Stephanie L. Tanner

A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds

BACKGROUND The management of open fractures requires wound irrigation and débridement to remove contaminants, but the effectiveness of various pressures and solutions for irrigation remains controversial. We investigated the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low irrigation pressure. METHODS In this study with a 2-by-3 factorial design, conducted at 41 clinical centers, we randomly assigned patients who had an open fracture of an extremity to undergo irrigation with one of three irrigation pressures (high pressure [>20 psi], low pressure [5 to 10 psi], or very low pressure [1 to 2 psi]) and one of two irrigation solutions (castile soap or normal saline). The primary end point was reoperation within 12 months after the index surgery for promotion of wound or bone healing or treatment of a wound infection. RESULTS A total of 2551 patients underwent randomization, of whom 2447 were deemed eligible and included in the final analyses. Reoperation occurred in 109 of 826 patients (13.2%) in the high-pressure group, 103 of 809 (12.7%) in the low-pressure group, and 111 of 812 (13.7%) in the very-low-pressure group. Hazard ratios for the three pairwise comparisons were as follows: for low versus high pressure, 0.92 (95% confidence interval [CI], 0.70 to 1.20; P=0.53), for high versus very low pressure, 1.02 (95% CI, 0.78 to 1.33; P=0.89), and for low versus very low pressure, 0.93 (95% CI, 0.71 to 1.23; P=0.62). Reoperation occurred in 182 of 1229 patients (14.8%) in the soap group and in 141 of 1218 (11.6%) in the saline group (hazard ratio, 1.32, 95% CI, 1.06 to 1.66; P=0.01). CONCLUSIONS The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group. (Funded by the Canadian Institutes of Health Research and others; FLOW ClinicalTrials.gov number, NCT00788398.).

Continuous Infusion of Local Anesthetic at Iliac Crest Bone-graft Sites for Postoperative Pain Relief: A Randomized, Double-blind Study

BACKGROUND Autologous bone graft is the so-called gold standard for reconstruction of bone defects and nonunions. The most frequent complication is donor site pain. The iliac crest is a common source for autologous bone graft. The purpose of this study was to determine whether a continuous infusion of 0.5% bupivacaine into the iliac crest harvest site provides pain relief that is superior to the relief provided by systemic narcotic pain medication alone in patients undergoing reconstructive orthopaedic trauma procedures. METHODS A prospective, double-blind randomized study of patients over eighteen years of age who were undergoing harvesting of iliac crest bone graft was conducted. The patients were randomized to the treatment arm (bupivacaine infusion pump) or the placebo arm. Postoperatively, all study patients received morphine sulfate with use of a patient-controlled analgesia pump. The patients recorded the pain at the donor and recipient sites with use of a scale ranging from 0 to 10. The use of systemic narcotic medication was recorded. Independent-samples t tests were used to assess differences in perceived pain relief between the treatment and control groups at zero, eight, sixteen, twenty-four, thirty-two, forty, and forty-eight hours after surgery. Pain was also assessed at two and six weeks postoperatively. RESULTS Sixty patients were enrolled. Across all data points, except pain at the recipient site at twenty-four hours, no significant differences in the perception of pain were found between the bupivacaine group and the placebo group. On the average, patients in the treatment group reported more pain than those in the control group. No significant difference was found between the two groups with regard to the amount of narcotic medication used. CONCLUSIONS No difference in perceived pain was found between the groups. The results of this small, unstratified study indicate that continuous infusion of bupivacaine at iliac crest bone-graft sites during the postoperative period is not an effective pain-control measure in hospitalized patients receiving systemic narcotic medication.

Translation step-cut osteotomy for the treatment of posttraumatic cubitus varus.

