Clinical pathway for hip fractures in the elderly: the Hospital for Joint Diseases experience

Hip fractures are common injuries in the elderly and are associated with considerable morbidity and mortality. Although technical advances in the treatment of the elderly have resulted in improved fracture fixation and surgical outcomes, clinical pathways have been developed to further improve patient outcome while shortening hospital length of stay after hip fracture. We describe the clinical pathway used since 1990 at the Hospital for Joint Diseases. The outcomes of 747 patients treated before 1990 were compared with outcomes of 318 patients treated at our hospital after initiation of the clinical pathway. Use of the clinical pathway was associated with significant decreases in the acute care hospital length of stay, in-hospital mortality, and 1-year mortality.

Functional outcomes and mortality vary among different types of hip fractures: a function of patient characteristics

A review of prospectively collected data was done to compare functional outcomes and mortality among patients with different hip fracture types. Five hundred thirty-seven elderly patients who sustained a hip fracture were followed up prospectively. Orthopaedists blinded to treatment and outcome radiographically classified the fractures as either: (1) nondisplaced or impacted femoral neck; (2) displaced femoral neck; (3) stable intertrochanteric; or (4) unstable intertrochanteric fracture. Functional independence measure scores were calculated for preinjury function and at 2- and 6- month follow-ups. Comorbidities, operative details, postoperative complications, and deaths were recorded. Six-month mortality was lowest for patients with nondisplaced femoral neck fractures (5.7%) and highest for patients with displaced femoral neck fractures (15.8%), but multivariate analysis only identified preinjury function as an independent predictor of mortality. All preinjury and followup functional independence measure scores were greatest for patients with nondisplaced femoral neck fractures and least for patients with unstable intertrochanteric fractures. However, multivariate analysis identified only patient age and preinjury functional independence measure scores as independent predictors of functional outcome. These data show differences in mortality and functional outcomes among fracture types that can be attributed to differences in functional status before injury.

Mismatch of current intramedullary nails with the anterior bow of the femur

OBJECTIVES

The anterior curvature of the femur affects intramedullary nail insertion, revision prosthesis design, and the biomechanics of the proximal femur. Two previous studies, using small numbers of femurs, determined femoral curvature and showed that it was significantly greater than that of the several intramedullary nails they evaluated. In this study, the curvature of 948 femurs (474 matched pairs) was determined and compared with current intramedullary nails. The correlation of femoral curvature to age, gender, femoral size, and race was also evaluated.

SETTING

Museum skeletal collections and a hospital biomechanics laboratory.

METHODS

The curvature of 892 femurs (446) from the skeletal collections of 2 museums was measured by processing the digital images of the femurs with a computer curve-fitting program. Fifty-six additional, embalmed femurs (28 pairs) from our collection were also digitally imaged and then radiographed and their medullary curvatures similarly determined for comparison. Curvatures of 8 current antegrade intramedullary nails and 3 long-stemmed femoral hip prostheses were obtained from manufacturers and confirmed by measurements from their templates after digitization.

RESULTS

We found the average femoral anterior radius of curvature was 120 cm (+/- 36 cm). There was no effect of age on femoral curvature nor was there a correlation between femoral width or femoral length to curvature. Black donor femurs had less curvature than white donor femurs (P < 0.001). There was close correlation (r = 0.967) between the femoral curvatures determined from the digital images and the radiographs. Radii of curvature of the intramedullary nails ranged from 186 to 300 cm (eg, straighter than the femurs).

CONCLUSIONS

There was a large mismatch between the curvature of some current antegrade intramedullary nails and the average femur. Although this is only 1 factor affecting nail insertion, the mismatch warrants a reappraisal of these intramedullary nail designs.

CLINICAL RELEVANCE

Because ease of intramedullary nail insertion and possibility of cortical comminution are determined by a number of factors including insertion point and fracture location, it appears that a decrease in radii of curvature (less straight) of current nail designs is warranted, particularly for those larger diameter nails designed for hip fracture stabilization that have greater rigidity due to design or material.

