Malpractice lawsuits in orthopedic trauma surgery: a meta-analysis of the literature

Introduction

The objectives for this study were to identify whether diagnostic or procedural errors more commonly resulted in lawsuit, as well as to elucidate how specific variables affected mean indemnity.

Methods

Systematic review of English-language articles in the PubMed and Google Scholar databases (through 2020) using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analysis was performed to estimate measures of proportions and differences in mean indemnity.

Results

The estimated probability of lawsuits related to orthopedic trauma in overall studies was 23.3%. There were no significant rate differences between main causes of claims (diagnostic vs procedural errors) and areas of injury (upper vs lower). There was no significant difference of mean indemnity between the probabilities of trauma-related claims, diagnostic error, and procedural error.

Conclusion

Non-trauma cases were more likely to result in lawsuit than trauma cases. Procedural errors accounted for most malpractice claims. The average indemnity increased according to the higher diagnostic errors, while the indemnity was lower with a relatively higher proportion of procedural errors. The most common cause of litigation varied between studies; however, among the most cited reasons were missed diagnosis/error in diagnosis, improper/substandard surgical performance, and, though not specifically studied in this analysis, errors of informed consent.

Level of Evidence

Economic and Decision Analyses Level VI.

Outcomes and Complications With Treatment of Open Tibial Plafond Fractures With Circular External Fixator

BACKGROUND

Open tibial plafond fractures (Orthopaedic Trauma Association and AO Foundation [OTA/AO] 43) are associated with severe complications, including deep infection (closed fractures, 20%; open fractures, 30%), amputation (3%-14%), and nonunion (up to 25%). Circular external fixators (CEFs) can minimize soft tissue injury. This study aimed to report the rate of union and occurrence of severe complications in patients with open tibial plafond fractures treated with CEFs.

METHODS

A retrospective review of case series was conducted at 3 level I trauma centers. The study included patients older than 18 years with open tibial plafond fractures treated with CEFs. The reported outcomes included union rate, deep infection, operative complications, and limb alignment. The radiographic measurements of anatomic alignment were obtained. Fifty-two patients were included in the study.

RESULTS

The primary union rate was 79%. No deep infection occurred in the majority (92%) of patients. No patient required amputation of the affected limb or free flap coverage.

CONCLUSION

Definitive fixation of open tibial plafond fractures with CEFs avoided severe soft tissue complications but resulted in variation in final radiographic alignment.

LEVEL OF EVIDENCE

Level IV, case series.

Operative Versus Nonoperative Management Of Traumatic Arthrotomies from Civilian Gunshot Wounds

BACKGROUND

Although the rate of non-fatal gunshot wounds (GSW) has increased, few studies have compared the effectiveness of operative and nonoperative treatment with specific focus on infection. We compared the risk of septic arthritis in patients with traumatic arthrotomies caused by GSW treated operatively with irrigation and debridement versus nonoperatively with antibiotics and wound care.

METHODS

From 2009 to 2016, 46 patients at our institution sustained traumatic arthrotomies from low-velocity GSW with at least 90-day follow-up. Medical records were reviewed for demographic information, imaging, type and duration of antibiotics, details of operative and nonoperative interventions, and evidence of infection at follow-up visits. We measured the rate of septic arthritis using a 2-tailed t test.

RESULTS

The knee was the most commonly affected joint (34 patients; 73.9%). Eight patients (17.4%) were treated nonoperatively and 38 (82.6%) were treated operatively. In the nonoperative group, one patient (12.5%) developed a superficial wound infection that resolved with oral antibiotics. In the operative group, one patient (2.6%) developed a superficial wound infection requiring operative irrigation and debridement. There was no statistically significant difference in risk of infection between the two groups (P = 0.32). No patient developed septic arthritis.

CONCLUSIONS

In select patients, nonoperative treatment with wound care and antibiotics may be sufficient for preventing infection after GSW-related traumatic arthrotomies. Findings of randomized studies and treatment algorithms are needed to further evaluate this relatively common injury.Level of Evidence: IV.

Reliability of the classification of proximal femur fractures: Does clinical experience matter?

BACKGROUND

Radiographic fracture classification helps with research on prognosis and treatment. AO/OTA classification into fracture type has shown to be reliable, but further classification of fractures into subgroups reduces the interobserver agreement and takes a considerable amount of practice and experience in order to master.

QUESTIONS/PURPOSES

We assessed: (1) differences between more and less experienced trauma surgeons based on hip fractures treated per year, years of experience, and the percentage of their time dedicated to trauma, (2) differences in the interobserver agreement between classification into fracture type, group, and subgroup, and (3) differences in the interobserver agreement when assessing fracture stability compared to classifying fractures into type, group and subgroup.

METHODS

This study used the Science of Variation Group to measure factors associated with variation in interobserver agreement on classification of proximal femur fractures according to the AO/OTA classification on radiographs. We selected 30 anteroposterior radiographs from 1061 patients aged 55 years or older with an isolated fracture of the proximal femur, with a spectrum of fracture types proportional to the full database. To measure the interobserver agreement the Fleiss' kappa was determined and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and 95% confidence intervals. We compared the Kappa values of surgeons with more experience to less experienced surgeons.