Background Cubitus varus deformity is the most common complication after the treatment of displaced supracondylar humerus fractures. Methods A retrospective analysis was performed evaluating patients who had undergone a translation step-cut osteotomy for correction of cubitus varus deformity between 1993 and 2008. Postoperative radiographs to union were reviewed for all patients. Subjective information and range of motion measures were documented from the medical records. Patients and their families were also contacted through telephone and administered a questionnaire as well as the QuickDash functional outcome measure to assess their function and satisfaction. Results Thirty-seven participants were identified and reviewed. Average age at the time of surgery was 8 years and 10 months, with an average follow-up of 2 years and 4 months. Outcomes were assessed in terms of technical, functional, and satisfaction domains. Technical Domain: Average humeroulnar angle (radiographic carrying angle) correction was 26 degrees. Baumans angle improved 21 degrees on average in patients who were skeletally immature. Functional Domain: Elbow range of motion was maintained in all planes with few exceptions. The clinical carrying angle improved 26 degrees on average, and was symmetric with the unaffected side in 22 of 25 cases in which it was documented. The QuickDash was applied to 15 participants. Eight participants had perfect scores for the symptoms/disability section, and 7 had scores in the top 20% for function. Satisfaction Domain: A study-specific questionnaire was applied to 16 participants. All patients and parents questioned would recommend the procedure to other parents/patients. Conclusion The translation step-cut osteotomy reliably corrects the coronal plane angular deformity associated with cubitus varus, resulting in excellent outcomes in technical, functional, and satisfaction domains. The osteotomy is relatively simple to perform, and is inherently more stable than other proposed methods. It also minimizes the prominence of the lateral condyle associated with simple lateral closing wedge osteotomy. Level of Evidence Level IV.

Effectiveness of serial stretch casting for resistant or recurrent knee flexion contractures following hamstring lengthening in children with cerebral palsy

A retrospective review of all cerebral palsy (CP) patients with resistant or recurrent knee flexion contractures treated with serial stretch casting was performed. The protocol consisted of sequential wedging (5 degrees per week) of fiberglass casts until maximum knee extension had been achieved. Measurements were made prior to the initiation of casting, at completion of the casting, and at 1 year after the casting. Forty-six subjects, with 75 involved extremities, met the study inclusion criteria. Mean age at the time of initiation of casting was 12.7 years. Using radiographic measurements, the mean initial degree of knee flexion contracture was −17.6 degrees. At the completion of casting, the mean knee flexion angle was -8.1 degrees. The mean duration of casting was 30 days. At 1 year after completion of the casting, the mean knee flexion angle was -12.2 degrees. Initial correction to within 10 degrees of full extension was achieved in 76% of extremities. Age less than 12 years and initial flexion contracture of less than −15 degrees were statistically significant factors related to maintenance of correction at 1 year. Complications included soft tissue compromise in 13 extremities (17%), transient neurapraxia in 9 extremities (12%), and tibial subluxation in 1 extremity (1%). Serial stretch casting was successful in correcting resistant knee flexion contractures in the majority of cases. Casting was less effective in teenagers and those with larger contractures. Complications were minimized by proper casting technique and controlled rate of correction.

Far cortical locking screws in distal femur fractures.

Distal femur fractures routinely heal by secondary bone healing, which relies on interfragmentary motion. Periarticular locking plates are commonly used for fixation in distal femur fractures but are associated with a high nonunion rate, likely due to the stiffness of the constructs. Far cortical locking (FCL) screws are designed to allow micromotion at the near cortex while maintaining purchase in only the far cortex. Although clinical data are limited, these screws have been shown in biomechanical studies to provide excellent interfragmentary motion, and animal models have shown increased callus formation compared with traditional locking screws. The purpose of this study was to examine the clinical effects that FCL screws have on healing in distal femur fractures treated with locked constructs. In this retrospective case series, 15 patients with a distal femur fracture treated with MotionLoc screws (Zimmer, Warsaw, Indiana) were analyzed. Serial radiographs were evaluated for callus presence and time to union. All fractures were either 33-A3 or 33-C2 according to the AO classification system, and 5 (33%) were open. Bone loss was recorded in 2 patients. There were no nonunions, and average time to union was 24 weeks. There were no implant failures, and all 5 open fractures, including the 2 with bone loss, healed without intervention. There was 1 reoperation due to painful hardware. Although this is a small case series, these results are promising. Far cortical locking screws may provide the answer to the high nonunion rate associated with distal femur fractures treated with traditional locked constructs.