Physical therapy and mobility 2 and 6 months after hip fracture

OBJECTIVES

To examine the relationship between early physical therapy (PT), later therapy, and mobility 2 and 6 months after hip fracture.

DESIGN

Prospective, multisite observational study.

SETTING

Four hospitals in the New York City area.

PARTICIPANTS

Four hundred forty-three hospitalized older patients discharged after surgery for hip fracture in 1997-98.

MEASUREMENTS

Patient demographics, fracture type, comorbidities, dementia, number of new impairments at discharge, amount of PT between day of surgery and postoperative day (POD) 3, amount of therapy between POD4 and 8 weeks later, and prefracture, 2-, and 6-month mobility measured using the Functional Independence Measure.

RESULTS

More PT immediately after hip fracture surgery was associated with significantly better locomotion 2 months later. Each additional session from the day of surgery through POD3 was associated with an increase of 0.4 points (P=.032) on the 14-point locomotion scale, but the positive relationship between early PT and mobility was attenuated by 6 months postfracture. There was no association between later therapy and 2- or 6-month mobility.

CONCLUSION

PT immediately after hip fracture surgery is beneficial. The effects of later therapy on mobility were difficult to assess because of limitations of the data. Well-designed randomized, controlled trials of the effect of varying schedules and amounts of therapy on functional status after hip fracture would be informative.

The effect of perioperative anemia on clinical and functional outcomes in patients with hip fracture

OBJECTIVES

To describe the epidemiology of perioperative anemia in patients with hip fracture and assess the relationship between the hemoglobin measurements and clinical outcomes.

DESIGN

Prospective observational cohort study.

SETTING

Four university and community teaching hospitals.

PATIENTS

A consecutive cohort of 550 patients who underwent surgery for hip fracture and survived to discharge from August 1997 and August 1998 were evaluated and followed prospectively.

MAIN OUTCOME MEASURES

Deaths, readmissions and Functional Independence Motor mobility scores within 60 days of discharge.

RESULTS

Anemia (defined as hemoglobin <12.0 g/dL) was present in 40.4% of patients on admission, 45.6% at the presurgery nadir, 93.0% at the postsurgery nadir, and 84.6% near discharge. The mean drop in hemoglobin after surgery was 2.8 +/- 1.6 g/dL. In multivariate analyses, higher hemoglobin levels on admission were associated with shorter lengths of hospital stay and lower odds of death and readmission even after controlling for a broad range of prefracture patient characteristics, clinical status on discharge, and use of blood transfusion. Admission and preoperative anemia was not associated with risk-adjusted Functional Independence Motor mobility scores. In multivariable analyses, higher postoperative hemoglobin was associated with shorter length of stay and lower readmission rates, but did not effect rates of death or Functional Independence Motor mobility scores.

CONCLUSIONS

Substantial declines in hemoglobin were common in patients with hip fracture. Higher preoperative hemoglobin was associated with shorter length of stay and lower odds of death and readmission within 60 days of discharge. Postoperative hemoglobin was also related to length of stay and readmission rates.

Effect of postoperative delirium on outcome after hip fracture

Nine-hundred twenty-one community-dwelling patients 65 years of age or older, who sustained an operatively treated hip fracture from July 1, 1987 to June 30, 1998 were followed up for the development of postoperative delirium. The outcomes examined in the current study were postoperative complication rates, in-hospital mortality, hospital length of stay, hospital discharge status, 1-year mortality rate, place of residence, recovery of ambulatory ability, and activities of daily living 1 year after surgery. Forty-seven (5.1%) patients were diagnosed with postoperative delirium. Patients who had delirium develop were more likely to be male, have a history of mild dementia, and have had surgery under general anesthesia. Patients who had postoperative delirium develop had a significantly longer length of hospitalization. They also had significantly higher rates of mortality at 1 year, were less likely to recover their prefracture level of ambulation, and were more likely to show a decline in level of independence in basic activities of daily living at the 1-year followup. There was no difference in the rate of postoperative complications, in-hospital mortality, discharge residence, and recovery of instrumental activities of daily living at 1 year.