RESULTS

There were no statistically significant differences in the Kappa values on each classification level (type, group, subgroup) between more and less experienced surgeons. When all surgeons were combined into one group, the interobserver reliability was the greatest for classifying the fractures into type (kappa, 0.90; 95% CI, 0.83 to 0.97; p < 0.001), reflecting almost perfect agreement. When comparing the kappa values between classes (type, group, subgroup), we found statistically significant differences between each class. Substantial agreement was found in the clinically relevant groups stable/unstable trochanteric, displaced/non-displaced femoral neck, and femoral head fractures (kappa, 0.60; 95% CI, 0.53 to 0.67, p < 0.001).

CONCLUSIONS

This study adds to a growing body of evidence that relatively simple distinctions are more reliable and that this is independent of surgeon experience.

Tibial Plateau Fractures: A New Rank Ordering Method For Determining To What Degree Injury Severity Or Quality Of Reduction Correlate With Clinical Outcome

BACKGROUND

Injury severity may be the most important factor in determining outcome after articular fractures, but there is a surprising paucity of clinical evidence to support this assertion. The purpose of this study was to utilize a new method for rank ordering a group of patient radiographs to assess the effect of injury severity and quality of reduction on patient outcomes after tibial plateau fractures.

METHODS

Tibial plateau fractures in 64 patients were treated operatively or non-operatively based on physician preference from standard of care techniques. Fracture severity and reduction quality were stratified from radiographs by four expert clinicians using an iTunes-based rank ordering methodology. The images were distributed electronically, and the ranks were performed on local computers at three different institutions. Clinical outcomes were measured with the SF-12 health questionnaire and the Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

There was excellent or very good agreement between raters for injury severity ranking (correlation 0.77-0.91) and quality of reduction (correlation 0.66-0.82). There was no correlation between the injury severity nor quality of reduction and general or joint-specific clinical outcomes.

CONCLUSIONS

Expert orthopaedic traumatologists strongly agree on how to rank order tibial plateau fractures based both on injury severity and quality of reduction. The novel electronic interface utilized allows an ever-expanding series of cases to be ranked quickly, conveniently, and across multiple centers. This interface holds great promise for establishing prospective, continuously expanding rank orders of various fracture types, which may have great value for clinical research, education about fracture severity, and for prognosis and treatment decisions. In the present study, neither injury severity nor quality of reduction correlated with the clinical outcomes. Other patient- and injury-related factors may be more important in determining clinical outcome of tibial plateau fractures than the appearances of the radiographs at the time of injury or after reduction. Level of Evidence: level III evidence.

How Many Orthopaedic Surgeons Does It Take to Write a Manuscript? A Vignette-Based Discussion of Authorship in Orthopaedic Surgery

The issue of appropriate authorship designation continues to be a topic of importance because authorship of scholarly work plays an important role in the academic community. It is a recognition of an individual's scholarly work and a factor in academic promotion. The Orthopaedic Trauma Association (OTA) sponsored a minisymposium in 2014 to encourage discussion of the issues that arise in authorship decisions. A residency program director/department chair, a journal editor, a clinical trials coordinator, and a promotions committee member provided viewpoints. In the pages that follow, vignettes are presented along with discussion points to encourage conversation on this topic. Authorship criteria are clearly defined. Authorship based simply on seniority or contribution of cases to clinical trials is inappropriate. Discussion of authorship criteria prior to the initiation of clinical research investigations is a standard that must be met. The International Committee of Medical Journal Editors (ICMJE) guidelines provide a framework for this discussion and should be reviewed by all authors prior to publication. Modifications to published authorship guidelines may be necessary to address some of the scenarios identified here that are not adequately addressed by the existing guidelines.

Titanium mesh as a low-profile alternative for tension-band augmentation in patella fracture fixation: A biomechanical study

OBJECTIVES

We performed a simple biomechanical study to compare the fixation strength of titanium mesh with traditional tension-band augmentation, which is a standard treatment for transverse patella fractures. We hypothesised that titanium mesh augmentation is not inferior in fixation strength to the standard treatment.

METHODS

Twenty-four synthetic patellae were tested. Twelve were fixed with stainless steel wire and parallel cannulated screws. Twelve were fixed with parallel cannulated screws, augmented with anterior titanium mesh and four screws. A custom test fixture was developed to simulate a knee flexed to 90°. A uniaxial force was applied to the simulated extensor mechanism at this angle. A non-inferiority study design was used to evaluate ultimate force required for failure of each construct as a measure of fixation strength. Stiffness of the bone/implant construct, fracture gap immediately prior to failure, and modes of failure are also reported.

RESULTS

The mean difference in force at failure was -23.0 N (95% CI: -123.6 to 77.6N) between mesh and wire constructs, well within the pre-defined non-inferiority margin of -260 N. Mean stiffness of the mesh and wire constructs were 19.42 N/mm (95% CI: 18.57-20.27 N/mm) and 19.49 N/mm (95% CI: 18.64-20.35 N/mm), respectively. Mean gap distance for the mesh constructs immediately prior to failure was 2.11 mm (95% CI: 1.35-2.88 mm) and 3.87 mm (95% CI: 2.60-5.13 mm) for wire constructs.

