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Shared decision-making (SDM) is the process by which the physician and the patient collaborate to arrive at the evidence-based treatment that best aligns with the patient's individual goals of care. The implementation of SDM practices is especially important when an invasive surgical procedure is among the treatment options. Ideally, the variation in the patient treatment choice would mirror the variability in patient goals rather than variation in a physician's ability to communicate effectively. Potentially aiding in these communication efforts, decision aids are tools gaining popularity for their ability to help physicians facilitate the SDM process with patients. This article is intended to give the practicing orthopaedic surgeon an understanding of the concept of SDM and how it can improve physician-patient communication. We will explore the key elements of SDM, attendant benefits, indications, and barriers to implementation and propose steps to begin the incorporation of SDM into practice.

The results of open reduction and internal fixation for tibial plateau fractures are generally favorable when articular morphology and stability are restored. When these goals of treatment are not achieved, limited function often results. The patient presented in this video complained of pain and an inability to resume his previous work. Evaluation suggested that root causes of these difficulties included widening of the plateau, significant depression of the articular surface, resultant valgus instability, and a displaced nonfunctioning lateral meniscus. This video demonstrates the planning and correction of a long-standing intraarticular malunion of a lateral tibial plateau fracture.

SUMMARY In this video, we present a unique approach to a purely ligamentous syndesmotic injury in a 16-year-old football player. Syndesmotic reduction was obtained using a large clamp and validated by matching fibular position to a fluoroscopic image of the contralateral ankle. Fixation was achieved using dual suture button devices in combination with a buttress plate. A small medial incision was used to protect the saphenous neurovascular bundle during button placement.

SUMMARY Subtalar distraction arthrodesis is a hindfoot reconstructive procedure designed to treat posttraumatic sequelae of certain calcaneal fractures. This video demonstrates one method of performing this procedure which resulted in dramatic pain improvement and functional restoration.

To the editor, We read the study by Murphy et al. [4] with interest. In their study, the reoperation rate for displaced fractures is 38% after fixation, and 7% after hemiarthroplasty. The author concluded that hemiarthoplasty resulted in fewer reoperations than internal fixation, and displaced fractures underwent reoperation more than nondisplaced. Murphy and colleagues reported an overall rate of failure of 38% in displaced internal fixation group. This failure rate is higher than a similar series by Healy et al. [1]. In the Healy and colleagues study, the authors reported 12.5% reoperation rate after internal fixation. Iorio et al. [2] stated that if urgent reduction was obtained, best functional results could be achieved in patients with a well-healed femoral neck without osteonecrosis after reduction and internal fixation of displaced femoral neck fractures in elderly patients. Patient selection and surgical skill were important variables, and THA was the best option in patients with complex fractures, poor medical condition, and poor bone quality. For intracapsular femoral neck fractures, time to operation is a determining factor of clinical outcomes. In the current study, the authors did not note the average of injury to operation time for internal fixation group. Therefore, high reoperation rates may be related to delayed surgery in the fixation group. Itadera et al. [3] reported that displaced femoral neck fractures that can be treated within 24 to 48 hours should be managed with internal fixation if they have a medial spike in the femoral head fragment (typical type). Itadera et al. [3] stated that crescent and mixed type without spike of the neck in the femoral head fragment were more complicated. We would like to thank Murphy et al. for this paper. However, when considering the medical conditions of eldery patient groups, we believe internal fixation for displaced femoral neck fractures is still logical because of decreased blood loss, shorter operative time, and lower intraoperative mortality rates.

Historically, physicians as participants in healthcare governance were shunned because of perceived potential for conflict of interest. This maxim is being revisited as health systems begin to appreciate the value presented by physician leaders.This overview of the orthopaedist's role in healthcare governance will be addressed in three sections: first to identify the need for change in American healthcare, second to examine the role that physicians should play in governing over this inevitable change, and third to outline strategies for effective participation for those physicians wishing to play a role in healthcare governance.The PubMed data set was queried applying the search commands "governance AND (healthcare OR hospital) AND (doctor OR physician OR surgeon)" for the time period 1969 to 2012. In addition, the bibliographies of relevant articles were reviewed. This search strategy returned 404 titles. Abstract and article review identified 19 relevant to the topic. Bibliographic review identified five more articles of relevance forming the foundation for this review.The delivery of American health care will require change to face current economic realities. Organizations that embrace this change guided by the insight of physician governors are well positioned to recognize the simultaneous improvement in value and quality. Although few physicians are formally trained for these roles, multiple paths to becoming effective governors are available.In this environment of rapid change in healthcare delivery, the medical insight of physician leadership will prove invaluable. Governing bodies should reach out to talented physicians and administratively talented physicians should rise to this challenge.

