In a meta-analysis of fourteen trials (N=1901 patients) in patients with displaced hip fractures, we identified significant reductions in the risk of revision surgery with internal fixation compared to arthroplasty. A trend towards increased mortality with arthroplasty was identified.

The purpose of this study was to determine the effect of arthroplasty (hemi-arthroplasty, bipolar arthroplasty and total hip arthroplasty) in comparison to internal fixation for displaced femoral neck fractures on rates of mortality and revision surgery

Arthroplasty for displaced femoral neck fractures, in comparison to internal fixation, significantly reduces the risk of revision surgery at the cost of greater infection rates, blood loss and operative time, and a possible increase in early mortality.

Over 220,000 fractures of hip occur per year in North America representing an annual seven billion dollar cost to the health care system. Current evidence suggests internal fixation may reduce mortality risk at the consequence of increased revision rates. A large trial is needed to resolve this issue.

We searched computerized databases (MEDLINE, COCHRANE and SCISEARCH) for published clinical studies from 1969–2002 and identified additional studies through hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts and personal files. We found a non-significant trend toward an increase in the relative risk of dying with arthroplasty when compared to internal fixation (relative risk=1.27, 95% confidence interval, 0.84–1.92, p = 0.25; homogeneity p= 0.45). Arthroplasty appeared to increase the risk of dying when compared to pin and plate, but not in comparison to internal fixation using screws (relative risk= 1.75 vs 0.86, respectively, p< 0.05). Fourteen trials provided data on revision surgery (n=1901 patients). The relative risk of revision surgery with arthroplasty was 0.23 (95% confidence interval, 0.13–0.42, p = 0.0003, homogeneity p = < 0.01).

Using patient-oriented outcome measures, we examined twenty-six patients following surgical repair of clavicular nonunion. Patient satisfaction was high, and there was only a minor degree of residual disability (mean DASH score 14.5, SF-36 scores within normal range). Time from injury to surgical repair did not influence results.

Using modern, patient-oriented limb-specific outcome measures, we sought to determine the effect of time to repair on patient satisfaction following surgical fixation of nonunion of the clavicular shaft.

As measured by the DASH and SF-36, patient satisfaction was high following clavicular nonunion repair with only minor degrees of residual disability. Time to repair did not have a significant effect on outcome.

Previous reports of clavicular nonunion repair have concentrated on radiographic or surgeon-based criteria. Our study shows that successful clavicular nonunion repair effectively restores upper extremity function and general health status to near-normal levels.

We identified twenty-six patients who had undergone open reduction, internal fixation of a nonunion of the clavicular shaft. There were sixteen men and ten women, with a mean age of forty-four years (range thirty to seventy-one years). The mean duration of nonunion was 1.9 years with a range from four months to thirty-one years. All patients underwent fixation with a plate, and 73% of patients also underwent iliac crest bone grafting. Two nonunions required revision surgery for healing: twenty-four healed after the index procedure. We assessed patient outcome using standard history and physical, radiographs, and the DASH and SF-36 outcome instruments. The mean DASH score (0 = perfect, 100 = complete disability, “normal” = 10) was 14.5 (range 0 to 58), indicating good restoration of upper extremity function with mild residual disability. SF-36 scores were within the normal range. There was no significant difference in DASH or SF-36 scores between those fixed “early” (< six months) and those repaired “late” (> six months), p=0.30, p=0.78, respectively.

Using patient-oriented outcome measures, we examined twenty-six patients following surgical repair of clavicular nonunion. Patient satisfaction was high, and there was only a minor degree of residual disability (mean DASH score 14.5, SF-36 scores within normal range). Time from injury to surgical repair did not influence results.

Purpose: The purpose of this study was to compare the biomechanical behavior of locking plates to conventional plate and allograft constructs for the treatment of periprosthetic femoral fractures.

Methods: Twenty synthetic femora were tested in axial compression, lateral bending and torsion to characterize initial stiffness and stiffness following fixation of an osteotomy created at the tip of a cemented femoral component. Stiffness was tested with and without a 5mm gap. Axial load to failure was also tested. Four constructs were tested: Construct A – Synthes locked plate with unicortical locked screws proximally and bicortical locked screws distally; Construct B – Synthes locked plate with alternate unicortical locked screws and cables proximally and bicortical locked screws distally. Construct C – Zimmer cable plate with alternate unicortical non locked screws and cables proximally and bicortical non locked screws distally. Construct D – Zimmer cable plate in same fashion as construct C plus anterior strut allograft secured with cables proximally and distally.