Intraoperative instrument repair using an electrocautery pad

Instrument wear and tear, mishandling, and abuse can lead to instrument damage, particularly closely machined mating surfaces, which then prevents them from functioning properly. Simple refinishing of these damaged surfaces often resolves these problems. The electrocautery scratch pad can be an excellent means of rapidly refinishing damaged instruments.

Comparison of a Sliding Hip Screw with a Trochanteric Lateral Support Plate to an Intramedullary Hip Screw for Fixation of Unstable Intertrochanteric Hip Fractures: A Cadaver Study

BACKGROUND

The lateral trochanteric support plate (LSP) was developed to prevent excessive sliding of unstable intertrochanteric femur fractures fixed with a sliding hip screw (SHS). This study compared the fracture stability and screw sliding characteristics of unstable intertrochanteric femur fractures fixed with either an SHS and LSP or an Intramedullary Hip Screw (IMHS).

METHODS

Six matched pairs of cadaveric human femurs with simulated, unstable intertrochanteric femur fractures were stabilized with either an IMHS or a 135-degree SHS with an attached LSP. Inferior and lateral head displacements and lag screw sliding distances were measured for applied static loads of 750 N, before and after cycling.

RESULTS

Four-part unstable intertrochanteric femur fractures showed comparable screw sliding characteristics and stability whether instrumented with an SHS and LSP or an IMHS.

CONCLUSION

A sliding hip screw with an attached lateral support plate provides stability and ability to resist medial displacement of the femoral shaft similar to that seen with the IMHS.

Heterotopic ossification of the quadriceps following distal femoral traction: a report of three cases and a review of the literature

We present the previously unreported complication of symptomatic heterotopic ossification of the quadriceps following placement of a large-diameter Steinmann pin for the purpose of temporary skeletal traction. Following the development of distal quadriceps heterotopic bone formation in three patients, we conducted a comprehensive search of the literature using the Medline database from 1966 to the present. A variety of publications, including review articles, case reports, and randomized prospective studies, were used for the literature review. This potential complication should be considered when using a large-diameter Steinmann pin in the distal femur for skeletal traction.

Accuracy of the axillary projection to determine fracture angulation of the proximal humerus

The accuracy of measuring angulation of stable proximal humerus fractures using the axillary lateral projection was investigated. A closing wedge osteotomy with apex anterior angulation was performed on two cadaveric humeri to simulate a stable surgical neck fracture. One specimen was fixed at 30 degrees angulation and the other at 55 degrees. Axillary radiographs were taken with each specimen articulating with the glenoid of a cadaveric scapula. The humerus was held in neutral rotation. Abduction was set at 30 degrees, 60 degrees, and 90 degrees. In each position of abduction, an axillary lateral radiograph was taken in 30 degrees forward flexion, neutral, and 30 degrees extension to simulate various arm positions. A total of nine radiographs were taken for each specimen. The axillary view is not accurate for measurement of proximal humerus angulation at the arm positions commonly encountered in the trauma setting.

Conflict of interest in orthopaedic research

BACKGROUND

The expanding role of industrial support in biomedical research has resulted in both substantial interest and controversy in recent years. Our hypothesis was that, from 1985 to 2002, the role of industrial support in orthopaedic research increased, as documented by the research presented at the annual meetings of the American Academy of Orthopaedic Surgeons.

METHODS

We analyzed the frequency and types of self-reported conflicts of interest for all presentations at the annual meetings of the American Academy of Orthopaedic Surgeons in 1985, 1988, 1992, 1997, 1999, and 2002. Conflicts of interest were recorded directly from the final program for each meeting analyzed. The analysis focused on the scientific presentations, Instructional Course Lectures, symposia, poster exhibits, and scientific exhibits. Information about specific types of support received by authors was first required in 1988.