CONCLUSIONS

Titanium mesh augmentation is not inferior to tension-band wire augmentation when comparing ultimate force required for failure in this simplified biomechanical model. Results also indicate that stiffness of the two constructs is similar but that the mesh maintains a smaller fracture gap prior to failure. The results of this study indicate that the use of titanium mesh plating augmentation as a low-profile alternative to tension-band wiring for fixation of transverse patella fractures warrants further investigation.

Under-utilization of the OTA Fracture Classification in the orthopaedic trauma literature

BACKGROUND

The OTA Fracture Classification is designed to provide a common language and facilitate effective communication among orthopaedic surgeons. We attempted to measure the degree to which this classification is currently being utilized in orthopaedic trauma literature.

METHODS

We reviewed all of the articles in the JOT in 2011. We determined which of these articles could have appropriately utilized the 2007 OTA Classification. We calculated the percentage that mentioned and correctly cited this classification system as a reference.

RESULTS

There were 145 articles in 2011. One hundred of these articles were appropriate for classifying a fracture. 38% of these articles utilized the OTA classification in the text. Only 42% of articles mentioning the OTA Classification cited a reference. 38% of these citations used the old (1996) OTA Classification reference, and only 8% overall correctly cited the 2007 OTA Classification reference. 51% of articles mentioned some other classification system; 21 in addition to OTA and 30 instead of the OTA classification.

CONCLUSIONS

The OTA Fracture Classification is being used more commonly (38%) but is not routinely used or correctly cited (8%) in articles currently being published in the Journal of Orthopaedic Trauma, despite the fact that it is "required" according to the instructions to authors. We conclude that future authors should utilize and correctly reference the 2007 OTA Classification so that the benefits of a common language can be realized. Routine and consistent utilization of the classification may ultimately lead to more consistency and improved interpretability of treatment outcomes in published orthopaedic trauma research.

LEVEL OF EVIDENCE

Level-III case-control study, decision analysis.

Pelvic crescent fractures: variations in injury mechanism and radiographic pattern

Pelvic crescent fracture, also known as sacroiliac fracture-dislocation, is traditionally considered as a lateral compression injury and a vertically stable injury. Thirty consecutive cases were analyzed and it was found that 63% of cases were caused by lateral compression (LC), 27% by anteroposterior compression (APC), and 10% by vertical shear (VS). APC and VS injuries cause significant displacement of the anterior iliac fragment, but 21% of LC injury cases showed minimal displacement and were treated successfully with nonoperative treatment. Different injury mechanisms also produce different types of pelvic instability. More important, different injury mechanisms produce distinct radiographic fracture patterns regarding the obliquity of the fracture line and fracture surface. These differences in the fracture pattern will influence the decision of internal fixation options. Therefore, treatment of pelvic crescent fractures should be based on individual analysis of injury mechanism and radiographic fracture pattern.

The course of the distal saphenous nerve: a cadaveric investigation and clinical implications

INTRODUCTION

Injury to the saphenous nerve at the ankle has been described as a complication resulting from incision and dissection over the distal tibia and medial malleolus. However, the exact course and location of the distal saphenous nerve is not well described in the literature. The purpose of this study was to determine the distal limit of the saphenous nerve and its anatomic relationship to commonly identified orthopaedic landmarks and surgical incisions.

METHODS

Sixteen cadaveric ankles were examined at the level of the distal tibia medial malleolus. An incision was made along the medial aspect of the lower extremity from the knee to the hallux to follow the course and branches of the saphenous nerve under direct visualization. We recorded the shortest distance from the most distal visualized portion of the saphenous nerve to the tip of the medial malleolus, to the antero-medial arthroscopic portal site, and to the tibialis anterior tendon.

RESULTS

The saphenous nerve runs posterior to the greater saphenous vein in the leg and divides into an anterior and posterior branch approximately 3 cm proximal to the tip of the medial malleolus. These branches terminate in the integument proximal to the tip of the medial malleolus, while the vein continues into the foot. The anterior branch ends at the anterior aspect of the medial malleolus near the posterior edge of the greater saphenous vein. The posterior branch ends near the posterior aspect of the medial malleolus. The average distance from the distal-most visualized aspect of the saphenous nerve to the tip of the medial malleolus measured 8mm +/-; 5mm; from the nerve to the medial arthroscopic portal measured 14mm +/-2mm; and from the nerve to the tibialis anterior measured 16mm +/-3mm. In only one case (of 16) was there an identifiable branch of the saphenous nerve extending to the foot and in this specimen it extended to the first metatarsophalangeal joint. The first metatarsophalangeal joint was innervated by the superficial peroneal nerve in all cases. Small variations were also noted.

