons who want to learn more about trauma care. Finally, the AAOS and OTA co-sponsor annual courses on extremity trauma in the fall and pelvic and acetabular trauma in the spring; this fall, the AAOS/OTA "Strategies and Tactics in Orthopaedic Extremity Trauma" will be held on November 19 through 21, 2009, at the Learning Center in Rosemont, Illinois. Please see the OTA web page for further details about OTA courses in 2010.
The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, all of which have high-quality study design. In addition to articles already cited in this update, three additional level-I articles were identified that were relevant to musculoskeletal trauma. A list of those articles is appended to this review following the standard bibliography.
Barker R, Schiferer A, Gore C, Gorove L, Lang T, Steinlechner B, Roumieh KA, Zimpfer M, Kober A. Femoral nerve blockade administered preclinically for pain relief in severe knee trauma is more feasible and effective than intravenous metamizole: a randomized controlled trial. J Trauma. 2008;64:1535-8.
Fifty-two patients with severe knee trauma randomly received femoral nerve blockade or intravenous metamizole at the accident scene, and were then transported to the hospital. Pain as assessed with a visual analog score was decreased by 50% in the nerve blockade group, and only two of the twenty-six patients who received nerve blocks were thought to have not benefited from it. The authors concluded that peripheral nerve blocks done in the field can be safely administered and improve patient care.
French DD, Bass E, Bradham DD, Campbell RR, Rubenstein LZ. Rehospitalization after hip fracture: predictors and prognosis from a national veterans study. J Am Geriatr Soc. 2008;56:705-10.
The authors studied a cohort of 41,331 veterans admitted to a Medicare facility with a hip fracture between 1999 and 2002 and very carefully determined the rates of readmission to any facility within thirty days. Nearly one-fifth (18.3%) of the patients were readmitted within thirty days. The one-year mortality in this subset of patients was 48.5%, which was twice the mortality rate that was observed among patients who were not readmitted (24.9%). Risk factors for readmission were primarily medical comorbidities, including fluid and electrolyte disorders, cardiac disease (arrhythmias, congestive heart failure), pulmonary disease, and renal failure. The authors discuss the implications of these findings as they related to health policy issues, including coordination of care and pay-for-performance.
Slobogean GP, Kennedy SA, Davidson D, O'Brien PJ. Single- versus multiple-dose antibiotic prophylaxis in the surgical treatment of closed fractures: a meta-analysis. J Orthop Trauma. 2008;22:264-9.
The authors reported the results of a meta-analysis of the wound infection rate in 3808 patients managed with either internal fixation or arthroplasty for the treatment of closed fractures. Compared with a multiple-dose regimen of prophylactic antibiotics, the risk ratio for a single dose of antibiotics was 1.24. However, the 95% confidence interval for the risk ratio spans 1.0, so even these data are insufficient to make a definitive recommendation.