We performed a systematic review of the literature to evaluate the use and interpretation of generic and disease-specific functional outcome instruments in the reporting of outcome after the surgical treatment of disruptions of the pelvic ring. A total of 28 papers met our inclusion criteria, with eight reporting only generic outcome instruments, 13 reporting only pelvis-specific outcome instruments, and six reporting both. The Short-Form 36 (SF-36) was by far the most commonly used generic outcome instrument, used in 12 papers, with widely variable reporting of scores. The pelvis-specific outcome instruments were used in 19 studies; the Majeed score in ten, Iowa pelvic score in six, Hannover pelvic score in two and the Orlando pelvic score in one. Four sets of authors, all testing construct validity based on correlation with the SF-36, performed psychometric testing of three pelvis-specific instruments (Majeed, IPS and Orlando scores). No testing of responsiveness, content validity, criterion validity, internal consistency or reproducibility was performed.

The existing literature in this area is inadequate to inform surgeons or patients in a meaningful way about the functional outcomes of these fractures after fixation.

Purpose: Several variables related to tourniquet (TQ) inflation contribute to ischemic muscle injury. Among these the duration of ischemia has been identified as a primary factor. The purposes of this study were to investigate the following during and after TQ-induced ischemia during orthopedic trauma surgery:

muscle oxygenation changes measured by near infrared spectroscopy (NIRS);

Method: Consented patients aged 19–69 yrs (n=18) with unilateral ankle fracture requiring surgery at our institution were recruited. A pair of NIRS probes was fixed over the midpoint of the tibialis anterior muscle (TA) on both the injured and healthy legs. A thigh TQ was applied to the injured leg and inflated to 300 mmHg. Using the NIRS apparatus coupled to a laptop with data acquisition software, changes in oxygenated (O2Hb), deoxygenated (HHb), and total hemoglobin (tHb) levels in the TA of both legs were measured before and during TQ inflation, and after release until values returned to baseline. PRE surgical biopsies were collected from the peroneus tertius muscle (PT) immediately after TQ inflation and incision. POST biopsies were collected from the same PT immediately before TQ deflation. Oxidation of PT myosin, actin, and total protein was quantified using Western blot analysis of 4-hydroxynonenal (4-HNE) modified proteins. Data are reported as mean±SD.

Results: In PRE biopsies compared to POST biopsies there were large and statistically significant increases in the PT content of 4-NE modified myosin (174.4±128%; P< 1×10-6), actin (223.7±182%; P< 5×10-9), and total protein (567.5±378%; P< 5×10-7). There was a greater increase in PT protein oxidation in male subjects than in female subjects (50.8% difference; P< 0.05). In the TA of the fractured side, there were moderate to strong linear correlations between total protein oxidation and: the relative change in tHb (r=−0.704) and O2Hb (r=−0.415) during the period of TQ inflation and the rate at which the muscle became reoxygenated following TQ release (r=0.502). There was no relationship between muscle protein oxidation and TQ time, nor between muscle protein oxidation and age of patients.

Conclusion: TQ-induced muscle ischemia for 21 to 74 min during lower extremity surgery leads to oxidative muscle injury as measured according to myofibrillar contractile protein oxidation. Importantly, we observed that when the TQ was “leaky,” local increases in muscle tHb were associated with a lower magnitude of protein oxidation, however, when local decreases in muscle O2Hb were observed, perhaps due to local blood loss below the TQ, more oxidative changes resulted. Intriguingly, gender appeared to influence the extent of muscle oxidative injury, but age did not. Surprisingly, there was no significant correlation between muscle oxidative injury and the TQ-induced ischemia interval.

FUNDING: MSFHR, COF, BCLA.

Purpose: Near-infrared spectroscopy (NIRS) detects changes in chromophore concentrations of oxygenated (O2Hb) and deoxygenated hemoglobin (HHb) in target tissues approximately 2 to 3 cm below the skin. The main purpose of this study was to non-invasively measure skeletal muscle oxygenation in the leg during and after tourniquet (TQ)-induced ischemia using continuous wave NIRS. Secondarily, we aimed to assess the sensitivity, specificity, and reliability of this optical technique for detection and continuous monitoring of changes in muscle oxygenation and hemodynamics during TQ-induced ischemia throughout orthopedic surgery.

Method: Consented patients aged 19–69 (n=21) with unilateral ankle fracture requiring emergency or elective surgery at our institution were recruited. All patients underwent standard general anesthetic. A pair of NIRS probes was fixed over the midpoint of the tibialis anterior muscle (TA) of both the fractured and healthy legs. A thigh TQ was applied to the injured leg and inflated to 300 mmHg. Using the NIRS apparatus coupled to a laptop with data acquisition software, changes in O2Hb, HHb, and total hemoglobin (tHb) levels in the TAs of both legs were measured at 10 Hz before and during TQ inflation, and after release until values returned to baseline. In each surgery the TQ was released when arterial obstruction was no longer required by the clinical team. Data are reported as mean±SD.