DISCUSSION AND CONCLUSIONS

This study highlights the proximity of the distal saphenous nerve to common landmarks in orthopaedic surgery. This has important clinical implications in ankle arthroscopy, tarsal tunnel syndrome, fixation of distal tibia medial malleolar fractures, and other procedures centered about the medial malleolus. While the distal course of the saphenous nerve is generally predictable, variations exist and thus the orthopaedic surgeon must operate cautiously to prevent iatrogenic injury. To avoid saphenous nerve injury, incisions should stay distal to the tip of the medial malleolus. The medial arthroscopic portal should be more than one centimeter from the anterior aspect of the medial malleolus which will also avoid the greater saphenous vein. Incision over the anterior tibialis tendon should stay within one centimeter of the medial edge of the tendon.

Outcome after femoral shaft fractures in the elderly: the effects of altitude

BACKGROUND

A paucity of knowledge currently exists surrounding the effects of altitude on femur fracture outcomes. The purpose of this study was to determine if altitude plays a significant role in determining the outcome of femoral shaft fractures in the elderly. The authors hypothesized that the additional cardiopulmonary stress of altitude would promote poorer outcomes of those individuals treated at high altitude, especially those individuals whose home residence was located at low altitude.

METHODS

Medicare part A claims data between 1996 and 2000 were searched and patients with open or closed femoral shaft fractures were identified for the study. The treatment altitude and home residence altitude for each patient was recorded by cross-matching Zip Code information provided in the Medicare part A database with a database providing altitude data by Zip Code. The patients were grouped both by the altitude of treatment and by the difference between the altitude of residence and the altitude of treatment. The data was analyzed for outcome measurements.

RESULTS

The claims data search identified 30,168 patients for the study. For the entire sample, the in-hospital mortality was 4.2%, 30-day mortality was 8.3%, 1-year mortality was 26.3%, and complication rate was 5.7%. Length of stay results demonstrated that patients treated at medium or high altitude had statistically shorter lengths of stay than those treated at low altitude (p < 0.01). Mortality rates and complications were not statistically different for those treated at high, medium, or low altitude with the exception of a slightly lower in-hospital mortality in the medium treatment altitude group (p = 0.04). Additionally, those patients who resided more than 1000 ft below the treatment altitude had shorter lengths of stay than those who resided more than 1000 ft above the treatment altitude (p < 0.01). Those patients who lived within 1000 ft of the treatment hospital or more than 1000 ft below the treatment hospital had fewer days in the intensive care unit (p < 0.01, p = 0.01; respectively).

CONCLUSIONS

Femoral shaft fractures treated at altitude were not associated with increased morbidity and mortality as compared to femoral shaft fractures treated at low altitude. Additionally, patients residing at low altitude and treated at high altitude did not suffer increased morbidity or mortality.

Amputation osteoplasty

Amputation osteoplasty is a technique modification promoted by Ertl to enhance rehabilitation after transtibial amputation. Two different techniques for creating sealing of the medullary canal and a distal bone block have been described in the literature. One technique consists of a periosteal sleeve that is sutured over the cut end of the bone. The second technique consists of hinging a segment of fibula into a slot in the cut end of the tibia. The desired goal of amputation osteoplasty is to create an end-bearing limb to enhance rehabilitation. In addition to creation of a bone bridge, Ertl also recommends myoplasty, neuroplasty, individual vessel ligation, and a special skin closure. This report is a small case series of five patients successfully treated with lower extremity amputation osteoplasty, to illustrate the techniques and report initial good results. Two patients had each of the techniques and one patient had both of the techniques. All five patients had good wound healing, accelerated rehabilitation, and the ability to use end-bearing prostheses.

Safe extracapsular placement of proximal tibia transfixation pins

OBJECTIVE

To identify the anatomic detail of the knee joint capsular insertion site on the proximal tibia, specifically as it relates to transfixation pins.

DESIGN

Identification of capsular anatomy by anatomical dissection of cadaveric specimens, with radiography and arthroscopy of patients.

SETTING

Cadaveric dissection.

OUTCOME MEASURES

Anatomic observation of the capsular attachment site in relation to the tibial articular surface.

RESULTS

The capsule inserts four to fourteen millimeters below the articular surface in a regular pattern. The anterior half of the circumference is close to the joint line (less than six millimeters). Posteromedially and posterolaterally, there are extensions distally to fourteen millimeters, occasionally communicating with the tibiofibular joint.

CONCLUSION

Transfixing wires and half-pins can be placed in the proximal tibia without capsular penetration if kept more than fourteen millimeters from the subchondral line. If wire placement closer to the joint is required, wires should be placed in Zone 1 (the anterior half) and at least six millimeters from subchondral bone to avoid capsular penetration.

