Jeffrey O. Anglen

Nail or Plate Fixation of Intertrochanteric Hip Fractures: Changing Pattern of Practice: A Review of the American Board of Orthopaedic Surgery Database

BACKGROUND A new method of fixation for intertrochanteric hip fractures that involves the use of an intramedullary nail that interlocks proximally into the femoral head was introduced in the early 1990s. Anecdotal observation of practice patterns during the Part II (oral) American Board of Orthopaedic Surgery examination suggested that the use of this method had increased substantially in recent years in comparison with the more traditional sliding compression screw technique. A study of the Part II database was undertaken to detect changing patterns of care for intertrochanteric fractures. METHODS During the process of Board certification, candidates for the Part II (oral) examination submit a six-month surgical case list and patient data into a secure database. The database was searched for all intertrochanteric fractures (International Classification of Diseases, Ninth Revision, code 820.20 or 820.21) over a seven-year period (1999 through 2006). The cases were categorized by intramedullary nail or plate fixation on the basis of surgeon-reported Current Procedural Terminology codes. Relative utilization of the two devices was analyzed according to year and region, and the devices were compared in terms of complications and outcomes. RESULTS A dramatic change in practice was demonstrated, with the intramedullary nail fixation rate increasing from 3% in 1999 to 67% in 2006. Regional variation was substantial. The highest rate of utilization of intramedullary nail fixation was recorded by candidates from the South, Southeast, and Southwest, who converted to the new technology faster than those in the Northeast, Northwest, and Midwest. Overall, patients managed with plate fixation had slightly less pain and deformity in comparison with those managed with intramedullary nailing, with no significant differences being identified in terms of function or satisfaction. Patients managed with intramedullary nailing had more procedure-related complications, particularly bone fracture. CONCLUSIONS From 1999 to 2006, a dramatic change in surgeon preference for the fixation device used for the treatment of intertrochanteric fractures has occurred among young orthopaedic surgeons. This change has occurred despite a lack of evidence in the literature supporting the change and in the face of the potential for more complications.

Fractures of the Distal Part of the Radius The Evolution of Practice Over Time. Where's the Evidence?

BACKGROUND During the administration of the oral (Part II) examinations for the American Board of Orthopaedic Surgery over the past nine years, it has been observed that orthopaedic surgeons are opting more often for open treatment as opposed to percutaneous fixation of distal radial fractures. Evidence to support this change in treatment is thought to be deficient. The present study was designed to identify changes in practice patterns regarding operative fixation of distal radial fractures between 1999 and 2007 and to assess the results of those treatments over time. METHODS As a part of the certification process, Part II candidates submit a six-month case list to the American Board of Orthopaedic Surgery. In the present study, we searched the American Board of Orthopaedic Surgery Part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of open and percutaneous fixation of distal radial fractures. All distal radial fractures that had been treated surgically over a nine-year period (1999 to 2007) were reviewed. The fractures were categorized according to fixation method with use of surgeon self-reported surgical procedure codes. Comparisons of percentage treatment type by year were made. Utilization was analyzed by geographic region, and open and percutaneous fixation were compared with regard to complications and outcomes as self-reported by candidates during the online application process. RESULTS The proportion of fractures that were stabilized with open surgical treatment increased from 42% in 1999 to 81% in 2007 (p < 0.0001). Although the differences were small, surgeon-reported outcomes revealed that a higher percentage of patients who had been managed with percutaneous fixation had no pain and normal function but some deformity as compared with patients who had had open treatment. Patients who had been managed with percutaneous fixation had a higher overall complication rate (14.0% compared with 12.3%; p < 0.006) and a higher rate of infection (5.0% compared with 2.6%; p < 0.0001) than those who had been managed with open treatment. Patients who had had open treatment had a higher rate of nerve palsy and/or injury (2.0% compared with 1.2%; p = 0.001). No other differences in the reported complication rates were found between the two techniques. CONCLUSIONS A striking shift in fixation strategy for distal radial fractures occurred over the past decade among younger orthopaedic surgeons in the United States. These changes occurred despite a lack of improvement in surgeon-perceived functional outcomes.

Incisional negative pressure wound therapy after high-risk lower extremity fractures.

