Triangular Osteosynthesis as a Treatment of Lumbopelvic Dissociation with Acute Cauda Equina Syndrome in an 11-Year-Old Patient.

This case offers a safe and effective method for treating lumbopelvic dissociation in a pediatric patient with cauda equina syndrome using a triangular osteosynthesis construct. After a high-speed accident, an 11-year-old girl was admitted to the hospital with bowel and bladder incontinence and bilateral lower extremity weakness. The orthopaedic trauma and spine teams elected for surgical treatment with a triangular osteosynthesis construct, a procedure usually reserved for adults. The surgery was uncomplicated, and the patient experienced complete resolution of her preoperative symptoms. She is doing well over 1-year postoperatively, with full neurologic recovery, maintained reduction, bony healing, and subsequent implant removal. To our knowledge, this is the youngest reported case of lumbopelvic dissociation treated in this manner and represents a viable treatment option.

Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial.

OBJECTIVES: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter randomized controlled trial. SETTING: Twenty academic trauma centers. PATIENTS/PARTICIPANTS: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

What Is the Rate of Displacement of Occult Posterior Malleolus Fractures in Nailed Tibial Shaft Fractures?

OBJECTIVE: To describe the radiographic consequences of posterior malleolus fractures (PMF) present with tibial shaft fractures fixed with intramedullary nails. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seven hundred thirty-three patients with tibial shaft fractures. INTERVENTION: Intramedullary nail fixation and prophylactic articular fixation. MAIN OUTCOME MEASURE: Displacement of PMF with intramedullary nail insertion. RESULTS: Seven hundred thirty-three patients were identified with tibial shaft fractures treated with intramedullary nail fixation at a Level 1 trauma center without a uniform preoperative computed tomography protocol. One hundred thirty-three patients had an identifiable PMF appreciated on preoperative imaging. Of the 600 remaining patients without a known PMF, 29 had PMF identified after nail insertion: 24 patients with nondisplaced fractures that all healed radiographically at final follow-up, 3 patients had fractures <30% of the articular surface displaced 1-2 mm, and 2 patients had fractures >30% of the joint surface that displaced 1-2 mm. CONCLUSIONS: The incidence of radiographically observable PMF associated with tibial shaft fractures is high, even without a preoperative computed tomography screening protocol in place. In patients without an appreciable PMF on injury films, less than 1% (2/600) had displacement of a large, clinically significant PMF with nail placement. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can we predict failure of percutaneous fixation of femoral neck fractures?

PURPOSE: This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns. METHODS: We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test. RESULTS: 139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p  0.03). The presence of a SIC and quality of screw placement were not predictive of failure. CONCLUSION: Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP.

Supracondylar Femur Fractures.

Supracondylar femur fractures are common fractures that represent a management challenge. Despite consistent fracture patterns and predictable challenges associated with reduction and stabilization, complications, including malunion, nonunion, and implant failure, can occur in patients who undergo treatment for the management of a supracondylar femur fracture. Although improvements in intramedullary nailing techniques, the emergence of biologically friendly surgical techniques, and the introduction of locked plating constructs have revolutionized orthopaedic fracture care, the surgical management of supracondylar femur fractures has improved minimally.

Now That I'm in Charge: What Do I Do?

Beginning one's practice can be overwhelming. Most young surgeons think this is all due to the stress of direct patient care. However, gathering all of the necessary support personnel and equipment to successfully do your job and then educating that team so it functions to ease your work life require planning and people skills. This knowledge can be learned during residency and fellowship training, which will help ease the stress of beginning one's career.

Treatment and complications in orthopaedic trauma patients with symptomatic pulmonary embolism.

OBJECTIVES: The purpose of this study is to characterize the presentation, size, treatment, and complications of pulmonary embolism (PE) in a large series of orthopaedic trauma patients who developed PE after injury. METHODS: We reviewed the records of orthopaedic trauma patients who developed a PE within 6 months of injury at 9 trauma centers and 2 tertiary care facilities. RESULTS: There were 312 patients, 186 men and 126 women, average age 58 years. Average body mass index was 29.6, and average Injury Severity Score was 18. Seventeen percent received anticoagulation before injury, and 5% had a history of PE. After injury, 87% were placed on prophylactic anticoagulation and 68% with low-molecular weight heparin. Fifty-three percent of patients exhibited shortness of breath or chest pain. Average heart rate and O2 saturation before PE diagnosis were 110 and 94%, respectively. Thirty-nine percent had abnormal arterial blood gas, and 30% had abnormal electrocardiogram findings. Eighty-nine percent had computed tomography pulmonary angiography for diagnosis. Most clots were segmental (63%), followed by subsegmental (21%), lobar (9%), and central (7%). The most common treatment was unfractionated heparin and Coumadin (25%). Complications of anticoagulation were common: 10% had bleeding at the surgical site. Other complications of anticoagulation included gastrointestinal bleed, anemia, wound complications, death, and compartment syndrome. PE recurred in 1% of patients. Four percent died of PE within 6 months. CONCLUSIONS: This is the first large data set to evaluate the course of PE in an orthopaedic trauma population. The complications of anticoagulation are significant and were as common in patients with lower risk clots as those with higher risk clots.