Results: In axial compression, construct D was significantly stiffer compared with all other constructs in the presence of a gap, with no differences between groups without a gap. For lateral bending stiffness, construct D was significantly stiffer than the other groups with and without a gap. In torsional testing, construct D was significantly stiffer than all other constructs in the presence of a gap. With no gap, construct D was significantly stronger than construct B. There were no significant differences between constructs A and B in all testing modalities. Axial load-to-failure ranged from 5561.5 to 6700.2 N. There were no significant differences in axial load to failure.

Conclusions: This study suggests that a single locked plate does not provide the same initial fixation stiffness as a plate-allograft strut construct in the setting of a gapped osteotomy. This may be particularly important in the setting of a comminuted fracture or with bone loss. In these settings, a construct with a lateral plate and an allograft strut placed anteriorly at 90 degrees to the plate, may be optimal.

We report preliminary results from the first, multicenter prospective study designed to define the incidence of symptomatic (Venous Thromboembolism) VTE in patients with isolated leg fractures distal to the knee. Eight hundred and twenty-six enrolled patients have completed three months of follow up. By three months, only seven patients had sustained a symptomatic VTE with no fatal PE. Symptomatic and fatal VTE were infrequent complications after isolated leg fractures distal to the knee without thromboprophylaxis. Routine thromboprophylaxis may not be warranted in isolated leg fractures distal to the knee.

To report results from the first, multicenter prospective study designed to define the incidence of symptomatic Venous Thromboembolism (VTE) in patients with isolated leg fractures distal to the knee.

Symptomatic and fatal VTE are infrequent complications after isolated leg fractures distal to the knee without thromboprophylaxis.

Routine thromboprophylaxis may not be warranted in isolated leg fractures distal to the knee.

From August 2002 to April 2004, one thousand eight hundred and eight consecutive patients with isolated leg fractures distal to the knee were screened for entry at five hospitals in Ontario. Patients with major trauma, active cancer and previous VTE were excluded. Thromboprophylaxis was not allowed. Patients were followed prospectively for three months, with telephone calls at fourteen days, six weeks and three months. Suspected DVT and PE were investigated in a standardized manner.

Eight hundred and twenty-six enrolled patients have completed three months of follow up. The mean age was forty-five years (range sixteen to ninety-three) and 59.5% of this cohort was female. 99% of these fractures were unilateral and 97% were closed. Fractures included: fibula (38%), metatarsal (29%), phalanges (13%), calcaneus, talus or tarsal (10%), tibia (10%) and patella (7%). Only 11% of fractures were surgically treated. 88% of fractures received a cast or splint for a mean duration of 41+/− 20 days. Complete follow-up was available for 97.5% of this cohort. By three months only seven patients had sustained a symptomatic VTE (2 proximal DVT, 3 calf DVT, 2 PE) with no fatal PE-an incidence of 0.9% (95% CI 0.3 to 1.8%).

Funding: This study was funded by a research grant from Pharmacia

The purpose of this study was to evaluate trabecular bone response, at fifty-two week follow-up, to four different synthetic graft materials (CaSO4 and CaSO4 – HA/TCP composites) as compared to autograft in a canine defect model. The group with the highest HA/ TCP proportion had the greatest amount of residual graft material and total mineralized material. Increasing the proportion of HA/TCP reduces the rate of dissolution, and appears to have little effect on bone formation at long term follow-up. This study further suggests that a range of composites could be created to match the spectrum of resorption rates demanded by clinical applications.

The purpose of this study was to evaluate trabecular bone response to four synthetic graft materials (CaSO4 and CaSO4 – HA/TCP composites) as compared to autograft in a canine defect model, at long term follow-up.

Both 85% CaSO4 – 15% HA/TCP and 65% CaSO4 – 15% HA/TCP showed bone formation similar to autograft. The group with the highest proportion of HA/TCP lasted longer than the other formulations. The results suggest that increased HA/TCP proportions reduce the rates of dissolution, without compromising bone formation in the current model.

Results suggests that a range of composites could be created to match the spectrum of resorption rates demanded by clinical applications.

In this REB-approved RCT, bilateral humeral and femoral cylindrical defects were filled with one of four types of pellets with varying proportions of CaSO4 – HA/TCP, autograft bone, or left unfilled. After sacrifice at six, twelve, twenty-six or fifty-two weeks, defect sites were evaluated histologically for tissue and inflammatory response, area fractions of residual graft material, and bone ingrowth in the defects.

The area of the defect occupied by residual graft material in the group with the highest percentage of HA/TCP was greater than in other composite groups (p< 0.0001). This group contained the greatest amount of total mineralized material (graft material + bone) (p< 0.03. The extent of new bone formation increased from twelve to twenty-six weeks (p< 0.0001). Both 85% CaSO4 – 15% HA/TCP and 65% CaSO4 – 15% HA/TCP showed bone formation similar to autograft.

Funding: Research grant from Stryker Howmedica, Matwah, NJ.

