Peter J. OʼBrien

Diagnostic techniques in acute compartment syndrome of the leg.

Objectives: To review the efficacy of the current diagnostic methods of acute compartment syndrome (ACS) after leg fractures. Data Sources: A Medline (PubMed) search of the English literature extending from 1950 to May 2007 was performed using “compartment syndromes” as the main key word. Also a manual search of orthopaedic texts was performed. Study Selection and Extraction: The results were limited to articles involving human subjects. Of 2605 primary titles, 489 abstracts limited to compartment syndromes in the leg and 577 articles related to the diagnosis of compartment syndromes were identified and their abstracts reviewed. Further articles were identified by reviewing the references. Sixty-six articles were found to be relevant to diagnostic techniques for compartment syndrome in the leg and formed the basis of this review. Conclusions: Early diagnosis of an ACS is important. Despite its drawbacks, clinical assessment is still the diagnostic cornerstone of ACS. Intracompartmental pressure measurement can confirm the diagnosis in suspected patients and may have a role in the diagnosis of this condition in unconscious patients or those unable to cooperate. Whitesides suggests that the perfusion of the compartment depends on the difference between the diastolic blood pressure and the intracompartmental pressure. They recommend fasciotomy when this pressure difference, known as the Δp, is less than 30 mm Hg. Access to a precise, reliable, and noninvasive method for early diagnosis of ACS would be a landmark achievement in orthopaedic and emergency medicine.

Muscle function and functional outcome following standard antegrade reamed intramedullary nailing of isolated femoral shaft fractures.

Objective: To evaluate the functional outcomes and long-term effects on muscle strength of femoral shaft fractures treated with intramedullary (IM) antegrade nailing using a standard piriformis start point. Design: Retrospective Outcome Study. Setting: Tertiary Level Teaching Hospital and Referral Centre for the Province of British Columbia. Patients/Participants: Twenty-one patients (7 female, 14 male; mean age 34.5 years, range 16-56 years) with isolated femoral shaft fractures who were treated with standard antegrade reamed interlocking IM nailing and who had a minimum 1-year follow-up were identified through the Orthopaedic Trauma Database. All patients had isokinetic muscle testing of their hip abductors, hip extensors, and knee extensors using the KinCom® muscle testing machine. Of the patients, 10 underwent formal gait lab analysis. All of the patients answered a questionnaire and completed the Short Form (SF)-36 and Musculoskeletal Functional Assessment outcome measures. Intervention: Antegrade reamed interlocking IM nailing of femoral shaft fractures using a standard trochanteric fossa (also referred to as piriformis fossa) starting point. Main Outcome Measurements: Examination of muscle strength, using 2 different objective measures (KinCom and gait analysis). The KinCom muscle testing machine was used for isokinetic muscle testing of hip abductors, hip extensors, and knee extensors. Outcome questionnaires were used to evaluate function (Musculoskeletal Functional Assessment) and general health (SF-36). Results: Isokinetic muscle testing showed a statistically significant lower peak torque generation by the hip abductors (P = 0.003) and hip extensors (P = 0.046) from the uninjured contralateral side. The gait lab analysis did not show important changes in gait pattern. Scores for the SF-36 were 51.77 ± 7.55 and 53.73 ± 8.70. Scores for the Short Musculoskeletal Functional Assessment (S-MFA) were 7.74 and 8.66. Both scores did not indicate any significant disability. Conclusions: Antegrade reamed interlocking IM nailing of femoral shaft fractures using a standard trochanteric fossa starting point is associated with a mild hip abductor muscle-strength deficit. Gait pattern returns to normal following femoral shaft fracture treated with this technique, and functional outcomes are good.

Leading 20 at 20: top cited articles and authors in the Journal of Orthopaedic Trauma, 1987-2007.

