Michael S. Sirkin

Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee.

The purpose of this new classification compendium is to republish the Orthopaedic Trauma Associations (OTA) classification. The OTA classification was originally published in a compendium of the Journal of Orthopaedic Trauma in 1996. It adopted The Comprehensive Classification of the Long Bones developed by Müller and colleagues and classified the remaining bones. In this compendium, the introductory chapter reviews new scientific information about classifying fractures that has been published in the last 11 years. The classification is presented in a revised format that is easier to follow. The OTA and AO classification will now have a unified alpha-numeric code eliminating the differences that have existed between the 2 codes. The code was significantly revised for the clavicle and scapula, foot and hand, and patella. Dislocations have been expanded on an anatomic basis and for most joints will be coded separately. This publication should stimulate new developments and interest in a unified language to code and classify fractures. Further improvements in classification will result in better patient care and clinical research.

A staged protocol for soft tissue management in the treatment of complex pilon fractures.

OBJECTIVE To determine whether open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol results in minimal surgical wound complications. DESIGN Retrospective. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Between January 1991 and December 1996, 226 pilon fractures (AO types 43A-C) were treated, of which 108 were AO type 43C. Fifty-six fractures were included in a retrospective analysis of a treatment protocol. Injuries were divided into Group I, thirty-four closed fractures, and Group II, twenty-two open fractures (three Gustilo Type 1, six Type II, eight Type IIIA, and five Type IIIB). METHODS The protocol consisted of immediate (within twenty-four hours) open reduction and internal fixation of the fibula when fractured, using a one-third tubular or 3.5-millimeter dynamic compression plate and application of an external fixator spanning the ankle joint. Patients with isolated injuries were discharged after initial stabilization and readmitted for the definitive reconstruction. Polytrauma patients remained hospitalized and were observed. Formal open reconstruction of the articular surface by plating was performed when soft tissue swelling had subsided. Complications were defined as wound problems requiring hospitalization. All affected limbs were then evaluated via chart and radiograph review, patient interviews, and physical examination until surgical wound healing was complete, for a minimum of twelve months. RESULTS Group 1 (closed pilon): Follow-up was possible in twenty-nine out of thirty fractures (97 percent). Average time from external fixation to open reduction was 12.7 days. All wounds healed. None exhibited wound dehiscence or full-thickness tissue necrosis requiring secondary soft tissue coverage postoperatively. Seventeen percent (five out of twenty-nine patients) had partial-thickness skin necrosis. All were treated with local wound care and oral antibiotics and healed uneventfully. There was one late complication (3.4 percent), a chronic draining sinus secondary to osteomyelitis, which resolved after fracture healing and metal removal. Group II (open pilon): Follow-up was possible in seventeen patients with nineteen fractures (86 percent). Average time from external fixation to formal reconstruction was fourteen days (range 4 to 31 days). By definition, all Gustilo Type IIIB fractures required flap coverage for the injury. Two patients experienced partial-thickness wound necrosis. These were treated with local wound care and antibiotics. All surgical wounds healed. There were two complications (10.5 percent), both deep infections. One Type I open fracture developed wound dehiscence and osteomyelitis requiring multiple debridements, intravenous antibiotics, subsequent removal of hardware, and re-application of an external fixator to cure the infection. One Type IIIA open fracture of the distal tibia and calcaneus developed osteomyelitis and required a below-knee amputation. CONCLUSION Based on our data, it appears that the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotation flaps, or free tissue transfers in our series. This technique appears to be effective in closed and open fractures alike.

The effect of sacral fracture malreduction on the safe placement of iliosacral screws.

Objectives To determine the effects of cranial displacement on the safe placement of iliosacral screws for zone II sacral fractures. Design Computer imaging and dimensional analysis of a human cadaveric sacral fracture model. Setting Cadaveric dissection, Orthopaedic Research Laboratories, Newark, New Jersey. Main Outcome Measurements Six cadaveric pelves with simulated zone II sacral fractures were imaged with computed tomography at controlled cranial displacements of 5, 10, 15, and 20 mm. The area of contact at the fracture site and volume of bone available for iliosacral screw placement was graphically measured using both two- and three-dimensional computer modeling. Areas of contact were also represented in terms of the maximal number of 7.0-mm screws that could be simultaneously implanted. Results Cross-sectional contact area was decreased by 30%, 56%, 81%, and 90% at 5, 10, 15 and 20 mm of displacement, respectively. Volume of bone was decreased by 21%, 25%, 26%, and 34% for 5, 10, 15 and 20 mm of displacement, respectively. In 50% of the specimens at 15 mm and 66% of the specimens with 20 mm displacement, two iliosacral screws could not be contained simultaneously within bone. In 17% of the specimens displaced 15 mm and 50% of the specimens displaced 20 mm, the cross-sectional area was insufficient to contain a single iliosacral screw. Conclusions Although previous authors have accepted up to 15 mm of cranial displacement, the data demonstrate substantial compromise of available screw space with displacements greater than 1 cm. Fracture reduction is mandatory, as screw placement with residual displacement of 10 mm or more can endanger adjacent neural and vascular structures.