Factors affecting outcome in tibial plafond fractures

To determine what fracture- and patient-specific variables affect outcome, 29 patients with 32 tibial plafond fractures were evaluated at a minimum of 2 years from the time of injury (range, 24-129 months; average, 46.5 months). The rank order method was used to assess severity of injury and accuracy of articular reduction on radiographs and agreement among the five surgeons was excellent with intraclass correlation coefficients of 0.93 and 0.94. Outcome was assessed by four independent measures: a radiographic arthrosis score, a subjective ankle score, the Short Form-36 (SF-36), and the patient's ability to return to work. The four outcome measures did not correlate with each other. Radiographic arthrosis was predicted best by severity of injury and accuracy of reduction. However, these variables did not show any significant relationship to the clinical ankle score, the SF-36, or return to work. These outcome measures were more influenced by patient-specific socioeconomic factors. Higher ankle scores were seen in patients with college degrees and lower scores were seen in patients with a work-related injury. The ability to return to work was affected by the patient's level of education. This study highlights the difficulties of predicting patient outcome, after these severe articular fractures.

Management of posttraumatic segmental bone defects

Because of difficulty in managing posttraumatic segmental bone defects and the resultant poor outcomes, amputation historically was the preferred treatment. Massive cancellous bone autograft has been the principal alternative to amputation. Primary shortening or use of the adjacent fibula as a graft also has been used to attempt limb salvage. Of more recent methods of management, bone transport with distraction osteogenesis has been suggested as the leading option for defects of 2 to 10 cm, but problems include delayed union at the docking site and prolonged treatment time. Free vascularized bone transfer has been suggested as the leading option for defects of 5 to 12 cm, but hypertrophy of the graft is unreliable and late fracture, common. Bone graft substitutes continue to be developed, but they have not yet reached clinical efficacy for posttraumatic segmental bone defects. Although each of the new techniques has shown some limited success, complications remain common.

Closed locked intramedullary nailing of femoral shaft fractures in the elderly

A review was performed of all patients over the age of 60 years who were treated with a locked intramedullary nail for a femoral shaft fracture. There were 15 patients with 16 femoral shaft fractures. Four patients died perioperatively. Of the surviving 11 patients with 12 fractures, union occurred in 100 percent. Knee range of motion was greater than 100 degrees in 11 of the 12 knees. Nine of the 11 patients returned to their preoperative level of ambulation. Intramedullary nailing of femoral shaft fractures in patients over the age of 60 years is an effective method of treatment. The mortality rate in elderly patients who sustain this injury is comparable to that seen after a femoral neck fracture in this age.

The role of plain films and computed tomography in the evaluation of scapular neck fractures

OBJECTIVE

To assess the ability of plain films and computed tomography scans to show the pattern, displacement, and angulation of scapular neck fractures. To assess the ability of computed tomography to identify concomitant occult shoulder injuries.

DESIGN

Masked retrospective radiographic review.

SETTING

Level I trauma center.

PARTICIPANTS

Three orthopaedic surgeons (two attending physicians and one senior resident) and one musculoskeletal radiology attending physician reviewed the imaging studies of scapula neck fractures in twenty patients treated at our institution.

MAIN OUTCOME MEASURES

Kappa analysis of agreement of fracture characteristics and benefits of computed tomography for scapular neck fractures.

RESULTS

The mean weighted kappa coefficient for interobserver reliability of fracture displacement was 0.49 when the fractures were assessed by plain films alone, 0.15 when they were assessed by computed tomography scans alone, and 0.35 when they were assessed by plain films and computed tomography scans. The mean weighted kappa coefficients for fracture angulation were 0.30, 0.23, and 0.16, respectively. The mean simple kappa coefficients for fracture classification were 0.81, 0.20, and 0.33, respectively. Concomitant injury to the superior shoulder suspensory complex was seen in 57 percent of cases, including nine clavicle fractures, one coracoid fracture, and three acromion process fractures. The coracoid fracture and two of the acromion process fractures were minimally displaced and seen on computed tomography scans only.

CONCLUSION

Scapular neck fracture displacement, angulation, and anatomic classification showed moderate interobserver reliability by plain films but were not enhanced by computed tomography. Computed tomography confused, rather than clarified, the assessment of these characteristics. Computed tomography may be useful to identify associated injuries to the superior shoulder suspensory complex, which can be missed by plain films alone. Routine computed tomography in patients with scapular neck fractures cannot be recommended based on this study. Computed tomography of scapular neck fractures may be useful in selected cases in which intraarticular extension is noted on plain films.

A comparison of operative times in arthroscopic ACL reconstruction between orthopaedic faculty and residents: the financial impact of orthopaedic surgical training in the operating room

There is no published data regarding the financial impact of training orthopaedic residents in the operating room. No comparisons between orthopaedic faculty and residents in regard to operative time and costs are known. One hundred eleven cases of anterior cruciate ligament reconstruction with or without partial meniscectomy were evaluated from 1996 to 1997. Fifty-three cases met the selection criteria of times, documentation and identification of the surgeon. Twenty-one cases were performed by the orthopaedic attending (RCS) while 32 cases were performed by the senior orthopaedic resident. All procedures had the same faculty member present in the operating room either as the primary surgeon or as an assistant providing supervision and instruction as needed. In a two year period, comparisons were made between the attending and residents for the total anesthesia time and actual operative case time. Attending case time and anesthesia times averaged 94.62 minutes (range 60-125 min) and 128.1 minutes (range 84-185 min) respectively. Resident case and anesthesia times averaged 137.09 minutes (range 95-210 min) and 190.48 minutes (range 145-255 min) respectively. The anesthesia time was significantly less for the attending (p<.0001) as was the case time (p<.0001). The true costs of training orthopaedic surgery residents in the operating room is not known. The operative time and subsequent cost difference between experienced faculty and orthopaedic residents in certain arthroscopic procedures is not inconsequential. On average, the difference is equivalent to $228.73 per case for anesthesia costs. Based on increased operative times, operating room costs, on average, were increased by $661.85. The significant differences demonstrated between residents and faculty suggest the need to develop strategies and technical training facilities in order to improve orthopaedic residents' surgical skills and efficiency outside of the cost-central operating room.