Purpose The optimal treatment for osteochondral fracture of the femoral head associated with posterior dislocation remains unclear. A case can be made to treat small fragments and those that concentrically reduce nonoperatively. On the other end of the spectrum are those where significant size and residual displacement warrant consideration of operative fixation. This video demonstrates the treatment of a large complex multifragmentary osteochondral femoral head fracture with surgical dislocation. Methods With the patient in lateral decubitus position, the trochanter is approached through lateral incision. The trochanter is cut and capsulotomy performed taking care to preserve the critical medial femoral circumflex artery. Fixation with headless screws is performed from the small comminuted fragments into the dominant section of intact femoral head. Results Experience suggests that anatomic fixation through surgical dislocation can be carried out with low incidence of subsequent avascular necrosis and degenerative articular change. Given the degree of local osseous and muscular trauma, consideration should be given to prophylaxis of heterotopic bone. Discussion Although small osteochondral fragments restricted to the acetabular fossa can be treated nonoperatively, the size and displacement of the presented fragment mandated operative reduction. Given the predicted complexity of repair, the surgical dislocation approach was chosen to provide maximum exposure optimizing the chances for successful fixation.

One of the most frequent complications after intraarticular fracture of the calcaneus is the development of posttraumatic arthritis of the subtalar joint. If conservative measures fail in the treatment of this condition, consideration of arthrodesis should be given. This video depicts the preoperative assessment and surgical technique applied to one such 54-year-old patient who had undergone internal fixation of a calcaneal fracture 9 years before. Shown within the video is exposure of the subtalar joint through a lateral incision, joint preparation, and the application of stable fixation. Subtleties of exposure, osteogenesis maximization, and postoperative management are covered.

It is well recognized by orthopedic surgeons that fractures of alcoholics are more difficult to heal successfully and have a higher incidence of non-union, but the mechanism of alcohol's effect on fracture healing is unknown. In order to give direction for the study of the effects of alcohol on fracture healing, we propose to identify gene expression and microRNA changes during the early stages of fracture healing that might be attributable to alcohol consumption. As the inflammatory stage appears to be the most critical for successful fracture healing, this paper focuses on the events at day three following fracture or the stage of inflammation. Sprague–Dawley rats were placed on an ethanol-containing or pair-fed Lieber and DeCarli diet for four weeks prior to surgical fracture. Following insertion of a medullary pin, a closed mid-diaphyseal fracture was induced using a Bonnarens and Einhorn fracture device. At three days' post-fracture, the region of the fracture calluses was harvested from the right hind-limb. RNA was extracted and microarray analysis was conducted against the entire rat genome. There were 35 genes that demonstrated significant increased expression due to alcohol consumption and 20 that decreased due to alcohol. In addition, the expression of 20 microRNAs was increased and six decreased. In summary, while it is recognized that mRNA levels may or may not represent protein levels successfully produced by the cell, these studies reveal changes in gene expression that support the hypothesis that alcohol consumption affects events involved with inflammation. MicroRNAs are known to modulate mRNA and these findings were consistent with much of what was seen with mRNA microarray analysis, especially the involvement of smad4 which was demonstrated by mRNA microarray, microRNA and polymerase chain reaction.

To assess the risk of injury to the superficial peroneal nerve, saphenous nerve, and saphenous vein in percutaneous fixation of the distal fibula and tibia.Ten adult cadaver lower extremities were instrumented with precontoured periarticular plates for the distal tibia and fibula. Plates were inserted percutaneously along the medial distal tibia and lateral fibula. Smooth wires were inserted percutaneously into each screw hole. Dissection of the superficial peroneal nerve, saphenous nerve, and saphenous vein was performed along their respective course. The position of the neurovascular structures relative to the smooth wires was recorded.The saphenous nerve and vein had a predictable course along the medial aspect of the ankle. Both structures were injured in every specimen. This occurred consistently at 2.0 to 4.7 cm from the tip of the medial malleolus. The superficial peroneal nerve demonstrated large variance in the exit point from the lateral compartment crural fascia, exiting at an average of 11.6 cm from the tip of the lateral malleolus. Injury occurred in a single specimen at 11.5 cm from this point.The superficial peroneal nerve, saphenous nerve, and saphenous vein are at risk during percutaneous submuscular plating of the distal fibula and tibia. Careful dissection proximally for the fibula and distally for the tibia can minimize the risk of damage to these structures.