Results: Changes in O2Hb, HHb, and tHb were successfully collected, stored and transmitted for graphic display in all subjects. TQ time (ischemia interval) varied among subjects, from 1245 s to 4431 s (2753±854). NIRS measured a progressive increase in HHb (2.6±2 μmol/L) during the first minute of TQ inflation and a sharp increase in O2Hb (23.3±12 μmol/L) during the first minute of leg muscle reperfusion (after deflation). Following TQ inflation a progressive increase in HHb (24.2±10.3 μmol/L) with a concomitant decrease in O2Hb (mean – 24.4±8 μmol/L) in the under-TQ TA were consistent across subjects. These changes in ΔHHb and ΔO2Hb began to reverse immediately after TQ deflation. Significant correlations were observed between ischemia interval and, respectively, oxygenation recovery time (r2=0.84) and changes of deoxygenated hemoglobin (r2=0.57).

Conclusion: We demonstrated that, following TQ inflation and deflation respectively, NIRS can sensitively monitor muscle deoxygenation and reoxygenation. Consistent patterns of ΔHHb and ΔO2Hb occurred during TQ-induced ischemia in all subjects. These data confirm that near infrared spectroscopy is useful for the non-invasive detection and monitoring of muscle ischemia. These results indicate that it may be useful to investigate the efficacy of NIRS in the early detection of muscle ischemia or hypoxemia in conditions such as compartment syndrome.

FUNDING: MSFHR, COF, BC Lung.

Purpose: It is well established that skeletal muscle ischemia followed by reperfusion induces oxidative damage, metabolic stress, and an inflammatory response. This ischemia-reperfusion injury has been studied extensively in experimental models and, importantly, in the clinical setting where it is associated with tourniquet (TQ) inflation during orthopedic trauma surgery. Of particular clinical concern is the notion that reperfusion upon TQ release is central to oxidative injury, since release necessarily follows surgery. Consequently, the effects of ischemia alone, without reperfusion, is poorly documented. That is, it remains unknown what are the effects of muscle ischemia, per se, on muscle properties that could influence functional recovery postoperatively or what preventative measures might be taken to minimize the potentially deleterious effects of the ischemic period alone. Hence the purpose of this study was to investigate changes in myofibrillar contractile protein oxidation over the course of TQ-induced leg muscle ischemia during orthopedic trauma surgery.

Method: Among patients with unilateral ankle fractures requiring surgery at our institution, 24 subjects gave informed consent to participate. All subjects underwent standard general anesthesia. PRE surgical biopsies were collected from the peroneus tertius muscle (PT) immediately after TQ inflation and incision of the skin and underlying connective tissue. POST surgical biopsies were collected from the same muscle immediately before TQ release. Oxidation of PT myosin, actin, and total protein was quantified using Western blot analysis for 4-hydroxynonenal (4-HNE) modified proteins. Results are reported as mean ± standard deviation.

Results: Total TQ time ranged from about 21 to 84 min (50.5±16). As anticipated, in PRE biopsies compared to POST biopsies there were large increases in the PT content of 4-NE modified myosin (174.4±128%; P< 1×10-6), actin (223.7±182%; P< 5×10-9), and total protein (567.5±378%; P< 5×10-7). Intriguingly, there was a much greater increase in PT protein oxidation in males than in females (43.3% difference; P< 0.05), although there was no relationship observed between PT protein oxidation and subject age. Surprisingly, there was no significant relationship between muscle protein oxidation and duration of the TQ-induced ischemia.

Conclusion: TQ-induced skeletal muscle ischemia for 21 to 84 min during orthopedic trauma surgery leads to considerable oxidative muscle injury as measured by muscle protein oxidation, including of the functionally relevant contractile proteins myosin and actin. This injury occurs even without reperfusion. Interestingly, the extent of oxidative muscle injury appears to be influenced by gender, but is not dependent upon the duration of ischemia.

FUNDING: MSFHR, COF, BCLA.

Purpose: To compare the functional outcome and quality-of-life following a displaced extra-articular proximal humerus fracture treated with open reduction and locking plate fixation versus non-operative management. To provide preliminary data for a subsequent prospective clinical trial.