RESULTS

The incidence of conflicts of interest increased from 3% in 1985 to 39% in 2002 for scientific papers (p < 0.001); from 10% to 74%, respectively, for symposia (p < 0.001); from 22% to 60% for Instructional Course Lectures (p < 0.001); from 10% to 60% for scientific exhibits (p < 0.001); and from 9% in 1992 to 14% in 2002 for posters (p < 0.001). For presentations of all types, the incidence increased from 10% to 32% (p < 0.001). The types of conflict of interest also changed significantly from 1999 to 2002. In 1999, 73% of conflicts were documented as support directed to institutions and 27%, as support to individuals; in 2002, 57% were reported as support directed to institutions and 43%, as support to individuals (p < 0.01).

CONCLUSIONS

The role of industrial support of orthopaedic research increased significantly between 1985 and 2002, as evidenced by the increase in the self-reported conflicts of interest for all types of presentations at the annual meetings of the American Academy of Orthopaedic Surgeons. In addition, the support directed to individuals, in contrast to that directed to institutions, increased significantly.

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.

Effects of blood transfusion on clinical and functional outcomes in patients with hip fracture

BACKGROUND

Anemia and transfusion are common among elderly patients requiring surgery. The effects of transfusion on morbidity and mortality are controversial. The influence of transfusion on risk-adjusted mortality, readmissions, and functional mobility was examined.

STUDY DESIGN AND METHODS

A consecutive cohort of 551 patients undergoing surgery for hip fracture at four hospitals was prospectively studied. Outcomes were death, readmission, and functional independence measure-locomotion scores within 60 days of discharge. The trigger Hb level was defined as the lowest value before the first postoperative transfusion. Multivariate analyses adjusted for a validated, hip-fracture-specific risk model and predictors of transfusion.

RESULTS

Overall, 54.4 percent of patients received transfusions after surgery. Seventy-two percent of patients with a lowest postoperative Hb level of less than 10.0 g per dL received transfusions compared to 19.6 percent of those whose lowest measurement was at least 10.0 g per dL (p < 0.0001). In the 60 days after discharge, 3.8 percent of patients died and 16.9 percent were readmitted. Transfusion was associated with lower risk-adjusted odds of readmission (OR, 0.54; 95% CI, 0.30-0.97), but it did not influence mortality or mobility functioning. In subgroups analyses, the benefit of transfusion on readmission rates appeared to be concentrated among patients with a trigger Hb level of less than 10.0 g per dL. For patients with a trigger Hb level of at least 10.0 g per dL, transfusion did not affect risk-adjusted rates of death or readmission, but was associated with better risk-adjusted functional mobility scores (p < 0.01).

CONCLUSIONS

Postoperative transfusion reduced the risk of readmission but did not decrease mortality or improve mobility. Randomized controlled trials of different transfusion strategies will be needed to clarify the true benefits and risks of transfusion in surgical patients.

Tape blisters following hip surgery. A prospective, randomized study of two types of tape

BACKGROUND

Tape blisters after hip surgery can be a source of postoperative morbidity and can increase patient discomfort. The purpose of this prospective study was to compare two different types of tape to determine whether the type of tape influences the rate of blister formation.

METHODS

Ninety-nine patients (100 hips) were enrolled in the study. Patients were randomized into one of two treatment groups: one treated with a nonstretchable silk tape and one treated with a perforated, stretchable cloth tape. After surgery, the assigned tape was applied over the postoperative dressing with care not to produce skin tension. At the first dressing change, the presence or absence of blisters was recorded as were the number, size, location, and type of any blisters. The presence or absence of tape blisters was recorded at the time of each subsequent dressing change.

RESULTS

A tape blister developed on twenty-five hips in twenty-five patients. The risk of a blister developing was 41% (twenty of forty-nine patients) when the nonstretchable silk tape was used and 10% (five of fifty patients) when the perforated cloth tape was used (relative risk = 4.08, 95% confidence interval = 1.53 to 10.87, p = 0.005). We found no association between formation of tape blisters and the age or gender of the patient, number of medical comorbidities, smoking history, results of nutritional assessment, or type of surgery.

CONCLUSIONS

The prevalence of tape blisters was significantly lower when perforated cloth tape was used than it was when nonstretchable silk tape was used.