Background: Ischemia-reperfusion injury plays an important role in limb salvage following limb ischemia. The purpose of the present study was to evaluate the effect of local hypothermia and chemical modulators on microvascular permeability following ischemia-reperfusion injury in skeletal muscle. Methods: Sprague-Dawley rats were randomized into nine groups. Postcapillary venules of the extensor digitorum longus muscle were visualized with use of intravital microscopy. Following an intravenous bolus of fluorescein isothiocyanate-labeled albumin, the intravascular and extravascular space was examined for leak. Rats in the sham group underwent a one-hour mock ischemic period without the application of a femoral artery tourniquet, followed by one hour of mock reperfusion. The treatment groups (n = 5 in each group) had the tourniquet applied for one hour, followed by one hour of reperfusion at 10°C (cold) alone, at 10°C with nitric oxide synthase inhibitor, at 10°C with heme oxygenase inhibitor, at 10°C with a combination of inhibitors, at 34°C (warm) alone, at 34°C with a heme oxygenase inducer, at 34°C with a nitric oxide synthase inducer, or at 34°C with a combination of inducers. Results: Rats in the sham group did not show a significant increase in microvascular permeability. Rats in the warm ischemia/reperfusion group displayed significant increases in microvascular permeability, as did the rats that received inhibitors of heme oxygenase and nitric oxide synthase at 10°C. No significant increase in microvascular permeability was observed in the animals in the cold ischemia/reperfusion group or in animals that received inducers of heme oxygenase and nitric oxide synthase at 34°C. Conclusions: Local hypothermia protects skeletal muscle from increased microvascular permeability following ischemia-reperfusion injury. This protective effect is also seen with the induction of the nitric oxide synthase and heme oxygenase systems at physiologic temperature. We also have shown that the protective effects of hypothermia are blocked by giving heme oxygenase and nitric oxide synthase inhibitors while keeping the muscle hypothermic. These findings demonstrate that heme oxygenase and nitric oxide synthase play a combined role in ischemia-reperfusion injury, suggesting possible pathways for clinical intervention to modulate injury seen following trauma, tourniquet use, vascular surgery, and microvascular surgery. Clinical Relevance: The present study provides evidence for the use of local hypothermia following ischemia-reperfusion-related tissue injury and provides biochemical insight for future pharmacologic intervention.

Objectives Open fractures are one of the injuries with the highest rate of infection that orthopaedic trauma surgeons treat. The main purpose of this survey was to determine current practice and practice variation among Orthopaedic Trauma Association (OTA) members and make treatment recommendations based on previously published resources. Design Survey. Setting Web-based survey. Participants Three hundred seventy-nine orthopaedic trauma surgeons. Methods A 15-item questionnaire-based study titled "OTA Open Fracture Survey" was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze numerous aspects of open fracture management, focusing on parameters of initial and definitive treatment. Results Eighty-six percent of participants responded that a period of time of less than 1 hour is the optimal time to antibiotic administration after identification of open fracture. Despite concerns with nephrotoxicity, 24.0%-76.3% of respondents reported the use of aminoglycosides in management of open fractures. A little over half of survey respondents continue antibiotics until next debridement in wounds that were not definitively closed after initial debridement and stabilization. Conclusions Rapid administration of antibiotics in open fracture management is important. Aminoglycoside use is still prevalent despite evidence questioning efficacy and toxicity concerns. Time to debridement of open fractures is controversial among OTA members. Antibiotic administration is commonly continued >48 hours despite concerns raised by Surgical Infection Society and The Eastern Association of the Surgery of Trauma. Regarding study logistics, survey participation reminders should be used when conducting this type of study as it can increase data accrual by 50%. Level of evidence Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE To determine how axial rotation around the anatomic axis of the femur, as would occur with malrotation of a femoral fracture, affects frontal and sagittal plane alignment and knee joint orientation. DESIGN Computer-generated models of the lower extremity were constructed using standardized dimensions. To simulate a malrotated fracture, these models were rotated in the shaft around the anatomic axis in 15 degrees increments from 60 degrees internal to 60 degrees external rotation. Rotation was performed at the proximal fourth, mid-shaft, and distal fourth. MAIN OUTCOME MEASUREMENTS At each rotational position, the mechanical axis deviation in millimeters and the changes in mechanical lateral distal femoral angle in degrees were measured to quantify frontal plane malalignment and malorientation, respectively. The mechanical axis deviation in millimeters in the sagittal plane was also measured at each rotatory position. RESULTS Femoral shaft malrotation greater than 30 degrees internal rotation of a subtrochanteric fracture or more than 45 degrees of a midshaft fracture or external rotation of 30 degrees or greater of a supracondylar fracture resulted in frontal plane malalignment. External rotation of a supracondylar fracture of 45 degrees or more results in knee joint malorientation. Any external rotation at all 3 fracture levels caused posterior displacement of the weight-bearing axis in the sagittal plane. CONCLUSIONS Malrotation of a femoral shaft fracture is not just a cosmetic problem. Internal and external rotation causes malalignment and malorientation in the frontal plane, depending on the level of the fracture and the magnitude of malrotation. External rotation of any degree at the proximal fourth, mid-shaft, and distal fourth causes a posterior shift of the weight-bearing axis in the sagittal plane.