Purpose: The purpose of this study was to examine how the “ideal” tibial nail insertion point varies with tibial rotation and to determine what radiographic landmarks can be used to identify the most suitable rotational view for insertion of a tibial intramedullary nail.

Methods: Twelve cadaveric lower limb specimens with intact soft tissues around the knee and ankle joints were used. A 2.0mm Kirschner wire was placed in the center of the anatomic safe zone and centered on the tibial shaft. The leg was rotated and imaged using a fluoroscopic C-arm until the K-wire was positioned just medial to the lateral tibial spine (defined as the neutral anteroposterior radiograph). The leg was then fixed and radiographs were taken in 5 degree increments by rotating the fluoroscope internally and externally (in total, a 50 degree arc). Following this a second K-wire was placed in 5 mm increments both medially and laterally and the fluoroscope rotated until this second K-wire was positioned just medial to the lateral tibial spine. Radiographs were digitized for measurements.

Results: Given the presence of a 30 degree rotational arc through which the radiograph appeared anteroposterior, it was possible to improperly translate the start point up to 15 mm. Relative external rotation of the image used for nail placement led to a medial insertion site when using the lateral tibial spine as the landmark. A line drawn at the lateral edge of the tibial plateau to bisect the fibula head correlated with an entry point that was central or up to 5 mm lateral to the ideal entry point. The use of a fibula head bisector line avoided a medial insertion point.

Conclusions: Rotation of the tibia may result in up to 15 mm of translation of the start point that may be unrecognized. Relative external rotation of the film used for nail placement leads to medial insertion sites when using the lateral tibial spine as a landmark. The fibula head bisector line can be used to avoid choosing external rotation views and thus avoid medial insertion points.

Purpose: The objective of this study is to investigate the effects of the Reamer-Irrigator-Aspirator (RIA) on fat embolism outcome, as compared to the standard AO reamer, utilizing physiologic parameters as outcome measures.

Methods: All animal procedures were approved by the Animal Care Committee. Fifteen animal experiments were completed. Following anesthesia, each pig was intubated and ventilated. Initial blood samples were analyzed for proper ventilation and acceptable baseline conditions (PaCO2 between 35–40 mm Hg). One third of the pig’s blood volume was withdrawn to simulate hemorrhagic shock. Each animal was kept in a state of hypovolemia for an hour before transfusion and resuscitation. Each pig underwent alternate assignment into either the RIA or AO group. The distal femur was exposed and reamed in a retrograde fashion, followed by cement pressurization with methylmethacrylate. Physiologic measurements included mean arterial pressure (MAP), pulmonary arterial pressure (PAP), partial pressure of arterial oxygen (PaO2), and cardiac output. Upon completion, the animals were euthanized. The data was analyzed using the SPSS statistical program.

Results: One animal in the AO group expired after cement pressurization associated with profound hypotension, pulmonary hypertension and eventual cardiac arrest. There was a statistically significant difference for PaO2 (P = 0.004), cardiac output (P = 0.002), and PAP (P = 0.005) between the AO and RIA groups. That is, by the completion of the experiment the RIA group had higher PaO2, lower PAP, and higher cardiac output measurements as compared to the AO group. There was no statistical significance between the two groups with respect to MAP (P = 0.468).

Conclusions: Using established physiologic parameters, there appears to be a difference between the standard AO reamer and the RIA in terms of fat embolism outcome. The RIA showed a more favorable outcome with respect to PAP, PaO2, and cardiac output. With its simultaneous irrigation and aspiration, the RIA may result in less intramedullary fat displacement into the systemic circulation.

We evaluated the clinical, radiographic, and functional outcome of uncemented total hip arthroplasty (THA) following vascularized fibular grafting for avascular necrosis (AVN) of the femoral head. A group of twenty-two patients who had been converted from a vascularized fibular graft to THA was compared to a similar group of twenty-two patients who had received a THA with no prior graft. The graft group was found to have worse outcomes than the control group as measured by SF-36, and WOMAC scores, as well as a hip score.

These results show that vascularized fibular grafting complicates future THA.

The Purpose of this study was to evaluate the clinical, radiographic, and functional outcome of uncemented total hip arthroplasty (THA) following vascularized fibular grafting for avascular necrosis (AVN) of the femoral head. These results indicate that functional and clinical outcome following post-graft THA is worse than outcome following THA performed as a primary intervention.

Judicious use of the vascularized fibular graft procedure is critical in order to minimize the number of graft failures and avoid the negative outcomes associated with THA after failed vascularized fibular grafting.