Getting organized in your job.

The benefits of being organized when starting one's career are countless and worth the time and effort in developing an effective and efficient practice. Established protocols, good habits, and methodical communication that include all members of the team will help create a system that keeps all components of one's practice organized. Adhering to these strategies requires self-discipline. Applying these concepts to patient care, education, research, and administrative responsibilities is the key to a successful and sustainable career.

Finding your first job in academics: interviewing strategies.

Successfully obtaining your first academic orthopaedic surgery position is a daunting adventure, but one in which you can succeed with proper preparation. First, you must identify specifically what you want to be doing on a daily basis at work. Then, you find places where you can potentially do those things. The interview will provide more definitive information and will allow you to assess if you can happily work in that environment. Remember that you must have balance in your life, so consider if the area is suitable to your and to your family's needs. By identifying your personal goals and desires of this initial position and thoroughly preparing for the entire interview process, you will be able to locate the most desirable opportunity available.

Authorship and ethical considerations in the conduct of observational studies.

Surgeons who participate in research studies frequently struggle with a number of challenges when determining authorship of the publications that arise from their research. Furthermore, new concerns relating to who receives credit and who takes responsibility have emerged with the increase in multicenter research collaborations. This paper provides a discussion of the importance of authorship and outlines a number of ethical issues that commonly arise when determining the author byline. We also present some strategies, such as publishing under group authorship, listing individual author contributions, and revising the mechanism for acknowledging nonauthor contributions, that have the potential to improve authorship and publication practices.

A comparison of acetate vs digital templating for preoperative planning of total hip arthroplasty: is digital templating accurate and safe?

The purposes of this study were to compare the accuracy of acetate and digital templating for primary total hip arthroplasty (THA) and to determine if digital templating is safe. Preoperative planning was performed on 50 consecutive preoperative radiographs during 2005. Templating results were compared with the actual hip implants used. Interrater reliability of acetate templating and accuracy of acetate and digital templating were recorded. Digital measurement overestimated acetabular size (P < .001) and underestimated the femoral size (P = .03). The absolute errors were larger for digital compared with acetate templating; however, mean absolute errors did not differ significantly (acetabulum, P = .090; femur, P = .114). Acetate and digital templating can accurately predict the size of THA implants. Digital templating was determined to be acceptably safe for preoperative planning of primary THA operations.

Single-leg-stance radiographs in the diagnosis of pelvic instability.

BACKGROUND: In the nonacute setting, the diagnosis of pelvic instability is difficult. Patients who present with pelvic pain may have underlying instability. The purpose of the present study was to report the effectiveness of single-leg-stance radiographs in the diagnosis of pelvic instability in a consecutive series of patients presenting with pelvic pain. METHODS: Thirty-eight consecutive patients (twenty-four women and fourteen men) ranging in age from eighteen to seventy-eight years who presented with pelvic pain and a history of injury (twenty-seven), childbirth (seven [four primiparous and three multiparous]), or osteopenia (four) were evaluated with a visual analog scale pain score and a standard series of radiographs in an attempt to identify pelvic instability. The average time from the onset of symptoms to the evaluation was forty-one months (range, six weeks to twenty-seven years). Each patient was evaluated with supine anteroposterior, inlet, and outlet pelvic radiographs; a standing anteroposterior pelvic radiograph; and two single-leg-standing pelvic radiographs (one with the patient standing on the left leg and one with the patient standing on the right leg). A positive finding was defined as >or=0.5 cm of vertical translation measured at the symphyseal bodies between the two single-leg-stance radiographs. RESULTS: Of the thirty-eight patients, twenty-five demonstrated pelvic instability (average, 1.98 cm; range, 0.5 to 5 cm). With the numbers available, the average visual analog scale pain score for the patients with a stable pelvis was not significantly different from that for the patients with an unstable pelvis (6.4 +/- 2.9 compared with 7.3 +/- 1.9; p = 0.28). CONCLUSIONS: Standing anteroposterior and single-leg-stance pelvic radiographs aid in the diagnosis of pelvic instability more effectively than do the standard three radiographs of the pelvis made in the supine position or a standing anteroposterior radiograph of the pelvis alone. Additional studies will be needed to correlate this instability with clinical symptoms. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Extraperiosteal plating of pronation-abduction ankle fractures. Surgical technique.