There are few cases in the medical literature documenting intrathoracic glenohumeral fracture-dislocations. A total of eight cases have been reported-two intrathoracic humerus dislocations with greater tuberosity fractures 1, 2 and six cases with intrathoracic fracture-dislocations in which the fracture involved the humeral neck. 3-8 With so few cases, treatment modalities vary, and no guidelines exist. Patients in five of the reported cases underwent surgery, 1, 3-6 while the other three were treated nonoperatively. 2, 7, 8 We present a case of a middle-aged woman involved in a high-speed motor vehicle accident who sustained an intrathoracic humeral head fracture-dislocation and underwent operative treatment.

Over recent years, orthopaedic traumatologists have been gaining experience with tibial nailing in the extended position. Originally developed to address the complexities of alignment in proximal tibial fractures, this technique has also proven valuable in the treatment of tibial shaft fractures combined with ankle injuries. Depicted in this video presentation is the surgical techniques used to simultaneously address a spiral fracture of the distal tibia associated with a large coronal plane fracture of the tibial articular surface. Discussed are leg positioning, technical aspects of the medial approach, strategies for preliminary ankle stabilization, and fine details of aligning the tibial component of the injury. With a growing body of evidence suggesting similar knee outcomes with semiextended and conventional infrapatellar approaches, it is anticipated that this technique will become increasingly popular in coming years.

The lower extremity has a mechanical axis with joint orientation that allows joint longevity and efficiency in bipedal gait. When normal alignment is lost because of trauma or other conditions, deviations from this anatomic norm may be deleterious to long-term joint function. In fractures that have healed with angular malunion, all facets of the deformity must be carefully considered, including alteration in length, rotation, alignment, and translation. Once all elements are fully defined, the effects of the malunion on mechanical axis and joint orientation can be understood. Techniques for surgical correction include wedge, dome, and oblique osteotomies and distraction osteogenesis. Each method possesses characteristics appropriate for certain clinical situations. Judicious patient selection and thoughtful preoperative planning may allow restoration of normal mechanics.

Fractures often heal with angular, rotational, or length malunion. In most situation, these deviations from the normare functionally well tolerated. Occasionally, malunions lead to problems of joint axis deviation, articular cartilage overload, instability, cosmesis. Although the existing literature is inconclusive about the long-term implications of angular malunions, there are situations where clinical judgment suggests that malunion correction is indicated. If surgical correction is contemplated, precise deformity assessment and preoperative planning is imperative. Available techniques include wedge osteotomy, oblique osteotomy, dome osteotomy, and distraction osteogenesis. Each of these methods possesses characteristics appropriate for certain clinical situations. The indications and surgical techniques of these methods will be discussed. In the author's experience, judicious patient selection, combined with thoughtful preoperative planning, may restore normal mechanics to legs malaligned from trauma.

