Biomechanical Comparison of Olecranon Sled Versus Intramedullary Screw Tension Banding for Olecranon Osteotomies.

BACKGROUND: Olecranon osteotomies are frequently performed to gain access to the distal humeral articular surface. Repair of the osteotomy or fixation of a simple 2-part olecranon fracture with traditional tension band construct is often plagued by complication. Proximal migration and irritation attributed to hardware are common complications of the standard construct of an intramedullary screw with tension band and are causes for reoperation. PURPOSE: To compare the biomechanical performance, time of implant, and prominence of an intramedullary screw and tension band construct with that of a newer low-profile continuous loop tension band (Olecranon Sled) construct in an olecranon osteotomy model. STUDY DESIGN: Controlled laboratory study. METHODS: Chevron osteotomies were created in 6 matched pairs of fresh-frozen human elbows (mean age, 66 ± 16 years). Each matched pair was then randomly divided into 1 of 2 groups: fixation with a screw and tension band construct or the Olecranon Sled. Bone mineral density, implant prominence, and time for implantation were recorded. Following olecranon fixation, each specimen underwent cyclic loading of 0 to 10 N for 100 cycles (to simulate unresisted active range of motion) and then 0 to 500 N for 500 cycles (to simulate pushing up from a chair) to measure for any displacement at the osteotomy site. The constructs were then loaded to failure and compared. RESULTS: No differences were found in bone mineral density between the 2 groups (P = .290). When measured from the tip of the olecranon, the continuous loop tension band had a medial prominence of only 3.57 ± 0.4 mm, as opposed to the intramedullary screw fixation of 7.288 ± 0.762 mm (P = .027). Total time of implantation, including osteotomy preparation, was a mean 155 seconds shorter with the Olecranon Sled versus the traditional tension band (P < .05). Because of the fracture of 1 specimen during cyclic loading, it and its matched counterpart were excluded, and only 5 matched pairs were analyzed for displacement and load to failure. There were no significant differences between groups in load to failure or displacement during cyclic loading (P > .05). CONCLUSION: The Olecranon Sled device was found to have no difference in biomechanical strength from that of the standard intramedullary screw with tension band construct. The Olecranon Sled was also found to be significantly less prominent while being faster to implant than the intramedullary screw. CLINICAL RELEVANCE: Evaluating an alternative option to the standard tension band construct is important for patients with olecranon fractures or osteotomies, as standard techniques have been fraught with hardware issues and need for revision surgery.

Costs of non-helmeted motorcycle riding in Connecticut.

Motorcycle-related head injuries and fatalities are a serious public health concern that can be reduced with helmet use. Caring for crash victims places additional economic stress on the healthcare system. The current Connecticut motorcycle helmet law does not require all motorcyclists to wear helmets. Universal motorcycle helmet laws increase helmet use. Efforts to increase helmet use through education and legislation should be considered for review, given the number of deaths and injuries that could be prevented.

Current Practice in the Management of Open Fractures Among Orthopaedic Trauma Surgeons. Part A: Initial Management. A Survey of Orthopaedic Trauma Surgeons.

OBJECTIVES: Open fractures are one of the injuries with the highest rate of infection that orthopaedic trauma surgeons treat. The main purpose of this survey was to determine current practice and practice variation among Orthopaedic Trauma Association (OTA) members and make treatment recommendations based on previously published resources. DESIGN: Survey. SETTING: Web-based survey. PARTICIPANTS: Three hundred seventy-nine orthopaedic trauma surgeons. METHODS: A 15-item questionnaire-based study titled "OTA Open Fracture Survey" was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze numerous aspects of open fracture management, focusing on parameters of initial and definitive treatment. RESULTS: Eighty-six percent of participants responded that a period of time of less than 1 hour is the optimal time to antibiotic administration after identification of open fracture. Despite concerns with nephrotoxicity, 24.0%-76.3% of respondents reported the use of aminoglycosides in management of open fractures. A little over half of survey respondents continue antibiotics until next debridement in wounds that were not definitively closed after initial debridement and stabilization. CONCLUSIONS: Rapid administration of antibiotics in open fracture management is important. Aminoglycoside use is still prevalent despite evidence questioning efficacy and toxicity concerns. Time to debridement of open fractures is controversial among OTA members. Antibiotic administration is commonly continued >48 hours despite concerns raised by Surgical Infection Society and The Eastern Association of the Surgery of Trauma. Regarding study logistics, survey participation reminders should be used when conducting this type of study as it can increase data accrual by 50%. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

The value of mentorship in orthopaedic surgery resident education: the residents' perspective.

BACKGROUND: The concept of mentoring is believed to be influential in an effective medical and surgical educational environment. Several authors have discussed the issue of mentorship and its challenges, yet no one has studied the prevalence of mentoring among orthopaedic residency programs and its perceived value from the orthopaedic residents' perspective. METHODS: Between January 1, 2008, and February 1, 2008, a survey created by the American Academy of Orthopaedic Surgeons was distributed by mail and e-mail to 3655 orthopaedic residents to obtain their opinion of the value of and their experience with mentorship. RESULTS: Five hundred and six (14%) of the surveyed residents responded. Nearly half of the responding residents either had a mentor or were involved in a mentoring program. Nearly all ranked the value of mentorship as very high and anticipated substantial help from their mentor in their career, research, and education. Only 44% were satisfied with their mentoring environment, and only 17% were highly satisfied. The residents were most satisfied with mentoring when there was a formal program in place. Ninety-six percent of the respondents thought that mentors were either critical or beneficial to their training. Residents who had selected their own mentor were more satisfied with their mentor than were those who had their mentor assigned. CONCLUSIONS: Residents with mentors, residents in mentoring programs, and residents who selected their own mentors had higher satisfaction with their mentoring environment than did those with no formal mentoring program. Residency programs should consider establishing formal mentorship programs and encourage residents to select their own mentors.