Radiographic fracture assessments: which ones can we reliably make?

OBJECTIVE

To identify the fracture characteristics that can be reliably assessed by analysis of plain radiographs of tibial plateau fractures.

DESIGN

Radiographic review study.

PARTICIPANTS

Five orthopaedic traumatologists served as observers.

INTERVENTION

Observers made assessments based on the radiographs of fifty-six tibial plateau fractures. Precise definitions of the assessments to be made were agreed on by all observers. The tested assessments included raters' abilities to identify and locate fracture lines, identify the presence of fracture displacement and comminution, make quantitative measurements of displacement, and characterize qualitative features of fractures. For thirty-eight of the fractures that had a computed tomography (CT) scan available, assessments were repeated using both radiographs and CT scans.

MAIN OUTCOME MEASURES

To characterize interobserver reliability, percentage agreement and kappa statistics were calculated for categorical variables, and intraclass correlation coefficients (ICC) were calculated for noncategorical variables.

RESULTS

Reliability of the assessments varied widely. Determining the location of fracture lines had the greatest reliability, whereas the subjective assessments of fracture stability and energy showed the poorest reliability. Although the ICCs for quantitative measurements approached acceptable levels, the tolerance limits were extremely wide. The addition of a CT scan improved the reliability of most assessments, but not to a statistically significant degree.

CONCLUSIONS

Many basic radiographic interpretations relied on in making treatment decisions are made variably by observers. Using experienced raters and precise definitions of fracture assessments does not guarantee a high level of agreement. Discrete assessments have higher interrater agreements than do more qualitative assessments. Quantitative measures have wide tolerance limits and, therefore, probably cannot be used reproducibly to classify fractures or make treatment decisions. We conclude the reliability of fracture classification is limited by raters' abilities to agree on basic radiographic assessments.

Antibiotic bead production

We are reporting a practical technique for the production of antibiotic beads for use in combating musculoskeletal infections. The technique utilizes bead molds with tobramycin powder mixed with polymethylmethacrylate on twisted wire strands to produce strands of 25 beads of various sizes. These beads are gas sterilized and available for use "off the shelf" in a manner that is much more efficient than traditional production by hand on the back table in the operating room. Our technique was also utilized at a second institution to demonstrate its efficacy at another site.

Safe extracapsular placement of proximal tibia transfixation pins

OBJECTIVE

To identify the anatomic detail of the knee joint capsular insertion site on the proximal tibia, specifically as it relates to transfixation pins.

DESIGN

Identification of capsular anatomy by anatomical dissection of cadaveric specimens, with radiography and arthroscopy of patients.

SETTING

Cadaveric dissection.

OUTCOME MEASURES

Anatomic observation of the capsular attachment site in relation to the tibial articular surface.

RESULTS

The capsule inserts four to fourteen millimeters below the articular surface in a regular pattern. The anterior half of the circumference is close to the joint line (less than six millimeters). Posteromedially and posterolaterally, there are extensions distally to fourteen millimeters, occasionally communicating with the tibiofibular joint.

CONCLUSION

Transfixing wires and half-pins can be placed in the proximal tibia without capsular penetration if kept more than fourteen millimeters from the subchondral line. If wire placement closer to the joint is required, wires should be placed in Zone 1 (the anterior half) and at least six millimeters from subchondral bone to avoid capsular penetration.

Biologic model of bone transport distraction osteogenesis and vascular response

We developed an experimental model in the rabbit of distraction osteogenesis through bone transport that closely corresponds to the clinical use of bone transport in humans. We also applied injection angiography to study the arterial response of a limb undergoing bone transport. This model includes a proximal osteotomy and bone transport to fill in a segmental tibial diaphyseal defect. Regenerate bone formed well in the gap that was created that trailed the transport segment, and slow healing at the docking site was observed, as seen in humans. The angiographic techniques clearly revealed, by radiography and anatomic dissection, the arterial response to bone transport. The results showed that the transport segment had an arterial supply after osteotomy and after transport. They also demonstrated an extensive increase in vessels in limbs that had undergone distraction osteogenesis, an observation made clinically in humans but not well demonstrated experimentally. Furthermore, angiography showed proximal stretching and distal kinking of the major artery of the leg. This model closely resembles distraction osteogenesis through bone transport in humans and definitively demonstrates that the transport segment can maintain blood supply and remain viable during the transport process. The results of this study provide a basis for further work on factors that enhance and interfere with successful bone transport in humans.