Objective: To determine the 20 most cited articles and authors in the Journal of Orthopaedic Trauma during the first 20 years of publication, 1987 to 2007. Design: Review. Methods: We used Web of Science “cited reference search” to determine the most cited articles originating in the Journal of Orthopaedic Trauma from 1987 to 2007, the first 20 years of publication. The characteristics of each article were recorded. Next, we manually searched each authors citations for works in the same time period to determine the most cited authors. The number of first authorships for each author was then determined using Medline, and a relative citation impact ratio was calculated. Finally, citation reports for the journal overall were created to evaluate the citation impact of the journal over the last 10 years. Results: The top cited articles ranged from 64 to 566 citations with two articles over 100. Fifteen were clinical articles with the most common topic being tibia fractures (shaft, plateau, and pilon). The top cited authors ranged for 111 to 566 citations, whereas the citations per lead authorship ratio for the authors on that list ranged from 9.5 to 566 citations per lead authorship. The number of citations to the Journal of Orthopaedic Trauma overall over the last 20 years has increased from 181 in 1997 to 3050 in 2007. Conclusions: The influence of the Journal of Orthopaedic Trauma, its articles, and its authors is readily apparent in this review of the most cited articles and authors in the journal over its first 20 years of publication. This journal is a source of highly cited original articles and the work of many highly cited leaders in the field of orthopaedic trauma.

Incidence, Magnitude, and Predictors of Shortening in Young Femoral Neck Fractures.

Objectives: To describe the incidence and magnitude of femoral neck fracture shortening in patients age younger than 60 years. Secondarily, to examine predictors of fracture shortening. Design: Retrospective chart review. Setting: Level I trauma centre. Patients/Participants: Sixty-five patients with a median age of 51 years (interquartile range: 42–56 years) were included. Seventy-one percent were male, 75% were displaced fractures, and 78% were treated with cancellous screws. Intervention: Internal fixation with multiple cancellous screws or sliding hip screw (SHS) + derotation screw. Main Outcome Measurements: Radiographic femoral neck shortening at a minimum of 6 weeks after fixation. Results: Fifty-four percent of patients had ≥5 mm of femoral neck shortening (22% had between ≥5 and <10 mm and 32% ≥10 mm). Initially, displaced fractures shortened more than undisplaced fractures (mean: 8.1 vs. 2.2 mm, P < 0.001), and fractures treated with SHS + derotation screw shortened more than fractures with cancellous screws alone (10.7 vs. 5.5 mm, P = 0.03). Even when adjusting for initial fracture displacement, fractures treated with SHS + derotation screw shortened an average of 2.2 mm more than fractures treated with screws alone (P = 0.03). Conclusions: The incidence of clinically significant shortening in our young femoral neck fracture population was higher than anticipated, and 32% of patients experienced severe shortening of >1 cm. Our findings highlight the need for further research to determine the impact of severe shortening on functional outcome and to determine if implant selection affects fracture shortening. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Methodology and interpretation of radiographic outcomes in surgically treated pelvic fractures: a systematic review.

Objective: To identify and evaluate previously described methods for the measurement, and interpretation, of radiographic outcomes of operatively treated pelvic fractures. Data Sources: A systematic review of the available literature was performed using all major databases (MEDLINE, EMBASE, MEDLINE IN-PROGRESS, and Cochrane Central) in August 2009. Study Selection: Inclusion criteria were case series, cohort studies, or clinical trials regarding orthopaedic treatment of acute traumatic pelvic ring fractures treated surgically in adults, with at least 12 weeks of radiographic follow-up. Exclusion criteria were case reports or case series of <10 patients, review articles, foreign language articles, and series where time frame of outcome measurement was not stated were excluded. Data Extraction: Modality, and timeline, of the radiographic assessment was recorded. Next, the description of the method of radiographic measurement technique used was scrutinized for standardization. The interpretation of the radiographic measurement was evaluated, and any grading scale used was recorded. The interpretation of the quality of the radiographic result as described by each author was recorded. Finally, a qualitative methodological analysis was performed. Data Synthesis: Number of standardized radiographic assessment techniques used (3 of 31) and interpretation scales used (13 of 31) were calculated. Nonweighted mean follow-up time (30.6 months) and overall positive radiographic outcomes were calculated (78.6% good or excellent). Conclusions: Reporting of radiographic outcomes in pelvic fractures has been done using largely unstandardized and universally untested measurement techniques. The interpretations of these measurements are also inconsistent and untested. Substantive future research is needed in this area.

