William R. Barfield

Ankle Arthrodesis Using Anatomically Contoured Anterior Plate

Background: More than 40 fusion techniques for the ankle joint have been reported. The purpose of this retrospective study was to review our preliminary clinical and radiographic results using an anatomically contoured anterior plate for ankle arthrodesis. Materials and Methods: Ten ankle arthrodeses with an anatomically contoured anterior plate performed by a single surgeon were reviewed with an average of 14 months followup. One underwent revision surgery due to screw loosening by reapplying the same plate. Plain radiographs were taken to help determine the stability of fixation and time of fusion. The AOFAS clinical rating system was applied to evaluate patients preoperatively and postoperatively. Results: Nine of ten patients achieved solid fusion radiographically and clinically at an average of 15 (range, 12 to 22) weeks. Bony healing was achieved after an additional 12 weeks for the patient who underwent revision fusion. There were no postoperative wound problems or infections. All patients reported an improvement in their pain level following successful fusion. Conclusion: The application of an anatomically contoured plate provides many advantages, including less soft tissue disruption by using a single anterior incision, ease of deformity correction, early rehabilitation, and high rate of union. Level of Evidence: IV, Retrospective Case Series

Efficacy of augmenting a subacromial continuous-infusion pump with a preoperative interscalene block in outpatient arthroscopic shoulder surgery: a prospective, randomized, blinded, and placebo-controlled study.

PURPOSE This studys purpose was to determine the effectiveness of adding a preoperative interscalene brachial plexus block to standard postoperative management, including oral narcotics and a subacromial bupivacaine infusion pump, after arthroscopic shoulder surgery. METHODS After performing a prospective power analysis and obtaining institutional board approval, we conducted a randomized placebo-controlled trial of 53 patients separated into a preoperative interscalene brachial plexus group and a control group. Group 1 received an interscalene block with 30 mL of 0.5% ropivacaine. Group 2 received a placebo with 10 mL of saline solution. All patients postoperatively received an arthroscopically placed subacromial infusion pump catheter for 72 hours and oral narcotics. Pain scores on a visual analog scale (VAS) and narcotic pill use were recorded at 6, 12, 20, 32, 40, 52, 60, 72, and 80 hours. RESULTS Preoperative pain scores between groups were not significant (P > .05). A statistically significant difference was found for decreased pain scores at 6 hours after discharge in patients receiving an interscalene block (P = .001) (VAS of 30.9 in group 1 v 61.8 in group 2). There was also a decrease in the number of narcotic pills taken at the 6-hour time interval (P = .1) (0.6 pills v 1.1 pills). Group 1 had a rebound phenomenon 20 hours after discharge. Pain scores spiked as the effects of the block wore off (P = .08) (net change in VAS score increase, 25.0 v 10.3). No other statistical or clinical differences were observed. CONCLUSIONS The addition of a preoperative interscalene block to a postoperative subacromial infusion pump provided significant improvement of pain control only at 6 hours after discharge. Twelve hours after discharge, this benefit had disappeared. A rebound phenomenon of increased pain at 20 hours was seen after the interscalene block had worn off. After 20 hours, no statistically significant or clinically applicable differences were found. LEVEL OF EVIDENCE Level I, randomized controlled trial.

Randomized prospective clinical trial comparing reamer irrigator aspirator (RIA) to standard reaming (SR) in both minimally injured and multiply injured patients with closed femoral shaft fractures treated with reamed intramedullary nailing (IMN)