Rank order analysis of tibial plafond fractures: does injury or reduction predict outcome?

We investigated the effects of severity of initial injury pattern and the quality of the articular reduction on outcome of displaced intra-articular distal tibial fractures, using a series of 25 patients who were treated with articulated external fixation and limited internal fixation, which provided a spectrum of reduction quality. Outcome was assessed by clinical ankle scores and radiographic arthrosis. The results demonstrate the rank order method to be a reliable means of stratifying severity of injury and quality of reduction. Neither injury nor reduction correlated with clinical ankle score. Reduction had a significant correlation with radiographic arthrosis. We conclude that the rank order method is useful in stratification of fracture patients, and that factors other than injury pattern and quality of articular reduction are important in determining outcome of patients with this severe articular injury.

Hip osteotomy arthroplasty: ten-year follow-up

We previously reported the initial success of combined osteotomy and arthroplasty of the hip for arthritis with femoral deformity. This technique has gained acceptance. We now report, for the first time, the ten year clinical and radiographic results with histology of 2 specimen. The osteotomies healed and the proximal femoral segment remained viable. One of three patients is symptom free without subsequent operative treatment. One of three patients had revision for acetabular loosening at eight years and biopsy of the proximal femur showed the proximal femoral segment to be viable. One of three patients had loosening of a macrofit bipolar prosthesis which required revision to total hip replacement at five years. Histology revealed viability of the proximal femur. All three patients are doing well at ten year follow-up. Based on the results of this study and current knowledge, the technique of osteotomy and arthroplasty for hip arthritis associated with femoral deformity is effective when combined with current techniques of ingrowth femoral component of total hip arthroplasty.

External fixation of tibial plafond fractures: is routine plating of the fibula necessary?

OBJECTIVES

To determine the advantages and disadvantages of plating an associated fibula fracture in tibial plafond fractures treated with external fixation that spans the ankle.

STUDY DESIGN

Retrospective clinical review.

METHODS

The incidence of treatment complications and the outcomes achieved were compared between two groups of patients with tibial plafond fractures and associated fractures of the fibula. Both groups were treated by a uniform technique of monolateral external fixation. One group, consisting of twenty-two patients with twenty-two fractures, had plate fixation of the distal fibula and the other group, thirty-one patients with thirty-two fractures, had no fibular fixation.

RESULTS

The demographics of the two groups, including sex, fracture classification, and number of open fractures, were similar. The outcome of the two groups for radiographic arthrosis and clinical ankle score, measured at minimum two-year follow-up, showed no statistically significant difference. The total numbers of complications were not statistically different between the two groups (p = 0.15), but the types of complications varied. Group I had eight complications: five fibular wound infections, two fibular nonunions, and one angular nonunion. Group II had seven complications: six angular malunions and one tibial wound infection.

CONCLUSION

Open reduction and internal fixation of the fibula fracture in tibial plafond fractures treated with external fixation that spans the ankle is associated with a significant rate of complications, and good clinical results may be obtained without fixing the fibula.

Assessment of the AO/ASIF fracture classification for the distal tibia

OBJECTIVES

The purpose of this study was to assess the interobserver reliability and intraobserver reproducibility of the AO/ASIF and Rüedi and Allgöwer classifications for fractures of the distal tibia, and to determine the benefit of a computed tomography (CT) scan and experience on observer agreement for several fracture characteristics, including classification.

METHODS

The radiographs of forty-three fractures of the distal tibia, fourteen of which had CT scans, were assessed by groups of experienced and less-experienced observers. Each case was classified according to the AO/ASIF and Rüedi and Allgöwer systems. Several other fracture characteristics also were assessed. The kappa coefficient of agreement was calculated and used to compare the interobserver reliability and intraobserver reproducibility of the classification systems and to determine the benefit of experience and CT scans. The intraclass correlation coefficient was used to assess noncategoric data.

RESULTS

Interobserver and intraobserver agreements were good when classifying fractures into AO/ASIF types and significantly better than that for the Rüedi and Allgöwer system. However, agreement was poor when classifying the fractures into AO/ASIF groups. For most assessments, the experienced group tended to have higher levels of interobserver agreement, but not intraobserver agreement. Viewing the CT scans improved agreement on the percentage of articular surface involved, but it did not improve interobserver reliability or intraobserver reproducibility for either of the classification systems.

CONCLUSION

The AO/ASIF classification for fractures of the distal tibia has good observer agreement at the type level, but poor agreement at the group level. Experience tends to improve interobserver agreement, but not intraobserver agreement. Viewing CT scans does not improve agreement on classification, but it tends to improve agreement on articular surface involvement.

Knee dislocation: initial assessment and implications for treatment

OBJECTIVE

To evaluate bicruciate knee injuries and determine whether they should be treated as knee dislocations, especially with regard to vascular injuries.

DESIGN

Retrospective.

SETTING

University hospital, level 1 trauma center.

PATIENTS

Fifty patients admitted between 1987 and 1994 who had sustained knee dislocations or bicruciate ligament injuries.