Is early definitive fixation of bicondylar tibial plateau fractures safe? An observational cohort study.

Objectives: The optimal treatment protocol for bicondylar plateau fractures remains controversial. Contrary to popular practice which favors a staged protocol in many high-energy fracture patterns, we have used early single-stage open reduction and internal fixation (ORIF) to treat these injuries whenever possible. The purpose of this study was to determine the complication rate and the functional and radiographic outcomes of this strategy. Design: Retrospective cohort study and prospective data collection. Setting: Level I trauma center. Patients/Participants: One hundred one patients with 102 OTA/AO type 41-C bicondylar tibial plateau fractures were treated with early definitive ORIF, defined as nonstaged surgery performed within 72 hours from injury. A subset of patients was part of a longitudinal study and reported functional outcomes at 1 year. Intervention: Early definitive ORIF. Main Outcome Measurement: Primary outcome: reoperation rate, defined as any surgery within 12 months after the index operation; secondary outcomes: quality and stability of radiographic fracture reduction; and functional outcome [Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and short musculoskeletal functional assessment (SMFA)]. Results: Nonstaged operative treatment of bicondylar plateau fractures was performed in 91.3% of the fractures during the study period. For those, early definitive ORIF (surgery within 72 hours from injury) was performed in 82.3% fractures. Mean time from injury to ORIF, for closed fractures, was 29.8 hours. Sixteen (15.7%) fractures, which were treated with early definitive ORIF, required an additional surgical procedure within 12 months. Complications included wound infection requiring surgical management, compartment syndrome requiring fasciotomies, nonunion, early fixation failure, and implant removal for discomfort. The reoperation rate was 12.7% if implant removal was excluded. At least 3 of the 4 radiographic criteria used to assess the adequacy of reduction were achieved in 95.1% of cases, and all 4 criteria were met in 59.8% of fractures. The Physical Component of the SF-36 at 12 months was 42.6, which is comparable to values reported in previous studies for operative treatment of bicondylar plateau fractures. Conclusions: In a model where surgery is performed without delay by experienced orthopaedic trauma surgeons, a large proportion of bicondylar tibial plateau fractures can be safely treated with early definitive ORIF. Early surgery was associated with satisfactory postoperative radiographic reductions. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Trajectory of Short- and Long-Term Recovery of Tibial Shaft Fractures After Intramedullary Nail Fixation

Objective: To determine the trajectory of recovery after tibial shaft fracture treated with intramedullary nail over the first 5 years and to evaluate the magnitude of the changes in functional outcome at various time intervals. Design: Prospective cohort study. Setting: A Level 1 trauma center. Patients/Participants: One hundred thirty-two patients with tibial shaft fracture (OTA 42-A, B, C) were enrolled into the Centers prospective orthopaedic trauma database between January 2005 and February 2010. Functional outcome data were collected at baseline, 6 months, 1 year, and 5 years. Intervention: Enrolled patients were treated acutely with intramedullary nailing of their tibia. Main Outcome Measurements: Evaluation was performed using the Short Form-36 and Short Musculoskeletal Function Assessment (SMFA). Results: Mean SF-36 physical component scores improved between 6 and 12 months (P = 0.0008) and between 1 and 5 years (P = 0.0029). Similarly, mean SMFA dysfunction index scores improved between 6 and 12 months (P = 0.0254) and between 1 and 5 years (P = 0.0106). In both scores, the rate or slope of this improvement is flatter between 1 and 5 years than it is between 6 and 12 months. Furthermore, SF-36 and SMFA scores did not reach baseline at 5 years (SF-36 P < 0.0001, SMFA P = 0.0026). A significant proportion of patients were still achieving a minimal clinically important difference in function between 1 and 5 years (SF-36 = 54%, SMFA = 44%). Conclusions: The trajectory of functional recovery after tibial shaft fracture is characterized by an initial decline in function, followed by improvement between 6 and 12 months. There is still further improvement beyond 1 year, but this is of flatter trajectory. The 5-year results indicate that function does not improve to baseline by 5 years after injury. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Role of Depression in Outcomes of Low-Energy Distal Radius Fractures in Patients Older Than 55 Years.