Method: Eligible subjects were identified through retrospective searches of a large emergency department admission database and the orthopaedic trauma database. All subjects ages ³ 55 treated for a proximal humerus fracture between 2002 to 2005 were invited to participate. The Disabilities of Arm, Shoulder, and Hand (DASH), Health Utilities Index Mark 3 (HUI), Euroqol-5D (EQ-5D), and the SF-36 questionnaires were mailed to all eligible subjects. Initial radiographs were reviewed using the AO/OTA classification system. Only patients with A3, B1, B2, or B3 fractures were included.

Results: Thiry-four subjects were included: 15 were treated with sling immobilization and 19 with locked plate ORIF. The non-operative group was approximately seven years older (mean age 74 versus 67, p = 0.046). DASH scores were similar between the groups: ORIF 26.6 ± 24 and Sling 26.5 ± 20. The 95% CI surrounding the 0.01 point difference (−16.0 to 15.9) slightly exceeds the 13 point cutoff for the instrument’s measurement error (minimal detectable change). Using univariable analysis, no statistically significant differences in health state values were detected. The mean HUI value for the ORIF group was 0.68 versus 0.75 for the sling (p=0.48). Mean EQ-5D values were 0.77 for the ORIF group and 0.80 for the sling group (p=0.73). The SF-36 PCS scores were also similar between the two groups: ORIF 41.1 versus Sling 39.8 (p=0.77). When controlling for age and pre-injury function, a 0.09 point difference in HUI values was detected favouring the sling treatment (p=0.036). No differences in DASH, EQ-5D, or SF-36 PCS scores were detected using regression models.

Conclusion: The results of this small cohort suggest, for extra-articular fractures, the functional and quality of life outcomes may be similar between the two interventions. No trial comparing locked plate fixation and non-operative management has been reported. A total of 96 subjects will be needed for a prospective clinical trial comparing the two treatments (DASH difference 15, 80% power, 0.05 two-sided alpha).

Purpose: Femoral and tibial shaft malunion may predispose to knee osteoarthritis but may also pose a problem for knee reconstruction; malposition of total knee prostheses being a known cause of early failure. Limb realignment may prove to be beneficial prior to proceeding with arthroplasty. The purpose of this study was to evaluate the outcome and effect of shaft osteotomy prior to total knee arthroplasty (TKA).

Method: A search of the trauma database between 1987 and 2006 was conducted. Twenty-two osteotomies were performed on 21 patients with femoral or tibial shaft malunion who had been considered for TKA. Mean age at osteotomy was 54 years and mean follow-up 86 months. Time intervals between surgical procedures and Knee Society scores were calculated. Patients were surveyed regarding pain relief and functional improvement.

Results: Femoral osteotomy improved mean Knee Society knee scores from 47 to 76 and function scores from 34 to 61. Tibial osteotomy improved knee scores from 53 to 82 and function scores from 28 to 50. Four osteotomies were complicated by nonunion and required further intervention. Osteotomy subjectively improved pain and function for a mean of 56 months. Femoral and tibial shaft osteotomy delayed TKA in 45% (10 cases) for a mean period of just over 6.5 years (89 and 73 months for femoral and tibial osteotomy respectively). Pre and post Knee society scores were: Femur: knee 56 to 88, function 41 to 72; Tibia: knee 65 to 85, function 25 to 57. One TKA was revised after 11 months due to valgus malalignment and was complicated by a wound infection. There were no other infections or wound complications. The procedure additionally relieved pain and improved function in the remaining 12 joints, not yet requiring arthroplasty.

Conclusion: Femoral and tibial shaft osteotomy may delay and possibly avoid TKA, relieve pain and improve function in patients who present with malunion and end-stage knee arthritis. The complication rate and clinical results of TKA following shaft osteotomy appear to be similar to primary TKA. This treatment strategy should be considered in younger patients with post traumatic osteoarthritis where significant femoral or tibial deformity is present.

Purpose: To quantify how well the physical examination of the shoulder predicts patient-reported functional outcome in a cohort of patients with previous proximal humerus fractures.

Method: Potential subjects were identified from a recent study cohort of proximal humerus fracture patients treated within the past six years. The cohort consisted of all fracture types and treatment modalities. Participants underwent a focused physical examination of their injured shoulder containing the components of the Constant-Murley shoulder score: range of motion for forward flexion, abduction, internal rotation, external rotation, and abduction strength measured by an IsoBex muscle strength analyzer. Participants also completed the following patient-reported functional outcome questionnaires: Disabilities of Arm, Shoulder, Hand (DASH), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Simple Shoulder Test (SST), and Oxford Shoulder Score (OSS). Forward- and backward-stepwise linear regression was used to assess the relationship between the functional outcomes and the physical exam measurements.

