Michael D. McKee

Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures.

BACKGROUND Recent studies have shown a high prevalence of symptomatic malunion and nonunion after nonoperative treatment of displaced midshaft clavicular fractures. We sought to compare patient-oriented outcome and complication rates following nonoperative treatment and those after plate fixation of displaced midshaft clavicular fractures. METHODS In a multicenter, prospective clinical trial, 132 patients with a displaced midshaft fracture of the clavicle were randomized (by sealed envelope) to either operative treatment with plate fixation (sixty-seven patients) or nonoperative treatment with a sling (sixty-five patients). Outcome analysis included standard clinical follow-up and the Constant shoulder score, the Disabilities of the Arm, Shoulder and Hand (DASH) score, and plain radiographs. One hundred and eleven patients (sixty-two managed operatively and forty-nine managed nonoperatively) completed one year of follow-up. There were no differences between the two groups with respect to patient demographics, mechanism of injury, associated injuries, Injury Severity Score, or fracture pattern. RESULTS Constant shoulder scores and DASH scores were significantly improved in the operative fixation group at all time-points (p = 0.001 and p < 0.01, respectively). The mean time to radiographic union was 28.4 weeks in the nonoperative group compared with 16.4 weeks in the operative group (p = 0.001). There were two nonunions in the operative group compared with seven in the nonoperative group (p = 0.042). Symptomatic malunion developed in nine patients in the nonoperative group and in none in the operative group (p = 0.001). Most complications in the operative group were hardware-related (five patients had local irritation and/or prominence of the hardware, three had a wound infection, and one had mechanical failure). At one year after the injury, the patients in the operative group were more likely to be satisfied with the appearance of the shoulder (p = 0.001) and with the shoulder in general (p = 0.002) than were those in the nonoperative group. CONCLUSIONS Operative fixation of a displaced fracture of the clavicular shaft results in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative treatment at one year of follow-up. Hardware removal remains the most common reason for repeat intervention in the operative group. This study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients.

Bone grafts and bone graft substitutes in orthopaedic trauma surgery. A critical analysis.

![Graphic][1] Osteoinduction is a process that supports the mitogenesis of undifferentiated mesenchymal cells, leading to the formation of osteoprogenitor cells that form new bone. ![Graphic][2] The human skeleton has the ability to regenerate itself as part of the repair process. ![Graphic][3] Recombinant bone morphogenetic protein has osteoinductive properties, the effectiveness of which is supported by Level-I evidence from current literature sources. ![Graphic][4] Osteoconduction is a property of a matrix that supports the attachment of bone-forming cells for subsequent bone formation. ![Graphic][5] Osteogenic property is a relatively new term that can be defined as the generation of bone from bone-forming cells. Orthopaedic trauma surgery requires the regular use of bone grafts to help provide timely healing of musculoskeletal injuries. The iliac crest autologous graft remains the gold standard. The morbidity associated with the harvest of bone graft has caused practitioners to seek methods of enhancing healing with bone graft substitutes. The term bone graft substitute describes a spectrum of products that have various effects on bone-healing. Unfortunately, there is little information in the literature about when and where to use these devices. In general, we categorize the properties of bone graft substitutes as osteoinductive, osteoconductive, or osteogenic. Going through the operating room storage areas in our institutions, we find many of these products available, with various trade names that can be misleading and confusing. The purpose of this review is to give the practicing surgeon a basic fund of knowledge on the topic of bone graft substitutes as well as an opinion on the levels of evidence in the current literature supporting the use of the various materials. The answers to the most difficult questions regarding bone graft substitutes require multicenter prospective randomized studies. These are extremely difficult to design and execute, with the cost being the most onerous obstacle. Industrial funding has been one of … [1]: /embed/inline-graphic-1.gif [2]: /embed/inline-graphic-2.gif [3]: /embed/inline-graphic-3.gif [4]: /embed/inline-graphic-4.gif [5]: /embed/inline-graphic-5.gif

Treatment of acute midshaft clavicle fractures Systematic review of 2144 fractures : On behalf of the evidence-based orthopaedic trauma working group

Background: Fractures of the clavicle were reported to represent 2.6% of all fractures1 with an overall incidence of 64 per 100,000 per year (1987, Malmö, Sweden).2 Midshaft fractures account for approximately 69% to 81% of all clavicle fractures.1-4 Treatment options for acute midshaft clavicle fractures include nonoperative treatment (mostly sling or figure-of-eight bandage), open reduction and internal fixation with plates, and closed or open reduction and internal fixation with intramedullary pins, wires, or a nail. Most surgeons prefer nonoperative treatment of nondisplaced midshaft clavicle fractures. However, the optimal treatment option for isolated acute displaced midshaft clavicle fractures remains controversial. Objectives: This study was designed to systematically summarize and compare results of different treatment options (nonoperative, operative extramedullary fixation, and operative intramedullary fixation) in the management of midshaft clavicle fractures, specifically for displaced fractures.

