Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study.

Operative fixation of midshaft clavicle fractures is controversial with few biomechanical data to assist surgical decision making. The purpose of this 2-phase biomechanical investigation is to report on the effects of plate location and selection on the stability of midshaft clavicle fractures. Thirty matched pairs of human adult formalin-fixed clavicles were used. In the first phase, in which a 3.5-mm reconstruction plate and simulated midshaft transverse clavicle osteotomies were used, we observed the effect of superior plate placement compared with anterior placement on fracture rigidity, construct stiffness, and strength. In the second phase, in which simulated midshaft oblique clavicle osteotomies were repaired on the superior aspect, we compared the fracture rigidity, construct stiffness, and strength of the 3.5-mm reconstruction, 3.5-mm limited contact dynamic compression (LCDC), and 2.7-mm dynamic compression (DC) plates. Intact clavicles were prepared, potted, and tested for axial and torsional stiffness in an Instron test frame equipped with gimbaled fixtures. Clavicles were band-sawed to simulate an osteotomy, repaired, re-mounted on the test frame with shear and opening extensometers placed across the osteotomy site, and then tested to observe axial and torsional fracture rigidity and stiffness. Constructs were then loaded to failure in compression. First-order regressions were used to estimate fracture rigidity (in kilonewtons per millimeter)and retained construct stiffness (in kilonewtons per millimeter), whereas the maximum applied compressive load at collapse or gross deformation determined the failure load. Values for the comparisongroups were tested for significance at the 95% confidence level. In the first phase we found that constructs plated at the superior aspect of the clavicle exhibited significantly greater fracture rigidity and mean retained stiffness than the anterior location (P <.05). In the second phase we found that the torsional fracture rigidity of LCDC-plated constructs significantly exceeded that of the reconstruction and DC plates (P <.05), whereas the axial fracture rigidity of the LCDC-plated constructs significantly exceeded that of the reconstruction plate (P <.05). In retained stiffness the performance of the LCDC-plated constructs significantly exceeded that of the DC plate in torsion (P <.05), whereas in load to failure the LCDC plate withstood significantly more compressive load than the reconstruction plate (P <.05). We concluded that clavicles plated at the superior aspect exhibit significantly greater biomechanical stability than those plated at the anterior aspect. Furthermore, we concluded that the LCDC plate offers significantly greater biomechanical stability than the reconstruction and DC plates.

Humeral shaft nonunions treated with fibular allograft and compression plating.

The present study is a retrospective review of the treatment of 12 humeral shaft nonunions by using an intramedullary allograft with compression plating. The average age of the patients was 61 years (range, 36-82 years). Eight cases involved the proximal shaft, 3 cases were at the mid-diaphyseal level, and 1 case was at the distal one third. Follow-up averaged 30 months (range, 12-96 months). Ten patients (83%) went on to uneventful healing at an average of 3 months after surgery. Two failures involving patients with multiple medical conditions occurred secondary to reinjury. Two cases of postoperative radial nerve neuropraxia involved the posterior approach to the humerus. Each resolved with no long-term residual morbidity. One patient developed postoperative adhesive capsulitis of the shoulder that resolved with nonoperative treatment. We feel that a fibular allograft, along with compression plating, can give satisfactory results for humeral shaft nonunions. This technique can be especially helpful in proximal humeral nonunions and in nonunions involving osteoporotic bone. Patients with multiple medical problems at risk for refalls should be protected until complete healing has occurred.

Misrepresentation of research criteria by orthopaedic residency applicants.