Impact of Ankle-Foot Orthoses on Static Foot Alignment in Children with Cerebral Palsy

BACKGROUND Children with cerebral palsy who are able to walk are often managed with an ankle-foot orthosis to assist with walking. Previous studies have shown kinematic, kinetic, and energetic benefits during gait with the addition of an ankle-foot orthosis, although the mechanism of this gait improvement is unknown. The ability of orthoses to correct foot malalignment in children with cerebral palsy is not known. The current study was performed to determine the impact of orthoses on static foot alignment in children with cerebral palsy. METHODS A retrospective radiographic review was performed for 160 feet (102 patients). All patients had a diagnosis of cerebral palsy. Standing anteroposterior and lateral radiographs of the foot and ankle were made with the patient barefoot and while wearing the prescribed orthosis and were compared with use of the technique of quantitative segmental analysis of foot and ankle alignment. RESULTS Analysis of the foot and ankle radiographs made with the patient barefoot and while wearing the brace revealed significant changes in all measurements of segmental alignment (p < 0.05). The magnitudes of these differences were small (<6 degrees or <10%) and would be considered clinically unimportant. The coupled malalignment of equinoplanovalgus (clinical flatfoot) showed radiographic correction of at least one segment (hindfoot, midfoot, or forefoot) to within the normal range in 24% to 44% of the feet. The coupled malalignment of equinocavovarus (clinical high arched foot) showed correction of at least one segment to within the normal range in 5% to 20% of feet. CONCLUSIONS The present study demonstrates that the use of the ankle-foot orthoses failed to improve the static foot alignment in the majority of feet in children with cerebral palsy who were able to walk. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Functional Outcomes Following Single-Event Multilevel Surgery of the Upper Extremity for Children with Hemiplegic Cerebral Palsy

BACKGROUND Outcomes following single-event multilevel surgery of the upper extremity for children with cerebral palsy have not been well described in the literature. Since 1996, all children with hemiplegic cerebral palsy at our institution thought to be candidates for upper extremity surgery have had serial Shriners Hospital for Children Upper Extremity Evaluation performed for both clinical decision making and outcome assessment. The goal of the current study was to determine the functional outcomes, as described by the Shriners Hospital for Children Upper Extremity Evaluation, following single-event multilevel surgery of the upper extremity in children with hemiplegic cerebral palsy. METHODS The study design was a retrospective, case-control series. The case group consisted of forty children with hemiplegic cerebral palsy who underwent upper-extremity single-event multilevel surgery. The control group consisted of twenty-six children with hemiplegic cerebral palsy who had not received any upper-extremity interventions. The spontaneous functional analysis, dynamic positional analysis, and grasp-release analysis sections of the Shriners Hospital for Children Upper Extremity Evaluation were compared between the two groups. RESULTS The operative and nonoperative groups were comparable with respect to age (p = 0.09), sex (p = 0.97), initial spontaneous functional analysis scores (p = 0.37), dynamic positional analysis scores (p = 0.73), and grasp-release analysis scores (p = 0.16). For the single-event multilevel surgery group, significant improvements were noted for the mean spontaneous functional analysis score (p < 0.0001) and the mean dynamic positional analysis score (p < 0.0001), but not the mean grasp-release analysis score (p = 0.75). For the nonoperative control group, no significant changes were noted for the mean spontaneous functional analysis score (p = 0.89), the mean dynamic positional analysis score (p = 0.98), or the mean grasp-release analysis score (p = 0.36). Significant differences were noted between the single-event multilevel surgery and nonoperative control groups for the mean changes in the spontaneous functional analysis score (p = 0.01) and the mean change in the dynamic positional analysis score (p < 0.0001), but not the mean changes in the grasp-release analysis score (p = 0.56). CONCLUSIONS Children with hemiplegic cerebral palsy showed significantly improved dynamic segmental alignment and, to a lesser degree, spontaneous use of the upper extremity following single-event multilevel surgery compared with a comparable nonoperative control group. However, the grasp-release ability did not significantly improve in either the operative or nonoperative group.