Percutaneous methods of tibial plateau fixation.

Various methods of percutaneous fixation of tibial plateau fractures are available. The optimal method of fixation is dictated by soft tissue injury, fracture characteristics, and functional demands of the patient. Unicondylar fractures are amenable to percutaneous stabilization with screws or plates although some fractures are best approached with open techniques. Hybrid and ring external fixators are most appropriate for patients with bicondylar injuries who have severe soft tissue trauma. Use of intramedullary nails to align ipsilateral shaft fractures adjacent to percutaneously fixed plateau injuries remains controversial but may be indicated for some patients with bicondylar lesions and combined plateau and shaft fractures.

THE TREATMENT OF PILON FRACTURES

Soft tissue complications, skin slough, and superficial infection lead to deeper infection and amputation. By avoiding these complications, it is expected that better results can be obtained. Two techniques are available to do this. The first is to limit incisions and use external fixation to obtain stability. Even in these cases, care must be taken with the soft tissues. The second is a staged reconstruction, whereby stage one allows soft tissue stabilization. To this end, the fibula is plated, and transarticular external fixation is performed; this maintains anatomic length, preventing soft tissue contraction and permitting edema resolution. The second stage, formal tibial open reduction and internal fixation, is performed with plates and screws when operative intervention is safe. These methods appear to be equally effective in reducing major soft tissue complications. Surgeons should treat these complex fractures with the method with which they are most comfortable. Surgeons who feel comfortable with techniques of internal fixation are best qualified to perform open reductions. Surgeons who have experience with percutaneous fixation and hybrid external fixator application should use this method. Surgeons with limited or minimal experience with pilon fractures should consider fibula fixation and transarticular external fixation followed by transfer to an orthopedic trauma surgeon for definitive management.

Measuring the Attitudes and Impact of the Eighty-Hour Workweek Rules on Orthopaedic Surgery Residents

BACKGROUND The literature on graduate medical education contains anecdotal reports of some effects of the new eighty-hour workweek on the attitudes and performance of residents. However, there are relatively few studies detailing the attitudes of large numbers of residents in a particular surgical specialty toward the new requirements. METHODS Between July and November 2004, a survey created by the Academic Advocacy Committee of the American Academy of Orthopaedic Surgeons was distributed by mail, fax, and e-mail to a total of 4207 orthopaedic residents at the postgraduate year-1 through year-6 levels of training. The survey responses were tabulated electronically, and the results were recorded. RESULTS The survey response rate was 13.2% (554 residents). Sixty-eight percent (337) of the 495 respondents whose postgraduate-year level was known were at the postgraduate year-4 level or higher. Attitudes concerning the duty rules were mixed. Twenty-three percent of the 554 respondents thought that eighty hours constituted an appropriate number of duty hours per week; 41% believed that eighty hours were too many, and 34% thought that eighty hours were not sufficient. Thirty-three percent of the respondents had worked greater than eighty hours during at least a single one-week period since the new rules were implemented; this occurred more commonly among the postgraduate year-3 and more junior residents. Orthopaedic trauma residents had the most difficulty adhering to the new duty-hour restrictions. Eighty-two percent of the respondents indicated that their residency programs have been forced to make changes to their call schedules or to hire ancillary staff to address the rules. The use of physician assistants, night-float systems, and so-called home-call assignments were the most common strategies used to achieve compliance. CONCLUSION Resident attitudes toward the work rules are mixed. The rules have forced residency programs to restructure. Junior residents have more favorable attitudes toward the new standards than do senior residents. Self-reporting of duty hours is the most common method of monitoring in orthopaedic training programs. Such systems allow ample opportunity for inaccuracies in the measurement of hours worked. Although residents report an improved quality of life as a result of these new rules, the attitude that the quality of training is diminished persists.

Femoral Nailing Without a Fracture Table

This retrospective trial was designed to evaluate the effectiveness and safety of femoral nailing on a radiolucent table with manual traction only. Eighty-three femoral shaft fractures treated by antegrade nailing were included in this study. Group 1 consisted of 24 femur fractures that were reduced and nailed with manual traction. Group 2 consisted of 59 femur fractures treated with the aid of a fracture table. There were 10 patients in Group 1 and 19 patients in Group 2 needing multiple procedures. In Group 1, significantly fewer redrapings and table transfers were necessary. There was no increase in operative time. There were no operative complications in Group 1 and there was 1 operative complication in Group 2-a radial nerve palsy. Postoperative malalignment was minimal in both groups. Intramedullary nailing of femoral shaft fractures on a radiolucent table using manual traction is associated with no increase in morbidity. It also facilitated quicker and more effective treatment of the patient with polytrauma. No undue risks or contraindications were identified; however, the help of an assistant was invaluable.