BACKGROUND: Pronation-abduction ankle fractures frequently are associated with substantial lateral comminution and have been reported to be associated with the highest rates of nonunion among indirect ankle fractures. The purpose of the present study was to report the technique for and outcomes of extraperiosteal plating in a series of patients with pronation-abduction ankle fractures. METHODS: Thirty-one consecutive patients with an unstable comminuted pronation-abduction ankle fracture were managed with extraperiosteal plating of the fibular fracture. The average age of the patients was forty-four years. There were nineteen bimalleolar and twelve lateral malleolar fractures with an associated deltoid ligament injury. No attempt to reduce the comminuted fragments was made as this area was spanned by the plate. The patients were evaluated functionally (with use of the American Orthopaedic Foot and Ankle Society score), radiographically, and clinically (with range-of-motion testing). RESULTS: Immediate postoperative and final follow-up radiographs showed that all patients had a well-aligned ankle mortise on the fractured side as compared with the normal side on the basis of standardized measurements. All fractures healed without displacement. At a minimum of two years after the injury, the average American Orthopaedic Foot and Ankle Society score (available for twenty-one patients) was 82. The range of motion averaged 13 degrees of dorsiflexion and 31 degrees of plantar flexion, with one patient not achieving dorsiflexion to neutral. There were no deep infections, and one patient had an area of superficial skin breakdown that healed without operative intervention. CONCLUSIONS: Extraperiosteal plating of pronation-abduction ankle fractures is an effective method of stabilization that leads to predictable union of the fibular fracture. The results of this procedure are at least as good as those of other techniques of open reduction and internal fixation of the ankle, although specific results for pronation-abduction injuries have not been previously reported, to our knowledge.

Reuse of external fixation components: a randomized trial.

OBJECTIVES: External fixation devices are sold in the United States as single-use devices and can be costly. Approved processes for refurbishment of nonimplantable components are available. We evaluated one such program for safety, efficacy, and fiscal ramifications. DESIGN: Randomized clinical trial SETTING: Single center, Level I trauma center PATIENTS/PARTICIPANTS: During the 30-month enrollment period (November 16, 2001 to May 16, 2004), 41 patients (13%) of 315 patients were not able to consent and were excluded. A total of 178 (65%) of the 274 eligible patients who were offered entry into a randomized trial of new versus refurbished external fixation components for their injury refused to participate, leaving 96 (35%) of the 274 eligible patients entered into the study. INTERVENTION: Consented patients were entered into a trial of new versus refurbished nonimplantable external fixation components for their injury (all pins were new). MAIN OUTCOME MEASUREMENTS: The frames were evaluated at the time of removal for efficacy and the complications of pin tract infections, loss of fixation, or loosening of components. RESULTS: A total of 48 distal radius fractures, 29 pilon fractures, and 19 tibial plateau fractures were entered into the study. With the 96 fractures treated in our study (50 new frames, 46 reused frames), we found no statistical differences in the incidence of pin tract infections (46% versus 52%, P=0.32), loss of fixation (4% versus 4%, P=0.70), or loosening of the components (1% versus 1%, P=1.0). CONCLUSIONS: Sixty-five percent of consentable patients did not wish to have an external fixation frame with refurbished clamps. Our study demonstrated that this type of program is safe and effective with an actual cost savings of $65,452. The potential savings of such a program is 25% of the cost of all new frames.

Extraperiosteal plating of pronation-abduction ankle fractures.

BACKGROUND: Pronation-abduction ankle fractures frequently are associated with substantial lateral comminution and have been reported to be associated with the highest rates of nonunion among indirect ankle fractures. The purpose of the present study was to report the technique for and outcomes of extraperiosteal plating in a series of patients with pronation-abduction ankle fractures. METHODS: Thirty-one consecutive patients with an unstable comminuted pronation-abduction ankle fracture were managed with extraperiosteal plating of the fibular fracture. The average age of the patients was forty-four years. There were nineteen bimalleolar and twelve lateral malleolar fractures with an associated deltoid ligament injury. No attempt to reduce the comminuted fragments was made as this area was spanned by the plate. The patients were evaluated functionally (with use of the American Orthopaedic Foot and Ankle Society score), radiographically, and clinically (with range-of-motion testing). RESULTS: Immediate postoperative and final follow-up radiographs showed that all patients had a well-aligned ankle mortise on the fractured side as compared with the normal side on the basis of standardized measurements. All fractures healed without displacement. At a minimum of two years after the injury, the average American Orthopaedic Foot and Ankle Society score (available for twenty-one patients) was 82. The range of motion averaged 13 degrees of dorsiflexion and 31 degrees of plantar flexion, with one patient not achieving dorsiflexion to neutral. There were no deep infections, and one patient had an area of superficial skin breakdown that healed without operative intervention. CONCLUSIONS: Extraperiosteal plating of pronation-abduction ankle fractures is an effective method of stabilization that leads to predictable union of the fibular fracture. The results of this procedure are at least as good as those of other techniques of open reduction and internal fixation of the ankle, although specific results for pronation-abduction injuries have not been previously reported, to our knowledge.