Olecranon fractures repaired with FiberWire or metal wire tension banding: a biomechanical comparison.

PURPOSE: Tension band constructs are commonly used for olecranon fracture fixation. The purpose of this study was to determine if a tension band constructed of FiberWire (Arthrex, Naples, FL), a high-strength polyester and polyethylene suture, will provide fixation that is equivalent to an 18-gauge metal wire tension band. METHODS: The following 4 fixation methods were biomechanically tested in cadaveric elbows with a simulated transverse olecranon fracture: (1) Kirschner wires (K-wires) with an 18-gauge metal wire tension band, (2) K-wires with a FiberWire tension band, (3) intramedullary screw with an 18-gauge metal wire tension band, and (4) intramedullary screw with a FiberWire tension band. Each elbow underwent all 4 repair methods. The K-wire repairs were performed first followed by the intramedullary screw repairs. The order of the tension band (FiberWire or metal wire) was randomly assigned. Specimens were tested under cyclic loading conditions that simulated stresses generated by (1) active range of motion and (2) pushing up from a chair. Fracture displacement was recorded by using transducers placed at the articular surface of the fracture and on the posterior surface of the olecranon. RESULTS: There were no significant differences in fracture displacement associated with the use of a high-strength suture or metal wire tension band under conditions simulating active range of motion or a more vigorous physiologic stress. Also, there were no significant differences associated with the use of an intramedullary screw versus K-wire fixation under either condition. CONCLUSIONS: The biomechanical characteristics of high-strength suture tension bands are equivalent to 18-gauge metal wire tension bands when used with either an intramedullary screw or K-wires. The fatigue patterns of high-strength suture tension bands and metal wire tension bands are similar. There is not a significant difference between the biomechanical strength of intramedullary screw fixation constructs and K-wire constructs. CLINICAL RELEVANCE: FiberWire tension bands may be used in place of metal wire tension bands without sacrificing fixation strength.

Chronic osteomyelitis: results obtained by an integrated team approach to management.

BACKGROUND: The pathology of chronic osteomyelitis suggests that thorough debridement of bone and soft tissue, with closure of dead space, supported by appropriate antibiotics would be the optimal therapeutic strategy. METHODS: In 1993, we formed a multidisciplinary Bone Infection Team (orthopaedic surgeon, infectious diseases specialist, plastic surgeon, and nurse practitioner) to apply those principles to the treatment of chronic osteomyelitis. We present the outcomes of such therapy in 82 patients treated by the Team in the first seven years. All patients underwent surgical debridement with other procedures including bone distraction, muscle flap implantation and bone grafts as necessary to foster restoration of bone and soft-tissue integrity. Antibiotic choice was based on sensitivity data, with a short course of intravenous antibiotics and a prolonged course of oral antibiotics being the usual therapy. RESULTS: During the first seven years, we treated 82 patients for chronic osteomyelitis. Most patients required multiple surgical procedures (mean = 2.2), with 10 patients requiring five or more operations. Staphylococcus aureus was the single most common pathogen, although the majority (57%) of the infections were polymicrobial. Intravenous antibiotics were administered for a median of 16 days; 16 patients received intravenous antibiotics only during the immediate perioperative period. Oral antibiotics were administered for a median of 59 days. The infection was cured in all but one patient in our clinic; the remaining patient had definitive surgical repair at another clinic and is now infection free. In 77/82 patients, the limb afflicted with chronic osteomyelitis was salvaged. Because of extensive damage to bones and surrounding soft tissues, amputation was necessary in five patients. Five patients required internal fixation 12 or more months after the infection was controlled for nonunion; all such procedures were successful. No patient whose infection remained inactive for six or more months after surgical debridement has reactivated the infection during a median follow-up of 56 months (range: 23-89 months). CONCLUSIONS: Management of chronic osteomyelitis requires thorough debridement of infected bone and soft tissues coupled with rigid stabilization with external fixators, elimination of dead space, often requiring soft-tissue flap coverage, and staged bone reconstruction. When such a surgical approach is accompanied by appropriate antibiotics based on the sensitivity of the microbes isolated from the infected site, the infected focus is eliminated and bone length and integrity are restored.

Moving toward a standard for spinal fusion outcomes assessment.

Previous spinal fusion outcomes assessment studies have been complicated by inconsistencies in evaluative criteria and consequent variations in results. As a result, a general consensus is lacking on how to achieve comprehensive outcomes assessment for spinal fusion surgeries. The purpose of this article is to report the most validated and frequently used assessment measures to facilitate comparable outcomes studies in the future. Twenty-seven spinal fusion outcomes studies published between 1990 and 2000 were retrospectively reviewed. Study characteristics such as design, evaluative measures, and assessment tools were recorded and analyzed. Based on the reviewed literature, an outcomes assessment model is proposed including the Short Form-36 Health Survey, the Oswestry Disability Questionnaire, the North American Spine Society Patient Satisfaction Index, the Prolo Economic Scale, a 0-10 analog pain scale, medication use, radiographically assessed fusion status, and a generalized complication rate.