MAIN OUTCOME MEASURES

Mechanism of injury, direction of dislocation, knee ligament injury pattern, presence or absence of periarticular fracture, presence of vascular and nerve injuries, and location of associated trauma were measured.

RESULTS

Twenty-two knees had classic knee dislocations. Twenty-eight knees presented as "reduced" bicruciate ligament injuries. Vascular injury occurred just as frequently in bicruciate ligament injuries as in knee dislocations. The direction of the knee dislocation did not predict ligament injury pattern or the presence of arterial injury.

CONCLUSION

Bicruciate ligament injuries are equivalent to knee dislocations with regard to mechanism of injury, severity of ligamentous injury, and frequency of major arterial injuries.

Staple leg profile influence on pullout strength: a biomechanical study

Bone staples have widespread applicability in orthopaedic surgery. Their use, however, is limited by inconsistent quality of fixation. Prior studies have shown potential for improvement in the reliability of staple fixation through a change in the design of the staple legs. To identify a superior leg cross section profile, pullout strength of 5 different newly designed staple leg cross sections were evaluated in fresh frozen human cadaveric bones before and after toggle loading. The tests were repeated in a synthetic bone model with variable but consistent densities. The curvilinear square profile had the highest pullout strength in both the cadaveric and synthetic bone, followed in descending order by square, circular, and triangular profiles. Controlling for density, the pullout strength of the curvilinear square profile was 8% higher than the square profile and 34% higher than the circular profile. The triangular profiles had the least resistance to pullout force before and after cyclic loading. The curvilinear square may be the best profile for the cross section of the staple leg for maximum pullout strength and may expand the clinical use of staples in bone fixation.

Heterotopic ossification

Heterotopic ossification is a well-recognized condition frequently encountered by the orthopedic surgeon. Although typically asymptomatic, heterotopic ossification can be a complication of extreme severity. This article is a review of literature and attempts to clarify the definition, and delineates the etiology, incidence, risk factors, and current modes of prophylaxis and treatment of various types of heterotopic ossification.

Mechanics of retrograde nail versus plate fixation for supracondylar femur fractures

Two common types of internal fixations for the supracondylar femur fractures--the retrograde intramedullary nail and the 95 degrees sideplate and screw--were mechanically tested in synthetic composite femur bones to determine the quantitative differences in their inherent rigidity. The medial and lateral femoral condyles were separated by a sagittal osteotomy, and a standardized medial segmental shaft defect was created at the distal shaft. The osteotomized specimens were stabilized using one of the two implants and were tested in different modes of loading. The bending stiffness of both constructs were not significantly different in varus compression, medial bending (pure varus), and bending in flexion. The plate and screw implant was three times stiffer in lateral bending (pure valgus) and 1.2 times stiffer in valgus compression than the retrograde supracondylar nail (p < 0.01). The torsional stiffness of the plate and screw implant was significantly higher, 1.6 times that of the nail. Clinically, the most important and common cause of implant failure is varus loadings due to loss of medial cortical contact. Although the retrograde nail was less rigid in other physiologically less critical modes of loading, it had a rigidity comparable to that of the plate in varus loading. Therefore, a supracondylar nail may be considered a mechanically possible alternative to plate fixation.

Septic knee from Ilizarov transfixation tibial pin

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Combined Monteggia and Galeazzi fractures in a child's forearm. A case report

We report the occurrence of a previously undescribed combined Monteggia and Galeazzi fracture pattern of the left forearm in an 8-year-old boy. Previous reports do not address the combined injury described in this article, which consists of a left radius shaft fracture with dislocation of the distal radioulnar joint, and a left ulna shaft fracture with anterior dislocation of the radiohumeral joint. An excellent result was obtained with closed reduction. Radiographic evaluation is crucial in these disorders for both diagnosis and for treatment decisions. A review of the literature is provided with specific emphasis toward the classifications, mechanisms of injury, diagnosis, associated injuries, and treatment.

Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size

Twenty-five patients with trimalleolar ankle fractures were evaluated using both conventional radiography and computed tomography (CT) to determine the size of the posterior fragment along with other fracture characteristics. Plain radiograph measurements indicated very poor inter- and intraexaminer reliability. When compared to the CT scan measurement, 54% of the plain radiographic readings revealed > 25% error. Plain radiographic interpretations erred in most cases by overrating the size of the fragment, but major underestimations also occurred. The larger size fragments showed more error than the smaller ones. This information confirms our clinical suspicion that the lateral radiograph is unreliable in assessing the posterior fragment size.

The reduction clamp: a simple device for closed reduction during intramedullary nailing

Reduction of femoral shaft fractures prior to passing the guide pin during intramedullary fixation may be a challenging problem, especially in delayed reductions or obese patients. We describe a simple and useful instrument for obtaining and maintaining reduction for closed intramedullary fixation. It provides a three-point fixation that may be locked into position to maintain the reduction. The surgeon is not required to hold the device in position while passing the guide pin, the reamer, or the nail. It frees the surgeon's hands, minimizes the need for an assistant, and reduces harmful x-ray exposure to the hands.