Intramedullary fixation of unstable intertrochanteric hip fractures: one or two lag screws

OBJECTIVE: To compare the screw sliding characteristics and biomechanical stability of four-part intertrochanteric hip fractures stabilized with an intramedullary nail using either one large-diameter lag screw (intramedullary hip screw [IMHS]; Smith & Nephew, Memphis, TN) or two small-diameter lag screws (trochanteric antegrade nail [TAN]; Smith & Nephew, Memphis, TN). DESIGN: Laboratory investigation using eight matched pairs of cadaveric human femurs with simulated, unstable intertrochanteric hip fractures. INTERVENTION: One femur of each matched pair was stabilized with an IMHS intramedullary nail, and the other was stabilized with a TAN intramedullary nail. Femurs were statically, then cyclically loaded on a servohydraulic materials testing machine. Finally, all specimens were loaded to failure. MAIN OUTCOME MEASURES: Screw sliding and inferior and lateral head displacements were measured for applied static loads from 500N to 1250N. The same measurements were obtained before and after cyclically loading the specimens at 1250N. Ultimate failure strength of the implant constructs also was determined. RESULTS: There was no significant difference between the TAN and IMHS in static or cyclical loading with respect to screw sliding or inferior and lateral head displacements. There was a statistically significant difference (P < 0.02) in failure strength, with the IMHS construct failing at an average of 2162N and the TAN construct failing at an average of 3238N. CONCLUSION: The two constructs showed equivalent rigidity and stability in all parameters assessed in elastic and cyclical tests. The TAN had a greater ultimate failure load.     

Lower-extremity function for driving an automobile after operative treatment of ankle fracture

BACKGROUND: The purpose of this study was to determine when patients recover the ability to safely operate the brakes of an automobile following operative repair of an ankle fracture. METHODS: A computerized driving simulator was developed and tested. Eleven healthy volunteers were tested once to establish normal mean values (Group I), and a group of thirty-one volunteers with a fracture of the right ankle were tested at six, nine, and twelve weeks following operative repair (Group II). The subjects were tested with a series of driving scenarios (city, suburban, and highway). Scores on the Short Form Musculoskeletal Assessment were recorded at six, nine, and twelve weeks and were compared with the results of the driving test. We investigated the effect of the time of the visit and of the testing condition on the braking times. RESULTS: The total braking time was 1079 msec for Group I and 1330, 1172, and 1160 msec for Group II at six, nine, and twelve weeks, respectively, postoperatively (p = 0.0094). The total braking time consistently improved for each of the driving scenarios at each successive data point (p = 0.05). The increase in the total braking time at six weeks meant an increase in the distance traveled by the automobile before braking of 22 ft (6.7 m) at 60 mph (96.6 km/hr), and the increase at nine weeks meant an increase of 8 ft (2.4 m) at 60 mph. The functional outcome improved at each successive visit, although no significant association was found between the functional scores and normalization of total braking time. CONCLUSION: By nine weeks, the total braking time of patients who have undergone fixation of a displaced right ankle fracture returns to the normal, baseline value.     

Surgical management of hip fractures: an evidence-based review of the literature. II: intertrochanteric fractures

Treatment of intertrochanteric hip fracture is based on patient medical condition, preexisting degenerative arthritis, bone quality, and the biomechanics of the fracture configuration. A critical review of the evidence-based literature demonstrates a preference for surgical fixation in patients who are medically stable. Stable fractures can be successfully treated with plate-and-screw implants and with intramedullary devices. Although unstable fractures may theoretically benefit from load-sharing intramedullary implants, this result has not been demonstrated in the current evidence-based literature.     

Perspective: Integrating research into surgical residency education: lessons learned from orthopaedic surgery

Orthopaedic research has advanced tremendously in parallel with accelerated progress in medical science. Possession of a fundamental understanding of basic and clinical science has become more essential than previously for orthopaedic surgeons to be able to translate advances in research into clinical practice. The number of medical graduates with prior education in scientific research who choose to pursue careers in orthopaedic surgery is small. Therefore, it is important that a core of research education be included during residency training to ensure the continued advancement of the clinical practice of orthopaedics. The authors examine some of the challenges to a comprehensive research experience during residency, including deficient priority, inadequate institutional infrastructure, financial strain on residency budgets, restricted time, and an insufficient number of mentors to encourage and guide residents to become clinician-scientists. They also present some strategies to overcome these challenges, including development and expansion of residency programs with clinician-scientist pathways, promotion of financial sources, and enhancement of opportunities for residents to interact with mentors who can serve as role models. Successful integration of research education into residency programs will stimulate future orthopaedic surgeons to develop the critical skills to lead musculoskeletal research, comprehend related discoveries, and translate them into patient care. Lessons learned from incorporating research training within orthopaedic residency programs will have broad application across medical specialties-in both primary and subspecialty patient care.     

Three- and Four-part Fractures Have Poorer Function Than One-part Proximal Humerus Fractures

Background  

Locking plates have become a commonly used fixation device in the operative treatment of three- and four-part proximal humerus fractures. Examining function in patients treated nonoperatively and operatively should help determine whether and when surgery is appropriate in these difficult-to-treat fractures.