Results: Thirty-one subjects with a mean age of 70 ± 8 years participated. Sixteen patients were previously treated with ORIF and 15 were treated with sling immobilization. The mean physical examination measures were: flexion 117° ± 31°, abduction 117° ± 37°, internal rotation 7° ± 2°, external rotation 7° ± 4°, and strength 6 ± 5 Newtons. The mean functional outcome scores were: DASH 21 ± 19, ASES 82 ± 17, SST 8 ± 3, and Oxford 20 ± 8. Using linear regression, adjusted R-squared statistics suggest components of the physical exam can explain 38% of the Oxford, 50% of the DASH, 58% of the SST, and 70% of the ASES variance. Abduction strength was a significant predictor for all functional outcomes. Combinations of flexion, abduction, or internal rotation were also significant predictors depending on the outcome instrument being modeled.

Conclusion: Physical exam of the shoulder accounts for differing amounts of patient-reported functional outcome variance. Abduction strength is the most consistent predictor of functional outcome within this cohort of proximal humerus fracture patients.

Purpose: To evaluate the long-term outcomes of the early management of severe ligamentous knee injuries.

Methods: We reviewed the long-term results of patients with multiple knee ligament injuries, i.e. at least 3 ligament ruptures, including both cruciates, in patients entered prospectively onto the trauma database between 1985 and 1999. Forty patients with this injury had Lysholm scores at long term follow-up a mean of 8 years post-injury. Non-operative treatment involved a cast or spanning external fixator (2–4 weeks) followed by bracing. The mode of operative treatment fell into 3 groups: direct suture or screw fixation of avulsions (Group 1), mid-substance ruptures treated with posterior cruciate reconstruction with hamstring tendons (Group 2), or suture repairs of mid-substance ruptures (Group 3). All operative procedures were undertaken within 2 weeks of injury. Statistical analysis was performed on the Lysholm scores.

Results: The 40 patients in the study group were predominantly young males, 40% had polytrauma, 33% had isolated injuries. Thirteen patients (33%) had non-operative management, the remainder had early operative treatment of their ligament injuries, tailored to the type of ligament injuries identified.

Long term patient outcome data shows statistically significant differences (p< 0.05) between the best results, in patients with direct fixation of bony avulsions (mean = 89), followed by those who had early hamstring reconstruction (mean = 79), followed by those who underwent simple ligament repairs (mean = 65). There was a statistically significant difference (p< 0.05) between the overall scores for the operative group (mean = 80) compared with the non-operative group (mean = 50).

Conclusion: Operative treatment of multiple ligament injuries, particularly fixation of avulsions and primary reconstruction of the posterior cruciate ligament appears to yield better results than non-operative or simple repair in the long term follow-up in this group with significant knee injuries.

The purpose of the study was to ascertain whether there were benefits from surgical treatment of acetabular fractures within 3 days of injury, as opposed to within a 2–3 week time period as stated in the current literature.

This is a matched-pair, retrospective study, using prospectively entered data from 2 trauma units’ databases, of patients with acetabular fractures treated operatively between 1991 and 1996. Patients were matched for age, acetabular fracture pattern and associated injuries. One group of patients had surgery within 3 days of injury (median time to surgery 1. 5 days), the other group had surgery at 4 or more days post-injury (median 8 days, range 4–19 days). There were 128 patients, 64 per group.

The proportion of patients with complications was higher in the later surgery group (relative risk 2. 1, CI 0. 24–0. 87). Median lengths of stay were significantly shorter in the early surgery group, 11 days compared to 22 days (p< 0. 001 Mann-Whitney-U test). The rate of HO in the early surgery group was 2% compared with 14% in the later surgery group. The rate of good or excellent results was 81% in patients with earlier surgery, and 72% in the later surgery group, in those with median follow-up time of 24 months.

Surgery for acetabular fractures can and should be undertaken as soon as possible. In the setting of our Trauma Units, this seems to confer lower risks of early and late complications, shorter inpatient stay and may improve long-term outcome.

Reamed intramedullary nailing was carried out on 57 Gustilo grade-IIIB tibial fractures in 55 patients. After debridement, there was substantial bone loss in 28 fractures (49%). The mean time to union was 43 weeks (14 to 94). When there was no bone loss, the mean time to union was 32 weeks; it was 45 weeks if there was bone loss. Fractures complicated by infection took a mean of 53 weeks to heal. Revision nailing was necessary in 13 fractures (23%) and bone grafting in 15 (26%). In ten fractures (17.5%) infection developed, in four within six weeks of injury and in six more than four months later. Of these, nine were treated successfully, but one patient required an amputation because of osteomyelitis.

Our results indicate that reamed intramedullary nailing is a satisfactory treatment for Gustilo grade-III tibial fractures.