Orthopaedic manifestations of systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease of unknown origin. It affects multiple organ systems, but most frequently the musculoskeletal system. Highly variable manifestations include small and large joint involvement, spinal involvement, periarticular tissue symptoms, and complications associated with chronic steroid use such as osteonecrosis, osteoporosis, and stress fractures. The following review summarizes the common orthopaedic manifestations of SLE.     

Arthrofibrosis: Etiology,classification, histopathology, and treatment

This article provides a complete review of arthrofibrosis following ACL reconstruction, and a complete review of theetiology, classification, and histology of arthrofibrosis. A clinician's guide to the recognition of arthrofibrosis and when the arthrofibrosis is clinically significant, treatment of arthrofibrosis after determination of arthrofibrosis, and its treatment to include surgical and nonsurgical management is noted. We emphasize prevention with appropriate indications and timing of ACL reconstruction and appropriate intraoperative surgical techniques for a correctly performed ACL reconstruction. The appropriate rehabilitation and expected clinical progress and parameters to follow after ACL reconstruction with emphasis on early recognition and early treatment will significantly improve the outcome of treatment of clinically significant arthrofibrosis and hopeful prevention of arthrofibrosis. By applying the techniques reviewed, prevention of arthrofibrosis is the orthopaedic surgeons best weapon.     

Does obesity influence the outcome after the operative treatment of ankle fractures?

Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion. This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures. We retrospectively reviewed 279 patients (99 obese (BMI > or = 30) and 180 non-obese (BMI < 30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function. These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities.     

Hip fracture management: tailoring care for the older patient

Hip fracture is a potentially devastating condition for older adults. Hip fracture leads to pain and immobilization with complications ranging from delirium to functional loss and death. Although a mainstay of treatment is orthopedic repair, a multidisciplinary comanagement approach, including medical specialists and rehabilitation, may maximize patient recovery. Using the case of Mr W, an older man who sustained a fall and hip fracture, we present evidence-based components of care both in the hospital and outpatient settings. Preoperatively, clinicians should correct medical abnormalities and consider the appropriateness, timing, and type of surgical repair in the context of the patient's life expectancy and goals of care. Perioperative care should include prophylaxis with antibiotics, chemoprophylaxis for venous thromboembolism, and correction of major clinical abnormalities prior to surgery. Pain control, delirium, and pressure ulcer prevention are important inpatient care elements. Multidisciplinary models incorporating these care elements can decrease complications during inpatient stay. Rehabilitation strategies should be tailored to patient needs; early mobilization followed by rehabilitation exercises in institutional, home, and group settings should be considered to maximize restoration of locomotive abilities. Attention to care transitions is necessary and treatment for osteoporosis should be considered. The road to recovery for hip fracture patients is long and most patients may not regain their prefracture functional status. Understanding and anticipating issues that may arise in the older patient with hip fracture, while delivering evidence-based care components, is necessary to maximize patient recovery.     

Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures

BACKGROUND: The purpose of this study was to confirm the prevalence of medial ankle widening among patients with an isolated fibular fracture and to determine the functional outcome of nonoperative treatment despite a diagnosis of a supination-external rotation stage-IV injury based on stress radiography. METHODS: One hundred and one patients with evidence of an isolated fibular fracture and an intact mortise seen on a standard ankle trauma radiograph series were evaluated with stress radiographs. Clinical signs were recorded at the time of presentation. A positive stress test was defined as > or =4 mm of widening of the medial clear space. Patients with a negative stress test were treated nonoperatively, those with a positive stress test and clinical signs of medial injury were treated surgically, and those with a positive stress test and no signs of medial injury were treated according to the preference of the surgeon and patient. The patients were followed prospectively with radiographs and ankle outcome scores. RESULTS: Sixty-six (65%) of the 101 patients had a positive stress radiograph. Thirty-six of them had signs of medial injury, and thirty had no medial injury. With regard to predicting a positive stress radiograph, medial tenderness had a sensitivity of 56% and a specificity of 80%, swelling had a sensitivity of 55% and a specificity of 71%, and ecchymosis had a sensitivity of 26% and a specificity of 91%. Of the subset of patients without signs of medial injury, twenty were treated nonoperatively (group I) and ten were treated operatively (group II). Two of the twenty patients in group I had evidence of persistent widening of the medial clear space at the time of the latest follow-up (mean, 7.4 months); only one of those patients was symptomatic. The average American Orthopaedic Foot and Ankle Society (AOFAS) score was 94 points in group I and 93 points in group II. CONCLUSIONS: We found a high rate of positive stress radiographs for patients who presented with an isolated fibular fracture and an intact ankle mortise on the initial radiographs. Medial tenderness, swelling, and ecchymosis were not sensitive with regard to predicting widening of the medial clear space on stress radiographs. All of the patients with a positive stress radiograph and no clinical symptoms who were treated without surgery had a good or excellent clinical result.     

Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures?

OBJECTIVE: Evaluate whether supplementary fibular fixation helped maintain axial alignment in distal metaphyseal tibia-fibula fractures treated by locked intramedullary nailing. DESIGN: Retrospective chart and radiographic review. SETTING: Three, level 1, trauma centers. PATIENTS: Distal metaphyseal tibia-fibula fractures were separated into 2 groups based on the presence of adjunctive fibular plating. Group 1 consisted of fractures treated with small fragment plate fixation of the fibula and intramedullary (IM) nailing of the tibia, whereas group 2 consisted of fractures treated with IM nailing of the tibia without fibular fixation. OUTCOME MEASURES: Malalignment of the tibial shaft was defined as 1) >5 degrees of varus/valgus angulation, or 2) >10 degrees anterior/posterior angulation. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up. Leg length and rotational deformity were not examined. RESULTS: Seventy-two fractures were studied. In 25 cases, the associated fibula fracture was stabilized, and in 47 cases the associated fibula fracture was not stabilized. Cases were more likely to have the associated fibula fracture stabilized where the tibia fracture was very distal. In multivariate adjusted analysis, plating of the fibula fracture was significantly associated with maintenance of reduction 12 weeks or later after surgery (odds ratio = 0.03; P = 0.036). The use of 2 medial-lateral distal locking bolts also was protective against loss of reduction; however, this association was not statistically significant (odds ratio = 0.29; P = 0.275). CONCLUSIONS: In this study, the proportion of fractures that lost alignment was smaller among those receiving stabilization of the fibula in conjunction with IM nailing compared with those receiving IM nailing alone. Adjunctive fibular stabilization was associated significantly with the ability to maintain fracture reduction beyond 12 weeks. At the present time, the authors recommend fibular plating whenever IM nailing is contemplated in the unstable distal tibia-fibular fracture.