BACKGROUND: Previous studies have shown that applicants for postgraduate training may misrepresent research citations. We evaluated the research citations that were identified in a review of the Publications and Work and Research sections from the Electronic Residency Application Service (ERAS) data for all applicants to our orthopaedic residency program for the 1998 to 1999 academic year. METHODS: The citations were searched for on Medline. We initially used the name of the first author, then the name of the applicant, the name of the journal, the volume number, the issue number, and the page numbers. When a journal was not listed in Medline, an interlibrary search was instituted with use of the same format. When no match was made for any category, the citation was defined as misrepresented. Point estimates are reported as percentages. RESULTS: Publications were listed on sixty-four (30.0 percent) of 213 applications. One hundred and thirty-eight publications were cited; there were fifteen citations (10.9 percent) to book chapters, twenty-six (18.8 percent) to journals not listed in Ulrich's International Periodicals Directory, and twenty-one (15.2 percent) to articles listed as in press, in print, or submitted for publication. Seventy-six articles that had been cited as appearing in journals listed in Ulrich's Directory were checked and verified. Fourteen (18 percent) of these seventy-six publications were misrepresented. Misrepresentations included citations of nonexistent articles in actual journals and nonauthorship of existing articles. CONCLUSIONS: We concluded that publications listed on postgraduate applications should be scrutinized carefully. Copies of cited publications should be required by residency programs before applications are considered complete. The importance of professionalism needs to be emphasized in the curricula of medical schools. Residency training programs should develop guidelines regarding misrepresentation.

Results of preprocedure and postprocedure toe cultures in orthopaedic surgery.

This study was to determine whether there is any benefit to wrapping the toes sterilely during orthopaedic procedures not involving the foot but performed on the lower extremity. The group studied consisted of 12 patients who had an orthopaedic procedure performed in which the foot and toes were included in the surgical prep, but not involved in the surgical procedure. Nine of the 12 patients (75%) had positive results from preprocedural aerobic cultures and two of the 12 (16.6%) had positive results from preprocedural fungal cultures. Recolonization of the bacteria between the toes was also demonstrated. Sterile draping of the toes would minimize the risk of infection and also protect against bacteria that recolonize during the procedure.

Fixation comparison for chevron osteotomies.

A comparison study of temporary K-wire fixation, permanent Herbert Whipple screw fixation, versus no osteotomy fixation was performed on distal chevron osteotomies for hallux valgus deformities. Nineteen chevron osteotomies were performed on 17 patients. Six patients received a Herbert Whipple screw for fixation, seven patients received temporary K-wire fixation, and six patients received no fixation for the chevron osteotomy. The average postoperative hallux valgus (HV) angle improved by 7.1 degrees with no fixation, 6.3 degrees with temporary K-wire fixation, and 9.5 degrees with Herbert Whipple screw fixation. Comparison of the three groups using the Student's t-test revealed no statistical difference between the three groups (P = 0.6). The increased anesthesia time and operative costs for Herbert Whipple screw fixation was found to be statistically significant in comparison with the use of no fixation (P = <0.001). Time and cost studies were not significantly different for the K-wire and no fixation groups. Follow-up averaged 3.3 years. All patients reported satisfaction with the procedure and an improvement of their preoperative complaints. No significant difference in patient satisfaction was found to exist between the groups receiving fixation and those who did not have fixation. The results of this study can find no long-term benefit when comparing costs and patient satisfaction with the use of any temporary or permanent fixation of osteotomy sites when performing chevron osteotomies.

Closed treatment of displaced middle-third fractures of the clavicle gives poor results.

We evaluated 242 consecutive fractures of the clavicle in adults which had been treated conservatively. Of these, 66 (27%) were originally in the middle third of the clavicle and had been completely displaced. We reviewed 52 of these patients at a mean of 38 months after injury. Eight of the 52 fractures (15%) had developed nonunion, and 16 patients (31%) reported unsatisfactory results. Thirteen patients had mild to moderate residual pain and 15 had some evidence of brachial plexus irritation. Of the 28 who had cosmetic complaints, only 11 considered accepting corrective surgery. No patient had significant impairment of range of movement or shoulder strength as a result of the injury. We found that initial shortening at the fracture of > or = 20 mm had a highly significant association with nonunion (p < 0.0001) and the chance of an unsatisfactory result. Final shortening of 20 mm or more was associated with an unsatisfactory result, but not with nonunion. No other patient variable, treatment factor, or fracture characteristic had a significant effect on outcome. We now recommend open reduction and internal fixation of severely displaced fractures of the middle third of the clavicle in adult patients.