Objectives: This study examines depression and outcomes in patients older than 55 years with distal radius fracture. Design: Prospective data collection included patient characteristics, treatment, general and limb symptoms and disability, and complications at baseline, 3 months, and 1 year. Bivariate analysis and multivariable linear regression were used to assess relationships between depression and outcome measures, specifically the Short Form-36 (SF-36), Disability of the Arm, Shoulder, and Hand (DASH) scores, and the Centre of Epidemiologic Studies Depression (CES-D) scale. Setting: The study was conducted in a level-1 trauma center. Participants: All patients older than 55 years with isolated distal radius fracture were recruited (2007–2011). Intervention: Patients were treated operatively or nonoperatively. Main Outcome Measures: The SF-36 and DASH scores measured general and upper extremity status. Depression was measured using CES-D scale. All complications were recorded. Results: Of 228 patients, 25% were depressed at baseline, 32% at 3 months, and 26% after 1 year. Thirty-two patients (14%) had complications. There was no relationship between depression at baseline and complications; however, there was a statistically significant relationship at 3 months (P = 0.021). There was a statistically significant association between baseline depression and the worse 1-year SF-36. Patients with baseline depression had poorer 1-year DASH scores (20 ± 2.3) than nondepressed patients (11 ± 1.3) (P = 0.0031), and less improvement in DASH scores over the first year (P = 0.023). Multivariable linear regression demonstrated that baseline depression is the strongest predictor of poorer 1-year DASH scores (3.7, P = 0.0078) and change in DASH scores over the first year (2.9, P = 0.026). Conclusions: Baseline depression predicts worse function and disability outcomes 1 year from injury. Depression (CES-D ≥16) is the strongest predictor of worse 1-year DASH scores and SF-36 outcome measures, after controlling for other potential predictors. Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Developing Orthopaedic Trauma Capacity in Uganda: Considerations From the Uganda Sustainable Trauma Orthopaedic Program.

Summary: Uganda, like many low-income countries, has a tremendous volume of orthopaedic trauma injuries. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) is a partnership between the University of British Columbia and Makerere University that was initiated in 2007 to reduce the consequences of neglected orthopaedic trauma in Uganda. USTOP works with local collaborators to build orthopaedic trauma capacity through clinical training, skills workshops, system support, technology development, and research. USTOP has maintained a multidisciplinary approach to training, involving colleagues in anaesthesia, nursing, rehabilitation, and sterile reprocessing. Since the programs inception, the number of trained orthopaedic surgeons practicing in Uganda has more than doubled. Many of these newly trained surgeons provide clinical care in the previously underserved regional hospitals. The program has also worked with collaborators to develop several technologies aimed at reducing the cost of providing orthopaedic care without compromising quality. As orthopaedic trauma capacity in Uganda advances, USTOP strives to continually evolve and provide relevant support to colleagues in Uganda.

Making Safe Surgery Affordable: Design of a Surgical Drill Cover System for Scale.

Summary: Many surgeons in low-resource settings do not have access to safe, affordable, or reliable surgical drilling tools. Surgeons often resort to nonsterile hardware drills because they are affordable, robust, and efficient, but they are impossible to sterilize using steam. A promising alternative is to use a Drill Cover system (a sterilizable fabric bag plus surgical chuck adapter) so that a nonsterile hardware drill can be used safely for surgical bone drilling. Our objective was to design a safe, effective, affordable Drill Cover system for scale in low-resource settings. We designed our device based on feedback from users at Mulago Hospital (Kampala, Uganda) and focused on 3 main aspects. First, the design included a sealed barrier between the surgical field and hardware drill that withstands pressurized fluid. Second, the selected hardware drill had a maximum speed of 1050 rpm to match common surgical drills and reduce risk of necrosis. Third, the fabric cover was optimized for ease of assembly while maintaining a sterile technique. Furthermore, with the Drill Cover approach, multiple Drill Covers can be provided with a single battery-powered drill in a “kit,” so that the drill can be used in back-to-back surgeries without requiring immediate sterilization. The Drill Cover design presented here provides a proof-of-concept for a product that can be commercialized, produced at scale, and used in low-resource settings globally to improve access to safe surgery.