Objectives: To investigate negative pressure wound therapy (NPWT) to prevent wound dehiscence and infection after high-risk lower extremity trauma. Design: Prospective randomized multicenter clinical trial. Setting: Four Level I trauma centers. Patients/Participants: Blunt trauma patients with one of three high-risk fracture types (tibial plateau, pilon, calcaneus) requiring surgical stabilization. Intervention: Incisional NPWT (Group B) was applied to the closed surgical incisions of patients randomized to the study arm of this trial, whereas standard postoperative dressings (Group A) were applied to the control patients. Main Outcome Measures: Acute and chronic wound dehiscence and infection. Results: Two hundred forty-nine patients with 263 fractures have enrolled in this study with 122 randomized to Group A (controls) and 141 to Group B (NPWT). There was no difference between the groups in the distribution of calcaneus (39%), pilon (17%), or tibial plateau (44%) fractures. There were a total of 23 infections in Group A and 14 in Group B, which represented a significant difference in favor of NPWT (P = 0.049). The relative risk of developing an infection was 1.9 times higher in control patients than in patients treated with NPWT (95% confidence interval, 1.03–3.55). Conclusions: There have been no studies evaluating incisional NPWT as a prophylactic treatment to prevent infection and wound dehiscence of high-risk surgical incisions. Our data demonstrate that there is a decreased incidence of wound dehiscence and total infections after high-risk fractures when patients have NPWT applied to their surgical incisions after closure. There is also a strong trend for decreases in acute infections after NPWT. Based on our data in this multicenter prospective randomized clinical trial, NPWT should be considered for high-risk wounds after severe skeletal trauma.

Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A prospective, randomized study.

BACKGROUND Irrigation of open fracture wounds is a commonly performed procedure, and irrigation additives have been used in an attempt to reduce the risk of infection. In vitro and animal studies have suggested that irrigation with detergent solution is more effective than irrigation with a solution containing antibiotic additives. This study was performed to compare the efficacy of those two solutions in the treatment of open fractures in humans. METHODS Adult patients with an open fracture of the lower extremity were prospectively randomized to receive irrigation with either a bacitracin solution or a nonsterile castile soap solution. The patients were followed clinically to assess for the development of infection, healing of the soft-tissue wound, and union of the fracture. RESULTS Between 1995 and 2002, 400 patients with a total of 458 open fractures of the lower extremity were entered into the study. One hundred and ninety-two patients were assigned to the bacitracin group (B), and 208 were assigned to the castile soap group (C). Outcomes were available for 171 patients with a total of 199 fractures in group B and 180 patients with a total of 199 fractures in group C. The mean duration of follow-up was 500 days. There was no difference between groups B and C in terms of gender, the Gustilo-Anderson grade of the open fracture, the time between the injury and the irrigation, smoking, or alcohol use. There were significant differences in the mean age (thirty-eight compared with forty-two years, p = 0.01), duration of follow-up (560 compared with 444 days, p = 0.01), prevalence of hypotension (23% compared with 14%, p = 0.04), and duration of treatment with intravenous antibiotics (eleven compared with nine days, p = 0.02). An infection developed at thirty-five (18%) of the 199 fracture sites in group B and at twenty-six (13%) of the 199 fracture sites in group C. This difference was not significant (p = 0.2). Bone-healing was delayed for forty-nine (25%) of the 199 group-B fractures and forty-six (23%) of the 199 group-C fractures (p = 0.72). Wound-healing problems occurred in association with nineteen group-B fractures (9.5%) and eight group-C fractures (4%). This difference was significant (p = 0.03). CONCLUSIONS Irrigation of open fracture wounds with antibiotic solution offers no advantages over the use of a nonsterile soap solution, and it may increase the risk of wound-healing problems.

Indomethacin compared with localized irradiation for the prevention of heterotopic ossification following surgical treatment of acetabular fractures

Background: There is controversy surrounding the relative effectiveness of local irradiation and oral indomethacin for prophylaxis against heterotopic ossification following surgical treatment of acetabular fractures. The purpose of this study was to compare the efficacy of these two commonly used methods in a prospective, randomized trial. Methods: From July 1992 to June 1999, 166 patients in whom a fracture of the acetabulum was treated surgically through a posterior, extensile, or combination approach were randomized to receive either indomethacin or radiation therapy postoperatively. Seventy-eight patients received 800 cGy of local radiation therapy within seventy-two hours after surgery, and seventy-two patients received a six-week course of indomethacin (25 mg three times a day) beginning within twenty-four hours after surgery. Sixteen additional patients were randomized but did not receive treatment with either prophylactic regimen. At an average of fourteen months, the extent of heterotopic ossification was assessed on plain radiographs with use of the classification of Brooker et al. The grade of ossification was correlated with hip motion. Results: There was no significant difference between treatment groups with regard to patient age, gender, Glasgow Coma Scale, operative time, estimated operative blood loss, duration of follow-up, or presence of closed head injury. The Injury Severity Score appeared to be the only covariate that was significantly different between the groups (p = 0.019). Grade-III or IV ossification developed in eight (11%) of the patients in the indomethacin group and three (4%) in the radiation therapy group. The difference was not significant (p = 0.22; 95% confidence interval, -1.1%, +15.7%). No complications related to the prophylaxis were noted in either group. Heterotopic ossification developed in all sixteen patients who did not receive prophylaxis, with six demonstrating grade-III or IV changes. The overall prevalence of grade-III or IV heterotopic ossification was 7% (eleven of 150) in the treated groups and 38% (six of sixteen) in the untreated group. We did not find any association between the prevalence of heterotopic ossification and fracture type (p = 0.296) or posterior hip dislocation (p = 0.306). Grade-I, II, and III heterotopic ossification did not decrease the range of motion of the hip except in flexion. Conclusions: Both local radiation therapy and indomethacin were found to provide effective prophylaxis against heterotopic ossification following surgical treatment of acetabular fractures through a posterior or extensile approach. We detected no significant difference in efficacy between the two prophylactic regimens.