Background The importance of the tip-apex distance (TAD) to predict the cut-out risk of fixed angle hip implants has been widely discussed in the scientific literature. Intra-operative determination of TAD is difficult and can be hampered by image quality, body habitus, and image projection. The purpose of this paper is to evaluate, through a cadaveric study, a novel computer assisted surgery system (ADAPT), which is intended for intraoperative optimisation of lag screw positioning during antegrade femoral nailing. A 3D measure for optimal lag screw position, the tip-to-head-surface distance (TSD), is introduced. Methods 45 intra-medullary hip screw procedures were performed by experienced and less experienced surgeons in a cadaveric test series: in 23 surgeries the ADAPT system was used, and in 22 it was not used. The position of the lag screw within the femoral head and neck was evaluated using post-operative CT scans. TAD, TSD, fluoroscopy as well as procedure time and variability were assessed. Results The use of the ADAPT system increased accuracy in TSD values (i.e. smaller variability around the target value) for both groups of surgeons (interquartile range (IQR) of experienced surgeons: 4.10 mm (Conventional) vs. 1.35 mm (ADAPT) (p = 0.004)/IQR of less experienced surgeons: 3.60 mm (Conventional) vs. 0.85 mm (ADAPT) (p = 0.002)). The accuracy gain in TAD values did not prove to be significant in the grouped analysis (p = 0.269 for experienced surgeons; p = 0.066 for less experienced surgeons); however, the overall analysis showed a significant increase in accuracy (IQR: 4.50 mm (Conventional) vs. 2.00 mm (ADAPT) (p = 0.042)). The fluoroscopy time was significantly decreased by the use of the ADAPT system with a median value of 29.00 seconds (Conventional) vs. 17.00 seconds (ADAPT) for the less experienced surgeons (p = 0.046). There was no statistically significant impact on the procedure time (p = 0.739). Conclusions The ADAPT system improved the position of the lag screw within the femoral head, regardless of the surgeon’s level of clinical experience, and at the same time decreased overall fluoroscopy usage. These positive effects are achieved without increasing procedure time.

Following intramedullary rodding of two long-bone fractures, a twenty-year-old woman developed the clinical picture of fat embolism syndrome with severe neurological involvement. Corroborating evidence suggested paradoxical embolization of fat as the precipitating cause of this neurologic deterioration. The suspected pathophysiology of this event is discussed.

Advances in automobile safety and prehospital transport systems have been successful in increasing the survivorship of victims of high-speed motor vehicle accidents. This positive development has led to a changing morphology of fractures to the distal tibial articular surface. The increasingly common pattern of massive articular comminution and extreme soft-tissue damage does not lend itself well to the conventional techniques of open reduction and internal fixation. High complication rates have led orthopedic traumatologists to seek new strategies in the management of these injuries. Common to all of these emerging techniques is the desire to minimize additional soft-tissue injury while satisfying the mandate for articular reconstruction and stable metaphyseal fixation. Limited periarticular incisions have emerged as a method of joint reduction. Several alternative methods for articular support must then be considered. The relative merits and difficulties of bridging external fixation, nonbridging external fixation, delayed open reduction, and subcutaneous plating are discussed.

Injuries that result in mechanical disruption of the posterior pelvis are often the source of chronic pain and impairment. Advancements of the last 2 decades have increased our understanding of the natural history of these injuries as well as the inherent risk and benefits of surgical treatment. This article presents an overview of the relative merits of anterior open reduction, posterior open reduction, and percutaneous treatment of posterior pelvic ring disruption. Surgical techniques are highlighted and a treatment algorithm is provided for assistance in decision making with these complex injuries.

Comminuted supracondylar femur fractures (AO-OTA 33A3) are commonly treated with locked plates. Weight bearing is generally restricted for 6 to 12 weeks until radiologic evidence exists of sufficient callous to support weight bearing. Recent clinical studies have reported high nonunion rates with distal femur locked plates. In an attempt to induce beneficial motion across the fracture site, some studies have recommended earlier weight bearing. The purpose of the current study was to determine the biomechanical feasibility of an immediate weight-bearing rehabilitation protocol to encourage healing of distal femur fractures treated with lateral locked plate fixation. Sixteen fresh-frozen cadaveric femora were used for this study. A 2.5-cm supracondylar gap osteotomy was made. Ten-hole, 4.5-mm distal femur locking plates were used with a standardized screw configuration that maximized the working length. The specimens were placed in a servohydraulic testing machine and axially loaded (unidirectional) at 1 Hz for up to 200,000 cycles. Failure was defined as 1 cm of deformation of the construct. The staircase method was used to determine the fatigue limit of the construct. The fatigue limit was calculated to be 1329±106 N. No specimen failed through the non-locking diaphyseal screws. Plastic deformation, when present, occurred at the metaphyseal flare of the plate. The fatigue limit of the locked plate constructs equaled 1.9 times body weight for an average 70-kg patient over a simulated 10-week postoperative course. Given that distal femoral loads during gait have been estimated to be more than 2 times body weight, the data from this study do not support immediate full weight bearing.