The Effect of an Attachable Lateral Support Plate on the Stability of Intertrochanteric Fracture Fixation with a Sliding Hip Screw

BACKGROUND

Use of a sliding hip screw (SHS) alone for some unstable intertrochanteric femur fractures can allow excessive medial shaft displacement during impaction. This study evaluated the effect of an attachable lateral support plate on these fractures after loading.

METHODS

Unstable, three-part intertrochanteric fractures were created in 10 matched pairs of embalmed femurs that were instrumented with 135-degree SHSs with or without an attachable lateral support plate. Under physiologic loading, inferior and lateral head displacements and lag screw sliding distances were measured.

RESULTS

After 10,000 cycles at 750 N, all measurements for femurs with the lateral support plate were significantly less than for the femurs with the SHS alone: mean lateral difference was 1.7 mm (34%) (p < 0.05), mean inferior difference was 3.0 mm (38%) (p < 0.05), and mean lag screw sliding difference was 4.5 mm (58%) (p < 0.05).

CONCLUSION

The addition of an attachable lateral support plate to an SHS significantly decreased displacement of the femoral head after cyclic loading.

Two or three screws for fixation of femoral neck fractures?

This study compares the stability of 3 cannulated cancellous lag screws with that of 2 cannulated cancellous lag screws for fixation of subcapital femoral neck fractures. Using 10 matched pairs of human cadaveric femurs, subcapital femoral neck osteotomies were created, reduced, and then randomized to 1 of the 2 fixation methods. The constructs were tested with anterior loading to 500 N, incremental axial loading from 100 N to 1000 N, and cyclic loading at 1000 N. The specimens stabilized using 3 screws showed greater resistance to anterior loading, less inferior femoral head displacement, and less superior gapping at the osteotomy site. Although 2 screws may be an acceptable fixation method for this fracture type, the addition of a third screw provides supplemental stability and appears justified.

Correction of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor Spatial Frame

OBJECTIVE

To determine the effectiveness of six-axis analysis deformity correction using the Taylor Spatial Frame for the treatment of posttraumatic tibial malunions and nonunions.

DESIGN

Retrospectively reviewed, consecutive series. Mean duration of follow-up was 3.2 years (range 2-4.2 years).

SETTING

Tertiary referral center for deformity correction.

PATIENTS/PARTICIPANTS

Eighteen patients were included in the study (11 malunions and 7 nonunions). All deformities were posttraumatic in nature. The mean number of operations before the application of the spatial frame was 2.6 (range 1-6 operations). All patients completed the study.

INTERVENTION

Six-axis analysis deformity correction using the Taylor Spatial Frame (Smith & Nephew, Memphis, TN) was used for correction of posttraumatic tibial malunion or nonunion. Nine patients had bone grafting at the time of frame application. One patient with a tibial plafond fracture simultaneously had deformity correction and an ankle fusion for a mobile atrophic nonunion. Two patients had infected tibial nonunions that were treated with multiple débridements, antibiotic beads, and bone grafting at the time of spatial frame application. A rotational gastrocnemius flap was used to cover a proximal third tibial defect in one patient. The average length of time the spatial frame was worn, time to healing, was 18.5 weeks (range 12-32 weeks).

MAIN OUTCOME MEASUREMENTS

Assessment of deformity correction in six axes, knee and ankle range of motion, incidence of infection, and return to preinjury activities.

RESULTS

Of the 18 patients treated with the Taylor Spatial Frame, with adjunctive bone graft as necessary, 17 achieved union and significant correction of their deformities in six axes (ie, coronal angulation and translation, sagittal angulation and translation, rotation, and shortening). Fifteen patients returned to their preinjury activities at last follow-up.

CONCLUSION

Six-axis analysis deformity correction using the Taylor Spatial Frame is an effective technique to treat posttraumatic malunions and nonunions of the tibia, with several advantages over previously used devices.

Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis

BACKGROUND

The optimal choice for the stabilization of displaced femoral neck fractures remains controversial, with alternatives including arthroplasty and internal fixation. Our objective was to determine the effect of arthroplasty (hemiarthroplasty, bipolar arthroplasty, and total hip arthroplasty), compared with that of internal fixation, on rates of mortality, revision, pain, function, operating time, and wound infection in patients with a displaced femoral neck fracture.