PURPOSE To investigate whether inflammatory markers are improved among patients with traumatic femur fractures who undergo RIA reamed intramedullary nailing (IMN) prior to fixation when compared to patients treated with standard reamed (SR) IMN. METHODS A prospective, randomized, single-blind trial was conducted on patients who had a closed femoral shaft fracture amenable to reamed IMN. Patients were randomized to undergo IMN with standard reaming or IMN with the RIA in a 1:1 ratio. Patients were stratified by Injury Severity Score (ISS) and by presence or absence of chest injury with AIS > 3. Patients had blood samples and bronchioalveolar lavage samples taken at specified time points pre- and postoperatively. Specimens from SR and RIA cohorts were compared for the presence of IL-2, IL-6, IL-8, TNF, and IL-10 in plasma and IL-1b and IL-8 in bronchioalveolar lavage (BAL) samples to determine the relationship between inflammatory markers and intramedullary reaming. RESULTS Nineteen consecutive patients participated in the study with 9 assigned in the RIA group and 10 in SR group. Significant differences existed for ISS between SR and RIA groups (p=0.04). Bronchial lavage data showed no statistical significant differences when RIA and standard reamers were compared and when ISS >16 and <16 were compared, however there were differences for the bronchial IL-8 change when those with chest injury were compared to those without chest injury. Plasma samples showed a trend towards increased IL-6 and IL-10 levels after reaming consistent with the second hit impact. A trend towards higher levels for IL-6 in the SR group was noted at 24 hours post-operatively whereas the IL-10 levels at the post-reaming time point were higher in the RIA group. CONCLUSIONS This prospective study of reamer type indicates that RIA may be protective of systemic inflammation. This is supported by data showing decreased levels of IL-8 in the bronchial washings and increased level of IL-10 in the serum. Reaming and intramedullary fixation may cause an increase in IL-6 levels regardless of reamer type. Further investigations with a larger cohort of patients are desirable.

Relationship of factors affecting age of onset of independent ambulation.

Despite the standard available pediatric developmental scales and popular lore that girls walk at an earlier age than boys, no large-scale evaluation of the age of onset of independent ambulation has been previously published. The purpose of this study was the prospective epidemiologic evaluation of a large heterogeneous group of normal children to determine the effect of gender, race, birth order, and socioeconomic status on the age of onset of independent ambulation. The study cohort consisted of 986 children (575 male, 471 female). A multivariable analysis of covariance model was used to examine the effects of race, gender, income, and birth order on age at ambulation. After controlling for the other variables in the model, race was the only statistically significant predictor of age at ambulation (p < 0.0001), with black children walking at a younger age (10.9 ± 2.1 months) than white children (11.6 ± 2.3 months). Overall, the independent variables included in the model were only able to explain 2.5% of the variance of age at ambulation.

Middle-third clavicle fracture with associated type IV acromioclavicular separation: case report and literature review.

Review of available English literature suggests that combined injuries involving a clavicle shaft fracture and an acromioclavicular (AC) separation are rare. The force dissipation after the occurrence of either a midshaft clavicle fracture or an AC separation typically renders the injuries mutually exclusive. This article presents a review of literature on this combined injury pattern. A variety of treatment approaches have been put forth, including nonoperative, operative, and hybrid management of the two distinct injuries. The most appropriate treatment rendered depends on the degree of AC joint instability. This case report involves a midshaft clavicle fracture associated with a type IV AC separation in a patient ejected during a high-speed motor vehicle collision. Internal fixation of each injury was chosen and the patient had a successful final result. Other reported treatment options and recommendations are reviewed.

Compartment syndrome after low-energy tibia fractures sustained during athletic competition.

Objective: The purpose of this study was to determine whether patients who sustain tibia fractures during athletic competition are at an increased risk of developing acute compartment syndrome (ACS). Design: Retrospective review. Setting: University Level I trauma center. Participants/Patients: Acute tibia fractures in 626 patients between July 2006 and June 2009. Methods: A retrospective review of 626 consecutive tibia fractures treated by our department between July 2006 and June 2009 was performed. We recorded the mechanism and type of fracture as well as whether or not ACS developed. Soccer and football injuries were analyzed as specific groups. Chi square was used to analyze our results. Main Outcome Measurements: The rate of ACS in patients injured during sporting events versus that of all patients with a tibia fracture. Results: Thirty-four patients (5.4%) developed ACS, which is consistent with the published literature. Nine patients sustained the injury while playing soccer (1.4% of patients), whereas 11 patients (1.7%) were injured playing football. Five of the nine soccer players (55%; P < 0.001) and three of the football players (27%; P < 0.001) developed ACS. Collectively, tibia fractures sustained in football and soccer led to 25% of ACS cases despite accounting for only 3.1% of all tibia fractures. Conclusions: Tibia fractures sustained during soccer and football had a statistically significant association with development of ACS in our patient population during this time period. Such patients should be monitored closely and followed with high clinical suspicion for ACS.