Deficits Following Nonoperative Treatment of Displaced Midshaft Clavicular Fractures

BACKGROUND Displaced fractures of the midpart of the clavicular shaft are generally treated nonoperatively, and few functional deficits have been reported. Whereas prior investigators have presented radiographic and surgeon-based outcomes, we used a patient-based outcome questionnaire and objective muscle-strength testing to evaluate a series of patients who had received nonoperative care for a displaced midshaft fracture of the clavicle. METHODS We identified thirty patients (twenty-two men and eight women with a mean age of thirty-seven years) who had sustained a displaced midshaft fracture of the clavicle. All patients were treated nonoperatively. At a mean of fifty-five months, and a minimum of twelve months, outcomes were measured with the Constant shoulder score and the DASH (Disabilities of the Arm, Shoulder and Hand) patient questionnaire. In addition, objective shoulder muscle-strength testing was performed with the Baltimore Therapeutic Equipment Work Simulator, with the uninjured arm serving as a control. RESULTS The range of motion was well maintained, with flexion averaging 170 degrees +/- 20 degrees and abduction averaging 165 degrees +/- 25 degrees . Compared with the strength of the uninjured shoulder, the strength of the injured shoulder was reduced to 81% for maximum flexion, 75% for endurance of flexion, 82% for maximum abduction, 67% for endurance of abduction, 81% for maximum external rotation, 82% for endurance of external rotation, 85% for maximum internal rotation, and 78% for endurance of internal rotation (p < 0.05 for all values). The mean Constant score was 71 points, and the mean DASH score was 24.6 points, indicating substantial residual disability. CONCLUSIONS Traditionally, good results with minimal functional deficits have been reported following nonoperative treatment of clavicular fractures. However, surgeon-based methods of evaluation may be insensitive to loss of muscle strength. We detected residual deficits in shoulder strength and endurance in this patient population, which may be related to the significant level of dysfunction detected by the patient-based outcome measures.

Standard Surgical Protocol to Treat Elbow Dislocations with Radial Head and Coronoid Fractures

BACKGROUND The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and stiffness from prolonged immobilization. We managed these injuries with a standard surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion at seven to ten days postoperatively and enhance functional outcome. METHODS We retrospectively reviewed the results of this treatment performed, at two university-affiliated teaching hospitals, in thirty-six consecutive patients (thirty-six elbows) with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. Our surgical protocol included fixation or replacement of the radial head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries, and in selected cases repair of the medial collateral ligament and/or adjuvant hinged external fixation. Patients were evaluated both radiographically and with a clinical examination at the time of the latest follow-up. RESULTS At a mean of thirty-four months postoperatively, the flexion-extension arc of the elbow averaged 112 degrees +/- 11 degrees and forearm rotation averaged 136 degrees +/- 16 degrees. The mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points), which corresponded to fifteen excellent results, thirteen good results, seven fair results, and one poor result. Concentric stability was restored to thirty-four elbows. Eight patients had complications requiring a reoperation: two had a synostosis; one, recurrent instability; four, hardware removal and elbow release; and one, a wound infection. CONCLUSIONS Use of our surgical protocol for elbow dislocations with associated radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. We recommend early operative repair with a standard protocol for these injuries.

Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: A RANDOMISED, CONTROLLED TRIAL

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups. During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised.

Coronal Shear Fractures of the Distal End of the Humerus

We identified a shear fracture of the distal articular surface of the humerus, with anterior and proximal displacement of the capitellum and a portion of the trochlea, in six patients (five female and one male). The average age of the patients was thirty-eight years (range, ten to sixty-three years). Each fracture was the result of a fall from a standing height. A characteristic radiographic abnormality, which we have termed the double-arc sign, was seen on the lateral radiograph of each patient and represented the subchondral bone of the displaced capitellum and the lateral trochlear ridge. All patients were managed with open reduction, internal fixation, and early motion of the elbow. The average duration of follow-up was twenty-two months (range, eighteen to twenty-six months). The fracture united in all patients at an average of six weeks (range, four to nine weeks), without radiographic evidence of osteonecrosis of the fracture fragment. Flexion of the elbow averaged 141 degrees (range, 130 to 150 degrees), with an average flexion contracture of 15 degrees (range, 0 to 40 degrees). Pronation of the forearm averaged 83 degrees, and supination averaged 84 degrees. All patients had a good or excellent functional result, according to the elbow-rating scale of Broberg and Morrey.