Objectives Ischemia-reperfusion (I/R) injury can have detrimental effects on skeletal muscle. We have shown that vessel permeability can be minimized in a hypothermic setting and also by administering the nitric oxide synthase (NOS) stimulator, L-arginine, at physiologic temperatures. The purpose of this study was to examine and compare skeletal muscle contractility after an I/R insult during hypothermic conditions, warm conditions, and also with the administration of L-arginine at physiologic temperatures. We hypothesized that hypothermia and L-arginine administration will also demonstrate protective effects to skeletal muscle contractility. Methods Using Sprague-Dawley rats, the extensor digitorum longus muscle was rotated on its vascular pedicle to a thermo-controlled stage. Ischemia was established using an atraumatic femoral artery tourniquet. Reperfusion was performed under control and experimental conditions including local hypothermia and intravenous L-arginine. After harvesting experimental muscles, contractility was then quantified by using a tissue bath stimulator with force transducers. Results Warm reperfusion resulted in marked decrease in muscle contractility compared with sham animals. Local hypothermia showed statistically significant preservation of contractility compared with the sham group. This protective effect was recapitulated by the application of NOS inducers (L-arginine) at warm conditions. Conclusions These findings demonstrate that hypothermia and L-arginine are protective of skeletal muscle contractility after an I/R injury. The results presented may have profound effects on future therapeutic recommendations and suggest possible pathways for clinical intervention to modulate I/R injury, which is commonplace in orthopaedic trauma and reconstructive surgery.

One of the goals of the annual American Orthopaedic Association (AOA) meeting is to address controversy, both in leadership and clinical practice. A panel of experts in their respective fields presented the background and literature behind three "myths" in orthopaedic management and made conclusions as to their validity. First, Dr. Kocher took on the myth of prophylactic pinning on the contralateral "normal" side for a patient with a slipped capital femoral epiphysis. Second, Dr. Probe evaluated the myth that all intertrochanteric fractures are best treated with intramedullary devices. Last, Dr. Foster and Dr. Silvestri tackled the myth that autograft is always the best choice for anterior cruciate ligament (ACL) reconstruction. All three of these topics are subjects of current debate. The panel's careful examination of the available data along with their expertise in the management of these problems is presented in this thought-provoking JBJS Critical Issues article.

A prospective randomized study of 116 patients with plantar fasciitis was performed to determine the effectiveness of adjuvant night splint therapy in relieving the acute symptoms of plantar fasciitis. Patients were randomized into one of two groups. Patients in Group 1 were treated with 1 month of oral antiinflammatory medication, Achilles stretching exercises, and shoe recommendations. Patients in Group 2 received identical treatment but also used a dorsiflexion night splint for 3 months. Blinded clinical review of patients was performed at 4, 6, and 12 weeks. Health status data Short Form 36 also was collected at these times and again at an average 19 months of followup. Overall, 68% of patients reported improvement with this nonoperative protocol for a 12-week period. No statistical difference was seen with the presence or absence of a night splint. In addition, no differences in improvement rates were observed with gender, duration of antecedent symptoms, the presence of bilateral symptoms, or the presence of a heel spur. Age older than 45 years did prove to be a statistically significant poor prognostic factor for improvement at the 12-week follow-up. Short Form 36 data obtained at baseline showed significantly lowered perception of health when compared with age matched controls. Patients in both treatment groups had significant improvement in Short Form 36 scores with 12 weeks of conservative care.

While gap defect models provide greater graft stability and are more representative of many clinical situations than segmental defect models, the healing in these models has not been well documented. To study the histologic course of cancellous bone graft healing in a long bone gap defect, 12 adult mongrel dogs were killed in groups of two at 1, 2, 3, 4, 6, and 12 weeks. Graft incorporation in these dogs was studied using macro- and microradiography, histologic sections, and computer-assisted digital surface analysis ; results are described. Unlike that seen in segmental defect models, the pattern of repair in a cancellous bone grafted gap defect provides consistent healing at 12 weeks and follows the same healing process seen with stable defects.