The impact of race on the development of severe heterotopic ossification following acetabular fracture surgery

OBJECTIVES To determine the association between race on severe heterotopic ossification (HO) following acetabular fracture surgery. DESIGN Retrospective case control study. SETTING Level I university trauma centre. METHODS Two hundred and fifty-three patients who were surgically treated for acetabular fractures were retrospectively evaluated. Postoperative radiographs were evaluated for HO by a blinded musculoskeletal radiologist, and classified based on a modified Brooker classification. RESULTS Of the 253 patients that met inclusion and exclusion criteria, 175 (69%) were male and 78 (31%) were female. One hundred and fifty-four (61%) patients were Caucasian, and 99 (39%) were African American (AA). Fifty-five (21%) patients developed severe HO. Of those who developed severe HO, 25 were Caucasian (45%), 30 were African American (55%). Forty-one patients (75%) with severe HO were male, and 14 (25%) were female. No statistical differences (p>0.05) were found between groups in terms of age, days to surgery, GCS at presentation, surgical approach, perioperative HO prophylaxis, or AO/OTA fracture classification. The patient population was then stratified by race, gender, and race/gender. AA were more likely than Caucasians to develop severe HO (odds ratio [OR], 2.24; confidence interval [CI], 1.22-4.11). When gender was considered independent of race, no statistical differences (p>0.05) were observed (OR, 1.40; CI, 0.71-2.75). AA males were much more likely to develop severe HO when compared to Caucasian females (OR, 4.4; CI, 1.38-14.06). CONCLUSION Race is associated with different rates of severe HO formation following acetabular fracture surgery. AA patients are significantly more likely to develop severe HO following acetabular fracture surgery when compared to Caucasian patients.

Heterotopic Ossification in Trauma

Better understanding of the biology of heterotopic ossification (HO) formation will lead to treatment and prevention modalities that can be directed specifically at the cellular level. Early identification of HO precursor cells and target genes may provide prognostic value that guides individualized prophylactic treatment. Better understanding of molecular signaling and proteomics variability will allow surgeons to individualize preemptive treatment to suppress inflammation and formation of HO. Careful surgical technique to avoid muscle damage is important. Damaged muscle should be debrided as a prophylactic measure. Hemostasis and avoidance of a postoperative hematoma may decrease the chance of formation of HO.

Clinical evaluation of nonarthritic shoulder pain: Diagnosis and treatment

Abstract Shoulder pain and dysfunction is a complex problem frequently encountered by primary care physicians. Common nonarthritic conditions seen in the primary care setting include rotator cuff syndrome, impingement, posttraumatic stiffness, adhesive capsulitis, and instability. A thorough history and physical examination can aid in the diagnosis of many common shoulder complaints. Pain and instability are the most common shoulder complaints. Pain that is sharp or burning is commonly radicular in origin, whereas pain caused by tendinitis is often dull, diffuse, and aching. Instability is frequently found in patients with a history of dislocation, but also may occur with no prior history. Imaging modalities such as magnetic resonance imaging can be helpful for more advanced pathology. However, many common shoulder conditions can be diagnosed without imaging, and may be initially treated with a short course of rest, ice, topical analgesics, nonsteroidal anti-inflammatory drugs, directed and supervised physical therapy, and occasionally subacromial corticosteroid injections. As always, a detailed history and a thorough physical exam by a primary care physician are vital for diagnosis. When conservative measures fail, referral to an orthopaedic surgeon may be necessary for further patient management.

The effect of tibial rotation on varus deformity measurement.

Purpose: Tibial osteotomy is used to treat a variety of orthopedic conditions, including reduction in pain and improvement of deformity and function. In templating for surgery, accurate radiographic measurement aids in planning for correction. The purpose of our study was to examine the effect of internal rotation and external rotation on measurement of tibial sawbone models with 5 closing wedge varus deformities at 10-degree increments between 10 and 50 degrees. One sawbone without deformity served as the control. Study Design: A total of 66 radiographs were measured by 5 individuals. Measurement deviations from the control in each of the 10 positions of rotation were assessed. Results: In the analysis of variance models, increased rotation and varus angulation were associated with increased deviation compared with the control. In external rotation for every 10 degrees of varus angulation, the degree deviation increased 0.69 degrees. In IR for every 10 degrees of angulation, the degree deviation increased by 0.84 degrees. Internal rotation had the greatest impact. Mean differences between different raters measurements were small (1.1 ± 1.2 degrees) and correlations suggested high interrater reliability. Conclusions: As the degree of rotation from neutral increased and varus angulation increased, deviation from neutral increased. Clinical Relevance: Clinically, the results of this study support the importance of proper alignment of the tibia during radiography to more precisely template surgery.