Simultaneous Biplanar Fluoroscopy for the Surgical Treatment of Slipped Capital Femoral Epiphysis

Background The current standard of care for treatment of slipped capital femoral epiphysis (SCFE) is in situ placement of a single, cannulated screw across the physis under direct fluoroscopic guidance. Previous studies have reported the theoretical advantages of shorter operative time and improved accuracy of screw placement when 2 fluoroscopy units are used simultaneously. Methods A retrospective review was performed to compare the use of 1 versus 2 C-arms in the surgical stabilization of SCFE. Data analysis, including demographics, surgical setup times, operative times, and precision of screw placement was performed in 77 consecutive hips (69 patients). Results No significant differences were found between the single and dual C-arm techniques with respect to operating room setup and surgery times. Center-center positioning of the screw was more precise when using the simultaneous dual C-arm technique. Surgical times were longer in obese children, irrespective of the number of C-arms used. Conclusions Efficient operating room setup time for the dual C-arm technique is possible. Precision of screw placement is improved when using simultaneous biplanar fluoroscopy for the in situ pinning of SCFE. Level of Evidence Level IV.

Analysis of the musculoskeletal trauma section of the Orthopaedic In-Training Examination (OITE).

Objective: To analyze the musculoskeletal trauma content domain of the Orthopaedic In-Training Examination (OITE) over a 5-year period (2005-2009) to better understand the question content and distribution of references cited. Methods: The questions, answers, and recommended readings from the musculoskeletal trauma portion (as defined by the American Academy of Orthopaedic Surgeons) of the OITE were reviewed from the five examinations. The total number of questions, presence/modality of images, topics covered, taxonomic classification, and references listed were compiled and analyzed. Results: Two hundred fifty-four of 1351 questions (18.8%) were included in the musculoskeletal trauma domain. Imaging modalities were included with 28% of questions with plain radiographs alone being most common (83%). Fifty-six percent of the questions required the test taker to recall facts directly from the orthopaedic literature (taxonomy 1). The remaining 44% involved the interpretation of data, making a diagnosis, or formulating a treatment plan (taxonomies 2 and 3). No taxonomy 1 question was accompanied by a medical image. Upper extremity injuries were included in 25%, pelvis and acetabulum in 15%, and the lower extremity in 60% of the questions. The Journal of Orthopaedic Trauma was the most frequently cited reference source (24.1%) followed by the Journal of Bone and Joint Surgery, American Volume (20.8%). Conclusions: The musculoskeletal trauma section of the OITE remains the largest of the 12 content domains. Questions with associated images require a higher cognitive taxonomy. The Journal of Orthopaedic Trauma was the most cited reference. This analysis may help test question writers, future test takers, and faculty involved with resident education to better understand and prepare for this portion of the OITE.

Are large fracture trials possible

Reliable clinical orthopaedic trauma research is important and necessary to guide orthopaedic surgeons and their patients to best practices and expected outcomes. Currently, most fracture care is guided by suboptimal clinical research. To address this need, large fracture trials are necessary to deliver Level I evidence and direct the orthopaedic trauma surgeon in the best treatments. Although trials of this nature have been rare, they have been completed successfully. Although each fracture trial comes with its own set of obstacles, the trial can be successful with proper expertise, study planning, and study design. The purpose of this article is to present the rationale, methodology, and implementation strategies to successfully complete a large fracture trial.