Neurovascular and tendinous damage with placement of anteroposterior distal locking bolts in the tibia.

Objective To determine the proximity of anteroposterior locking bolts inserted into the distal metaphyseal tibia to nearby neural, vascular, and tendinous structures. Design A cadaver study. Setting University trauma center. Methods Sixteen legs (8 matched pairs) were nailed in either neutral (Group 1) or 10° of internal rotation (Group 2) and locked using one anteroposterior bolt. The anterior tibial and extensor hallucis longus tendons and neurovascular bundle were identified, and their respective locations in relation to the bolt head were measured. Average distances were calculated for each structure in each group and statistically compared. Damage to any structure was noted at final dissection. Results Average distances from the bolt head to the neurovascular bundle, extensor hallucis longus, and anterior tibial tendons were 0.6, 0.5, and 1.6 mm, respectively, for Group 1 and 1.0, 1.5, and 1.8 mm, respectively, for Group 2 legs. Statistical comparison of distances for each anatomic entity for the two groups revealed no detectable significant differences (P = 0.7, 0.4, 0.7, respectively). For all specimens, the rate of nerve, artery, extensor hallucis longus, and anterior tibial tendon injury was 25%, 19%, 0%, and 6%, respectively. However, the incidence of at least one structure damage in Group 1 legs was 63% versus 12% in Group 2 specimens (P = 0.2). Conclusion Anteroposterior distal tibial locking bolts lie in close proximity to the neurovascular bundle. With standard percutaneous techniques, these structures can be damaged. Although 10° of internal rotation does not statistically affect the measured distance of the locking bolt to the neurovascular bundle, it appears to decrease the incidence of neurovascular injury. This difference may best be explained by the necessary path the drill bit must take through the soft tissues to reach the underlying bone. Regardless of nail orientation, larger incisions with careful dissection and clear visualization of the anatomy are recommended to help prevent this complication.

Anteroinferior 2.7-mm versus 3.5-mm plating for AO/OTA type B clavicle fractures: a comparative cohort clinical outcomes study.

Objectives: To compare the Disability of the Arm, Shoulder, and Hand (DASH) and Constant scores, time to union, rate of union, patient cosmetic satisfaction rate, and the need for secondary procedures between 2.7- and 3.5-mm anteroinferior plating for Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type B clavicle fractures. Design: Retrospective, comparative cohort clinical outcomes study. Setting: Level I university trauma center. Patients/Participation: Thirty-seven patients with an AO/OTA type B clavicle fracture who underwent open reduction internal fixation with either a 2.7- or 3.5-mm reconstruction plate placed in the anterior–inferior position. The main outcome comparisons included DASH score, Constant score, time to union, rate of union, rate of hardware failure, cosmetic satisfaction, and secondary procedure. Main Outcome Measurement: DASH score, constant score, time to union, rate of union, cosmetic satisfaction, secondary procedure. Results: At 1-year follow-up, analysis yielded no significant differences in DASH scores (P = 0.26) and Constant Shoulder scores (P = 0.79) between the 2 cohorts. There were no statistically significant differences in the time to union (P = 0.86) and the rate of union (P = 0.49). Although the 2.7-mm cohort had a lower reoperation rate, it was not statistically significant (P = 0.11). However, the 2.7-mm cohort did demonstrate a significantly higher rate of cosmetically acceptable reconstruction (P = 0.003). Conclusions: Compared with 3.5-mm anterior–inferior plating, 2.7-mm anteroinferior plating for AO/OTA type B clavicle fractures leads to significantly higher rates of cosmetic acceptability while reducing the need for a secondary procedure and achieving excellent clinical outcomes as measured by the DASH and Constant scores. There were no differences between the 2.7 and 3.5 cohorts in time to union or in union rate. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral version of the general population: does "normal" vary by gender or ethnicity?

Objective: The purpose of this study was to compare various gender and ethnic groups to characterize differences in baseline version and rates of retroversion. Design: Retrospective. Setting: Level 1 trauma center. Patients/Participants: Between 2000 and 2009, 417 consecutive patients with femur fractures were treated with an intramedullary nail at level I trauma and tertiary referral center. Of these, 328 with computed tomography scanogram of the normal, uninjured contralateral femur were included in this study. Main Outcome Measurements: Femoral version. Results: The mean alignment for the all patients was 8.84 ± 9.66° of anteversion. There were no statistically significant differences in mean version between African American, white, and Hispanic patients for males or females. Although there were also no significant differences in rates between ethnicities, retroversion was found to be common in white males (21.4%), African American males (15.1%), and all groups of females (>14.3%). Furthermore, nearly 6% of both African American males and females exhibited >10° retroversion. Conclusions: Although there may not be a significant difference in average femoral version between ethnic and gender groups, retroversion is relatively common, and retroversion >10° was observed in nearly 6% of the African American population. This may have important implications in proper alignment restoration and successful clinical outcomes after intramedullary nailing of femur fractures.