Wound Irrigation in Musculoskeletal Injury

Wound irrigation to remove debris and lessen bacterial contamination is an essential component of open fracture care. However, considerable practice variation exists in the details of technique. Volume is an important factor; increased volume improves wound cleansing to a point, but the optimal volume is unknown. High-pressure flow has been shown to remove more bacteria and debris and to lower the rate of wound infection compared with low-pressure irrigation, although recent in vitro and animal studies suggest that it may also damage bone. Pulsatile flow has not been demonstrated to increase efficacy. Antiseptic additives can kill bacteria in the wound, but host-tissue toxicities limit their use. Animal and clinical studies of the use of antiseptics in contaminated wounds have yielded conflicting outcomes. Antibiotic irrigation has been effective in experimental studies in some types of animal wounds, but human clinical data are unconvincing due to poor study design. There are few animal or clinical studies of musculoskeletal wounds. Detergent irrigation aims to remove, rather than kill, bacteria and has shown promise in animal models of the complex contaminated musculoskeletal wound.

Early outcome of hybrid external fixation for fracture of the distal tibia.

OBJECTIVE To evaluate the early results of treatment when using hybrid external fixation for fractures of the tibial plafond. DESIGN Retrospective review of patients treated according to protocol. Patients treated with the hybrid fixator were compared with patients treated with open reduction and internal fixation. SETTING Orthopaedic trauma service of a Level I trauma center, with a single surgeon directing care. PATIENTS/PARTICIPANTS All patients with fractures of the distal tibia during a five-year period (n = 63) were treated according to protocol, with specific criteria determining method of treatment. Eleven patients were lost to follow-up, and three additional patients were not reviewed for other reasons. Follow-up period averaged twenty months. INTERVENTION Fracture stabilization was accomplished with the use of a hybrid external fixator (n = 34) or with internal fixation (n = 27), as determined by patient or fracture criteria. Two patients did not receive planned treatment. MAIN OUTCOME MEASUREMENTS Range of motion, clinical ankle score, and incidence of complications. RESULTS Patients treated with hybrid fixation had lower clinical scores, slower return to function, a higher rate of complications, more nonunions and malunions, and more infections. CONCLUSIONS Due to differences in patient populations, the superiority of either treatment method is uncertain; however, hybrid fixation did not seem to solve the problems inherent in severe pilon fractures. The sanguine results reported in the literature did not hold true in this group.

The "Gull Sign": a harbinger of failure for internal fixation of geriatric acetabular fractures.

Objectives To identify factors affecting the outcomes of surgery for acetabular fracture in patients over the age of 60 years. Design Retrospective review of records and radiographs; current examination, radiographs and outcome surveys when possible. Setting Academic, Level 1 trauma center. Patients/Participants Forty-eight patients over age 60 with displaced acetabulum fractures. Intervention Surgical reduction and fixation. Main Outcome Measurements Clinical ratings and radiographic evaluations, Short Musculoskeletal Functional Assessment survey (SMFA), SF-36, and hip-specific questions. Radiographs were evaluated using the criteria of Matta. Results Ten patients died since surgery. Four were lost to follow-up. Seven had >12 months of follow-up information in the chart. Twenty-seven had current evaluations for the study. Average follow-up was 37 months, range 1–114 months. The average age at surgery was 71.6 years (range 61–88). No perioperative deaths occurred. Initial reductions achieved: 61% anatomic, 34% imperfect, and 5% poor. A specific radiographic finding (superomedial dome impaction) predictive of failure was identified. This was designated the “Gull Sign.” These patients had inadequate reduction, early fixation failure, or medial/superior joint narrowing and subluxation. Functional outcomes in patients with current examination were similar to age-matched controls. Radiographic outcomes: 30% excellent, 30% good, 9% fair, 23% poor, and 7% arthroplasty. Anatomic reduction was closely related to good or excellent radiographic result. Conclusions While some patients over sixty years of age can have satisfactory functional outcomes after acetabular fracture fixation, a significant number will have failure of the procedure. Osteopenic patients with superomedial dome impaction (the Gull Sign) did not benefit from attempted open reduction and internal fixation in this series.

