Andrew R. Evans

Autologous Bone Graft: Properties and Techniques

Bone grafting is involved in virtually every procedure in reconstructive orthopaedic surgery. Although autologous bone grafts have excellent biologic and mechanical properties, considerable donor site morbidity and the limited volume available must be taken into consideration. Currently, there are no heterologous or synthetic bone substitutes available that have superior biologic or mechanical properties. This review article summarizes the biologic and mechanical properties of autologous bone grafts, differentiates various autologous bone graft types, and compares them with other bone substitutes.

The OTA open fracture classification: a study of reliability and agreement.

Objectives: To determine the reliability of the Orthopaedic Trauma Association (OTA) Open Fracture Classification. Design: Video-based reliability study. Setting: Orthopedic meetings and grand rounds. Patients/participants: Orthopedic surgeons. Intervention: None. Main Outcome Measurements: Interobserver reliability assessment classification. Results: The results demonstrate the system to have high reliability and much improvement compared with published Gustilo–Anderson classification reliability studies. Overall interrater reliability (&kgr;) values were highest for arterial injury, with near perfect agreement across all raters and within each value. Skin injury, bone loss, and contamination demonstrated moderate to substantial levels of agreement. Muscle injury had the most disagreement between raters but still demonstrating a fair level of interrater agreement, which is a level of agreement superior to the literature related to the Gustilo–Anderson classification. Levels of agreement were similar between attending surgeons and residents for all categories. Conclusions: This study, which included a diverse multicenter multinational cohort of orthopaedic surgeons and residents, of the OTA Open Fracture Classification demonstrated moderate to excellent interobserver reliability.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

OBJECTIVES To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach. DESIGN Retrospective review. SETTING Two level one trauma centres. PATIENTS Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up. INTERVENTION Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients). MAIN OUTCOME MEASUREMENTS Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p=0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p<0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p=0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p=0.333). CONCLUSIONS A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome. LEVEL OF EVIDENCE Level III.

Staged Treatment of High Energy Midfoot Fracture Dislocations

Background: Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious. Methods: One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed. Results: The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred. Conclusion: Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients. Level of Evidence: Level III, retrospective comparative study.

Determining the efficacy of screw and washer fixation as a method for securing olecranon osteotomies used in the surgical management of intraarticular distal humerus fractures.

Objectives: The purpose of this study was to critically evaluate the efficacy of single screw and washer fixation in comparison with other methods for securing olecranon osteotomies. The hypothesis is that screw and washer fixation is a safe and effective means of olecranon osteotomy fixation with fusion and complication rates similar to other methods of fixation. Design: Retrospective review. Setting: Two Level I Urban Trauma Centers. Patients/Participants: Patients were treated within the last 20 years and received 1 of 4 types of fixation (screw and washer alone, screw and washer augmented with tension band, tension band alone, or plate and screws) after osteotomy. Intervention: Open reduction and internal fixation of OTA/AO 13B/C distal humerus fractures with an olecranon osteotomy. Main Outcome Measurements: The primary outcome measure was the presence of osteotomy union. Secondary outcome measures were olecranon nonunion, loss of articular reduction, and removal of hardware. Logistic regression was used to determine the associations between method of osteotomy fixation and removal of hardware or nonunion rates. Comorbidities were stratified using the Charlson comorbidity index. Results: One hundred sixty patients met the inclusion criteria. Thirty-nine patients underwent screw fixation alone, 47 had tension band fixation, 16 had plate fixation, and 58 had tension band and screw fixation. Screw fixation demonstrated equal or better rates of union, maintenance of reduction, absence of infection, and implant removal compared with alternative fixation techniques. Higher Charlson scores were associated with higher rates of nonunion. Conclusions: Screw and washer fixation is a safe and effective means of securing an olecranon osteotomy. Charlson comorbidity score is one factor that may influence the development of nonunion after osteotomy. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Oblique distraction external pelvic fixation.

Simple anterior pelvic external fixation is a safe and effective strategy for reduction of pelvic ring deformity as well as the provisional or definitive stabilization of selected patterns of pelvic ring disruption. A two-pin oblique anterior pelvic deformity correction frame is a unique frame configuration designed to reduce and stabilize lateral compression pelvic ring disruptions associated with flexion/internal rotation hemipelvic deformities. In a small case series, we demonstrate that the oblique distraction external fixation frame alone or in combination with internal fixation is a simple and safe strategy for reduction and stabilization of unstable multiplanar hemipelvic deformities associated with partial posterior ring stability.

Musculoskeletal function assessment outcomes scores over time for tibial plafond (OTA/AO 43) and proximal humeral (OTA/AO 11) fractures: a pilot project.

Objectives: What is the return to function after an isolated proximal humerus or tibial plafond fracture? Design: Prospective observational. Setting: Orthopaedic outpatient clinics. Patients/Participants: Consecutive patients were enrolled with isolated proximal humerus (N = 155) and tibial plafond fractures (N = 120). Intervention: None. Main Outcome Measurements: Musculoskeletal Function Assessment. Results: Patients who sustained isolated proximal humerus or tibial plafond fractures showed gradual improvement over 1 year. Women consistently demonstrated greater dysfunction than men at 6, 9, and 12 months after tibial plafond fracture. Age had an impact on return to function after injury for both fractures. Younger patients (18–29 years) with either type of injury tended to have better scores compared with the older patients. Conclusions: Detailed analysis of this data demonstrates variation in patient-based outcomes during recovery from a proximal humerus or tibial plafond fracture. These data need to be reviewed in the context of the individual patient when following a patients recovery. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Open Reconstruction of Complex Proximal Metadiaphyseal Fragility Fractures of the Humerus

Purpose: A proactive surgical and rehabilitation protocol was implemented to manage humeral fractures involving both the proximal end and shaft in an older patient population. Primary treatment goals were early return to function and reliable fracture union with minimal complications. Methods: From 2008 to 2012, 21 such operations were performed; 18 were considered “fragility” fractures based on mechanism, patient age, and evidence of osteopenia or osteoporosis. Open reduction and internal fixation (ORIF) was employed using direct reduction and fixation with a long periarticular locking plate. Physiotherapy was commenced 2 weeks postoperatively. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was used to assess functional outcome at a time point greater than 1 year postoperative. Results: The study group consisted primarily of elderly females (83% with a median age of 69 years) whom sustained complex metadiaphyseal proximal humeral fractures after simple mechanical fall (78%). Uneventful union occurred in all cases. Local complications included 1 case of partial radial nerve palsy, which had resolved completely by 1 year. No cases of infection were identified. Long-term return to functionality was evident with a median DASH score of 12 (mean = 21, standard deviation = 20, n = 13). Seventy five percent of patients reported minimal or no pain (question [Q] 24), and 75% achieved return of overhead function (Q6, 12, and 15). Conclusion: Treatment of complex metadiaphyseal fragility fractures with anatomic reduction, fixed angle plating, and early physiotherapy returns the older patient to optimized functionality with minimal risk of complication. The DASH outcomes are equivalent to ORIF of isolated proximal humerus fractures and clinically indistinguishable from the general population.