Midshaft Malunions of the Clavicle

Background: The purpose of this study was to analyze the functional results of corrective osteotomy of a malunited clavicular fracture in patients with chronic pain, weakness, neurologic symptoms, and dissatisfaction with the appearance of the shoulder. Methods: We identified fifteen patients (nine men and six women with a mean age of thirty-seven years) who had a malunion following nonoperative treatment of a displaced midshaft fracture of the clavicle. The mean time from the injury to presentation was three years (range, one to fifteen years). Outcome scores revealed major residual deficits. The mean amount of clavicular shortening was 2.9 cm (range, 1.6 to 4.0 cm). All patients underwent corrective osteotomy of the malunion through the original fracture line and internal fixation. Results: At the time of follow-up, at a mean of twenty months (range, twelve to forty-two months) postoperatively, the osteotomy site had united in fourteen of the fifteen patients. All fourteen patients expressed satisfaction with the result. The mean DASH (Disabilities of the Arm, Shoulder and Hand) score for all fifteen patients improved from 32 points preoperatively to 12 points at the time of follow-up (p = 0.001). The mean shortening of the clavicle improved from 2.9 to 0.4 cm (p = 0.01). There was one nonunion, and two patients had elective removal of the plate. Conclusions: Malunion following clavicular fracture may be associated with orthopaedic, neurologic, and cosmetic complications. In selected cases, corrective osteotomy results in a high degree of patient satisfaction and improves patient-based upper-extremity scores. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach

Background: While surgical repair is considered the standard of care of displaced intra-articular distal humeral fractures, most investigators have assessed its results with use of surgeon-based and/or radiograph-based outcome measures. The purpose of our study was to determine the functional outcome of fixation of displaced intra-articular distal humeral fractures with use of a standardized evaluation methodology consisting of objective testing of muscle strength and use of patient-based questionnaires (both limb-specific and general health-status questionnaires). Methods: We identified twenty-five patients (fourteen male and eleven female), with a mean age of forty-seven years, who had an isolated, closed, displaced, intercondylar, intra-articular fracture of the distal part of the humerus repaired operatively through a posterior approach and fixed with plates on both the medial and the lateral column. All patients returned for follow-up that included recording of a complete history, physical examination, radiographic examination, completion of both a limb-specific questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]) and a general health-status questionnaire (Short Form-36 [SF-36]), and objective muscle-strength testing. Results: The mean duration of follow-up was thirty-seven months (range, eighteen to seventy-five months). The mean flexion contracture was 25 degrees (range, 5 to 65 degrees), and the mean arc of flexion-extension was 108 degrees (range, 55 to 140 degrees). Significant decreases in mean muscle strength compared with that on the normal side were seen in both elbow flexion measured at 90 degrees (74 percent of normal, p = 0.01) and elbow extension measured at 45 degrees (76 percent of normal, p = 0.01), 90 degrees (74 percent of normal, p = 0.01), and 120 degrees (75 percent of normal, p = 0.01). The mean DASH score was 20 points, indicating mild residual impairment. The SF-36 scores revealed minor but significant decreases in the role-physical and physical function scores (p = 0.01 and 0.03, respectively) but no alteration of the mental component or mean scores. Six patients (24 percent) had a reoperation; three of them had removal of prominent hardware used to fix the site of an olecranon osteotomy. Conclusions: The surgical repair of an intra-articular distal humeral fracture is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. Our study quantified a decrease in the range of motion and muscle strength of these patients, which may help to explain the mild residual physical impairment detected by the limb-specific outcome measures and physical function components of the general health-status measures.

The use of an antibiotic-impregnated, osteoconductive, bioabsorbable bone substitute in the treatment of infected long bone defects: Early results of a prospective trial

Objective We sought to evaluate the use of a bioabsorbable, tobramycin-impregnated bone graft substitute (calcium sulfate alpha-hemihydrate pellets) in the treatment of patients with infected bony defects and nonunions. Study Design/Methods Twenty-five patients (15 male and 10 female, mean age 43 years (range 27–69 years) requiring surgical debridement of culture-positive long bone infection (16 with associated nonunion) were entered into an ongoing consecutive, prospective clinical trial. Involved bones included the tibia (15), femur (6), ulna (3), and humerus (1). All defects were posttraumatic in origin, and each patient had had previous surgery at the involved site (mean 4.3 surgeries; range 1–8 surgeries). The duration of infection ranged from 4 months to 20 years (mean 43 months). According to the Cierny-Mader classification system, there was 1 stage I (medullary osteomyelitis), 6 stage III (localized osteomyelitis), and 18 stage IV (diffuse osteomyelitis) lesions. There were 4 normal (A) hosts and 21 locally and/or systemically compromised (B) hosts. Mean bone defect/void was 30.5 cm3 (range 3–192 cm3). Results Mean follow-up was 28 months (range 20–38 months). Radiographically, pellets were resorbed at a mean of 2.7 months postoperatively. Infection was eradicated in 23 of 25 patients (92%). Isolated bony defects healed in all nine patients without further treatment. Fourteen of 16 patients with nonunion achieved union, although nine required autogenous bone grafting. Union was achieved in five of seven nonunion patients treated with bone graft substitute in isolation. Complications included refracture (three), recurrence of infection (two), persistent nonunion (two), and superficial wound necrosis (one). Eight patients developed sterile draining sinuses that healed upon radiographic resorption of the pellets. Conclusions In patients with posttraumatic osteomyelitis, the bone graft substitute was effective in eradicating bone infection in 23 of 25 patients. Isolated bony defects healed reliably (nine of nine) following addition of bone graft substitute alone. The role of the bone graft substitute in isolation in the treatment of nonunion is unclear at present.