Rotator cuff disorders.

The supraspinatus, infraspinatus, teres minor and subscapularis muscles form a musculotendinous rotator cuff that provides dynamic stability to the shoulder joint. Symptoms of rotator cuff injury include limitation of motion, weakness and pain that often radiates down the upper arm and is present at night. Examination may reveal deltoid and rotator cuff atrophy, tenderness, limited passive range of motion and weakness on abduction and external rotation. Radiographs may show degenerative changes of the acromion or acromioclavicular joint, cysts, sclerosis and spurs of the greater tuberosity, and calcific deposits within the supraspinatus tendon. In most patients with subacromial impingement, conservative management, including physical therapy, nonsteroidal anti-inflammatory drugs and subacromial injections, is successful. Failure of conservative therapy after six to 12 weeks merits further evaluation with magnetic resonance imaging or arthrography, and consideration of surgery.

Complications following arthroscopic ankle arthrodesis.

Forty-two patients underwent an arthroscopic ankle arthrodesis utilizing a bi-framed distraction technique and demineralized bone matrix-bone marrow slurry as a graft substitute. The average follow-up was 27 months (range, 12-64 months). The overall complication rate was 55%, including three nonunions (7%), two fractures (4.8%), four pin site infections (9.5%), one deep infection, four hardware problems (9.5%), and four symptomatic painful subtalar joints (9.5%). Overall, 85% of patients were satisfied with their final result. The complication rate was high but most complications were minor and manageable. The demineralized bone matrix and bone marrow did not seem to increase the fusion rate over what has been documented previously for arthroscopic ankle fusions without the use of this graft substitute.

Open reduction and internal fixation of type II intra-articular calcaneus fractures.

Open reduction and internal fixation of 23 type II calcaneus fractures in 21 patients was performed using a standard extended lateral approach. Average follow-up was 26 months (range, 12-47 months). The Creighton-Nebraska Health Foundation Assessment Score for Fractures of the Calcaneus was used to evaluate fractures. The average score was 91.4 (range, 80-100), which represented an excellent result. A series of 10 type II fractures treated with closed methods was also evaluated using the same evaluation methods. The average score was 70 (range, 60-84), which represented a fair result. There was a clear statistically significant superiority with type II calcaneus fractures treated with open reduction and internal fixation (P < 0.0001). We recommend type I calcaneus fractures (nondisplaced) be treated with closed methods, and type II calcaneus fractures (displaced) be treated with open reduction and internal fixation.

Basic rescue and resuscitation. Trauma system concept in the United States.

Trauma has become the most expensive health care problem in the United States. It is the leading cause of death in persons younger than 44 years old. In 1990, there were approximately 92,000 deaths from trauma, 50% of which were caused by automobile accidents. Before 1976, there was no systemized approach for care of the traumatized patient. The American College of Surgeons Committee on Trauma has developed guidelines covering the spectrum of care of the trauma patient from access and prehospital care to hospital treatment and rehabilitation. The effectiveness of trauma systems has been proven in many studies that show a significant decrease in the preventable death rate in traumatized patients receiving care at a trauma center. The implementation of a national trauma system has proven difficult because of expense, commitment, and effective legislation. Small strides continue to be made, but many hurdles remain.

Irreducible dorsal dislocation of the great toe interphalangeal joint: case report and literature review.

Irreducible dorsal dislocation of the interphalangeal joint of the great toe is rare. Few case reports can be found in the literature. Most cases have been treated with operative exploration of the joint and reduction through a dorsal midline incision. We present a case where a medial approach was used under local block anesthesia to treat an irreducible complex dislocation of the interphalangeal joint of the great toe.