The treatment of open tibial shaft fractures using an interlocked intramedullary nail without reaming.

Summary: Between January 1989 and September 1991, 117 consecutive open tibial shaft fractures were treated at our institution. Of these, 64 (55%) met the inclusion criteria and were prospectively treated according to protocol using unreamed interlocking intramedullary nails as definitive fixation. Wounds were classified according to the method of Gustilo et al., and included 10 type I, 16 type II, and 38 type III (17 type IIIA, 21 type IIIB) wounds. Contraindications to intramedullary nailing included (a) fractures involving the proximal or distal one fifth of the tibia, (b) patients with open physes, and (c) an associated vascular injury (type IIIC). Proximal locking was routinely performed, whereas distal locking was used as needed for axial and/or rotational stability. Soft-tissue coverage was obtained after adequate debridement within 7 days: 26 of 64 fractures (41%) required a soft-tissue procedure (17 split-thickness skin grafts, eight free-tissue transfers, one rotational muscle flap). Patients were encouraged to bear full weight in a short leg cast or Sarmiento brace as soon as other injuries or pain permitted. Average follow-up time was 24.8 months (range 12–44) and was possible in 46 fractures (71.875%; nine of 10 type I, 12 of 16 type II, 10 of 17 type IIIA, and 15 of 21 type IIIB). Mean time to healing was as follows: type I, 4.8 months; type II, 4.7 months; type IIIA, 8.28 months; and type IIIB, 9.30 months. Twenty fractures exhibited a delay in healing (>6 months). This included two of 12 type II (16%), six of 10 type IIIA (60%), and 12 of 15 type IIIB fractures (80%). Nine received no treatment, five underwent exchange nailing with a reamed nail, and six were bone grafted. All but one went on to uneventful healing. There were no malunions in either rotation, angulation, or length. Clinically, patients complained of only occasional pain. All had full range of motion of the knee and ankle unless associated with other pathology. Complications included one bent nail and 12 broken screws in 10 fractures (15%). There were six acute infections (13%), all in type III fractures (one IIIA, five IIIB). Two of these patients developed chronic osteomyelitis requiring saucerization; both had type IIIB fractures. Our data indicate that unreamed tibial nailing is an acceptable technique for use in all open tibial shaft fractures (excluding type IIIC). Our overall chronic infection rate was 4%, with no chronic infections in types I, II, and IIIA open fractures and a 13% rate in type IIIB open fractures. In addition, this series was not associated with any malunions. Although delayed union was prevalent, it appeared to be related to the amount of soft-tissue stripping and nail stiffness. The fact that all but one fracture healed with excellent alignment and a minimal infection rate makes this technique suitable for the stabilization of open tibial shaft fractures.

Indomethacin versus radiation therapy for prophylaxis against heterotopic ossification in acetabular fractures: A randomised, prospective study

We report a prospective, randomised, blinded clinical comparison of the use of indomethacin or radiation therapy for the prevention of heterotopic ossification (HO) in 75 adults who had open reduction and internal fixation of acetabular fractures through either a Kocher-Langenbeck, a combined ilioinguinal and Kocher-Langenbeck, or an extended iliofemoral approach. Indomethacin, 25 mg, was given three times daily for six weeks. Radiation with 800 cGy was delivered within three days of operation. Plain radiographs were reviewed and given Brooker classification scores by three independent observers who were unaware of the method of prophylaxis. One patient died from unrelated causes and two were lost to follow-up, leaving 72, 33 in the radiation group and 39 in the indomethacin group, available for evaluation at a mean of 12 months (6 to 48). There was no significant difference in the two groups in terms of age, gender, injury severity score, estimated blood loss, delay to surgery, head injury, presence of femoral head dislocation, or operating time, and no complications due to either method of treatment. The final extent of HO was already present by six weeks in all patients who were followed up. Three patients in the radiation group and five who received indomethacin developed HO of Brooker grade III. Two patients in the indomethacin group developed Brooker IV changes; both had failed to receive proper doses of the drug. Cochran-Armitage analysis showed no significant difference between the two treatment groups as regards the formation of HO. Indomethacin and single-dose radiation therapy are both safe and effective for the prevention of HO after operation for acetabular fractures. Radiation therapy is, however, approximately 200 times more expensive than indomethacin therapy at our institution and has other risks.