METHODS

We searched computerized databases for randomized clinical trials published between 1969 and 2002, and we identified additional studies through hand searches of major orthopaedic journals, bibliographies of major orthopaedic textbooks, and personal files. Of 140 citations initially identified, fourteen met all eligibility criteria. Three investigators independently graded study quality and abstracted relevant data, including information on revision and mortality rates.

RESULTS

Nine trials, which included a total of 1162 patients, provided detailed information on mortality rates over the first four postoperative months, which ranged from 0% to 20%. We found a trend toward an increase in the relative risk of death in the first four months after arthroplasty compared with the risk in the first four months after internal fixation (relative risk, 1.27). At one year, the relative risk of death was 1.04. The risk of death after arthroplasty appeared to be higher than that after fixation with a compression screw and side-plate but not higher than that after internal fixation with use of screws only (relative risk = 1.75 and 0.86, respectively; p < 0.05). Fourteen trials that included a total of 1901 patients provided data on revision surgery. The relative risk of revision surgery after arthroplasty compared with the risk after internal fixation was 0.23 (p = 0.0003). Pain relief and the attainment of overall good function were similar in patients treated with arthroplasty and those treated with internal fixation (relative risk, 1.12 for pain relief and 0.99 for function). Infection rates ranged from 0% to 18%, and arthroplasty significantly increased the risk of infection (relative risk, 1.81; p = 0.009). In addition, patients who underwent arthroplasty had greater blood loss and longer operative times than those who were treated with internal fixation.

CONCLUSIONS

In comparison with internal fixation, arthroplasty for the treatment of a displaced femoral neck fracture significantly reduces the risk of revision surgery, at the cost of greater infection rates, blood loss, and operative time and possibly an increase in early mortality rates. Only larger trials will resolve the critical question of the impact on early mortality.

Biomechanical comparison of five external wrist fixators

The relative stiffness of five different external wrist fixators currently in use for distal radius fractures was determined using a uniform fracture model consisting of wood dowels to isolate the effects of the fixators themselves. Each construct was loaded in axial compression, eccentric and cantilever modes of bending, and torsion. The stiffest of the fixators varied by a factor of three in compression, five in bending, and three in torsion. Although the ideal stiffness of a wrist fixator is unknown, there is a large variation in the stiffness of existing devices.

Posterior olecranon plating: biomechanical and clinical evaluation of a new operative technique

The purpose of this investigation was to compare the biomechanical analysis of a new plating technique for olecranon fractures to tension band wiring, and review early clinical results. Six matched pairs of cadaveric ulnae were used for the biomechanical analysis. A transverse osteotomy of the mid part of the olecranon was made. One ulna of each pair was stabilized using a tension band and the other with a posterior hook plate. The ulnae were mounted and loaded, and displacement at the osteotomy site recorded. Twenty patients treated with this new technique (14 fractures and 6 osteotomies) were reviewed at one year (range: 8 to 18 months) for infection, union rate, hardware related complaints. and removal. Statistical analysis showed significantly less displacement occurred at the osteotomy site in the plating group. Clinically, all patients had fracture union, and there were no hardware related problems. Posterior plating with this technique achieves greater stability compared to tension band wiring. Early clinical results indicate a low level of hardware related complications.

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.

Efficacy of telemedicine in the initial management of orthopedic trauma

In order to determine the clinical usefulness of teleradiology in the initial treatment of musculoskeletal injury, a panel of orthopedic trauma surgeons developed a survey that was presented to participants at the annual meeting of the Orthopedic Trauma Association. Selected orthopedic trauma cases from a level-1 trauma and a tertiary care center were presented orally (including a description and interpretation of the radiographic findings) to volunteer participants. Questions related to treatment and patient management were then asked prior to and following the participants' viewing of digital radiographic images. Overall, 90% of respondents found telemedicine useful. They disagreed with the verbal radiographic report 49% of the time. Respondents changed their mind with regard to the need for admission 17% of the time; surgical indications, 22% of the time; and need for more information, 30% of the time.