Titanium plates and screws have become widely used for the fixation of fractures and osteotomies. We began using them in 1992 ; however, several early hardware failures prompted a retrospective review of the occurrence of this complication. A 2-year time period was reviewed at two institutions with comparison of hardware failure rates using titanium and stainless steel implants. At one institution, 51 fractures or osteotomies of the long bones were fixed by the senior author using titanium implants between July 1992 and July 1994. One hundred one similar cases were treated over the same period by the same surgeon using stainless steel implants. The outcome is known for 48 of the cases performed with titanium and for 80 of the cases performed with stainless steel. There were five postoperative implant failures using titanium and one using stainless steel. Metallurgical analysis of one set of broken implants retrieved during a revision surgery showed no manufacturing defects. At the second institution, 21 titanium and 138 stainless steel platings were performed over 2 years. There were four titanium implant failures in four patients and one stainless steel implant failure. Our experience suggests that these implants should be used with care, particularly in high-demand settings such as nonunion or noncompliance, and that further research needs to be conducted to establish appropriate clinical indications for their usage.

Malunion is often a problem in adolescent femoral shaft fractures treated with traction and subsequent casting. We used external fixation as an alternative treatment method to control alignment and allow early mobilization. After fracture healing and fixator removal, two patients experienced refracture. This unusual complication is the basis of our report. Prolonged rigid or static fixation appears to be detrimental to sufficient callus formation and healing.

Surgical fixation, early weight-bearing, and bony union remain a challenge in the treatment of peritrochanteric femur fractures, especially if the fractures are comminuted or unstable. Preliminary experience with the Gamma locking nail, a short intramedullary nail connected to a sliding compression screw augmented with distal locking screws, is presented. In a consecutive series of 29 patients, all fractures were adequately reduced and immediate weight-bearing was begun regardless of fracture configuration (13/27 fractures classified as unstable). Twenty-seven patients were reviewed at 6 months. At follow-up, all patients continued to be ambulatory and all fractures healed. Major complications included screw migration in the femoral head (two patients), difficulty in securely placing the distal screws (eight patients), and a femoral shaft fracture through the distal locking screws following a fall. The technical problems inherent in the device and its instrumentation are discussed. In this early experience, the Gamma nail appears to allow for early patient ambulation regardless of the fracture configuration with excellent clinical results.

Study Design. The authors recorded the contamination rate at a mock surgical site below a high-speed burr creating debris from a fresh-frozen allograft specimen. Ojectives. To document possible contamination rates associated with high-speed burr use. Summary of Background Data. The literature contained no studies addressing a known rate of contamination from high-speed burr use. Methods. Samples of debris were collected in a mock-up of an operation involving bone burring. Set distances were maintained between objects within the field. High-speed bone burring was performed on fresh-frozen allograft bone specimens, and falling debris was collected on sterile culture plates. Control specimens were obtained randomly. Two hundred test and 20 control samples were collected by means of standard sterile techniques. Results. Thirty-five percent of the cultured specimens from the test group grew skin flora, compared with 10 % from the control group (P = 0.02). Conclusions. The authors propose that the higher contamination rate in the experimental samples resulted from airbone bone chips striking nonsterile surfaces before landing on the culture plates. Such contamination may increase the risk of wound infection.

Autogeneic canceUous bone graft has been recommended as a vehicle for local antibiotic delivery. Its effect on graft incorporation, however, is unknown. The healing of defects grafted with tobramycin-impregnated cancellous bone were compared with those grafted with cancellous bone alone. Plane roentgenographs, microradiographs, bone density analyses, histologic examination, and biomechanical testing were performed on specimens throughout the course of healing. The presence of large concentrations of local tobramycin does not appear to affect the normal healing characteristics of cancellous bone graft

The increasingly popular ilioinguinal anterior approach for select fractures of the acetabulum provides excellent exposure with minimal soft tissue dissection. Vascular complications reported with this procedure, although infrequent, are usually quite pronounced in their presentation. The authors encountered a more subtle case of femoral artery thrombosis secondary to vessel retraction while using this approach. The susceptibility of major vessels to thrombus formation is noteworthy. The precautions, and the close postoperative monitoring necessary to detect such vascular lesions, are emphasized.

Crush syndrome is due to extensive muscle damage characterized by haemodynamic shock, hyperkalaemia, metabolic acidosis, and myoglobinuric acute renal failure. The literature is somewhat divided on its treatment; some surgeons opting for late surgery while others maintain that early surgical intervention is best. We report a case of a young man with a crush syndrome presenting 3 days after his leg was caught in a train door and examine the current literature on the topic.