Twenty-six hips in twenty-two patients who had a THA following a failed vascularized fibular graft were compared to a group of twenty-three hips in twenty-two age and sex-matched patients who had received a THA with no prior graft (combined mean age: 39.0 yrs). Primary outcome measures included the SF-36 (patient-based general health assessment – total score and physical sub-component) and WOMAC (patient-based arthritis specific score) scores at matched follow up times (mean: 6.2years, range: two to fourteen years). An objective hip score was also used, as were several radiographic variables. The post-graft group had lower SF-36 final scores (p< 0.006), lower SF-36: physical function scores (p< 0.001), and lower WOMAC scores (p< 0.045) than the control group. Post-graft THA was complicated by longer operative time (p< 0.025) and greater subsidence of the femoral prosthesis (p< 0.004) compared to controls. Additionally, the post-graft group had worse hip score values (p< 0.05) than controls.

Vascularized fibular grafting is a commonly used procedure to cure or delay progression of AVN in the hip. Currently this procedure is used for young (< 40 years) patients with hip AVN who are in an early, pre-collapse stage of the disease. Although the efficacy of vascularized fibular grafting has been proven, up to 29% of grafts fail at five years and need to be converted to THA (Urbaniak et al., 1995). This study shows that THA after failed vascularized fibular grafting has a worse outcome than THA as a primary intervention. Therefore judicious use of the graft procedure is critical in order to minimize the number of graft failures and avoid the negative outcomes associated with it.

The purpose of this study was to investigate patient-based functional outcome and objectively measure strength following plate fixation of fractures of both bones of the forearm. Twenty-five subjects were clinically and radiographically reviewed. Strength of elbow flexion, extension, supination, pronation, wrist flex-ion, extension and grip were significantly reduced in the injured arm. (p< 0.01, range 62%–84% of normal). Mean (+/− SE) DASH score was 19.5 +/− 4.0 and eighty-eight percent (22/25) scored good to excellent on the Gartland-Werley scale (mean 4.04 +/− 0.91). No statistical difference in mean maximal radial bow (MRB) or location of MRB between injured and non-injured arm was found.

The purpose of this study was to investigate functional outcome and objectively measure strength following plate fixation of fractures of both bones of the forearm (BBOF).

Anatomic reduction was associated with good to excellent functional outcome. However strength of the elbow, forearm, wrist and grip were significantly reduced in the injured arm.

Despite good to excellent functional outcome following this injury, significant reduction in strength of the upper extremity should be expected, and thus is an area for potential improvement in post-operative care.

Twenty-five subjects (M/F 19/6, mean age 47.6 (range 20–71)) treated with plate fixation for fractures of BBOF were clinically and radiographically reviewed. Mean duration of follow-up was 5.7 years (range 2–13.4 y). Post-operative protocol included short-term immobilization followed by active-assisted ROM and strengthening starting between four and six weeks. Isometric muscle strength was objectively measured with the Baltimore Therapeutic Equipment work simulator (model WS-20). Strength of elbow flexion (72% of non-injured arm, p< 0.0001), elbow extension (84%, p=0.0004), forearm supination (75%, p=0.005), forearm pronation (69%, p< 0.0001), wrist flexion (81%, p=0.009), wrist extension (62%, p< 0.0001) and grip (70%, p< 0.0001) were all significantly reduced in the injured arm. Mean (+/− SE) DASH and Gartland-Werley scores were 19.5 +/− 4.0 (range 0–61) and 4.04 +/− 0.91 (range 0–15) respectively. Eighty-eight percent (22/25) scored good to excellent on the Gartland-Werley scale. No statistical difference in mean maximal radial bow (MRB) between injured and non-injured arm was found (mean +/− SE, 1.42 +/− 0.07 vs 1.58 +/− 0.05 respectively) or in location of MRB (61% vs 59%).

This study was undertaken to assess the contribution of fat embolism (FE) to the development of acute lung injury in the presence of resuscitated hemorrhagic shock. Twenty-seven NZW rabbits were randomly assigned into four groups: resuscitated hemorrhagic shock and FE (HR/FE), resuscitated hemorrhagic shock, FE, and control. FE was induced via intramedullary femoral canal pressurization using a 1–1.5 ml bone cement injection. Only HR/FE animals displayed significant proinflammatory cytokine release as compared to controls. These findings suggest that the combination of resuscitated shock with FE initiates an inflammatory response, which may lead to the development of fat embolism syndrome.

The objective of this study was to assess the contribution of fat embolism caused by intramedullary femoral canal pressurization to the development of acute lung injury in the presence of resuscitated hemorrhagic shock.

Only the animals that underwent resuscitated shock and fat embolism displayed amplified BALF proinflammatory cytokine expression.

These findings suggest that the combination of resuscitated shock with fat embolism initiates an inflammatory response, which may play a role in the development of fat embolism syndrome.

Only HR/FE BALF IL-8 and MCP-1 levels were significantly higher than controls (0.72 ng/ml vs. 0.26ng/ ml, p=0.03; 18.3 ng/ml vs. 2.0 ng/ml, p=0.01, respectively).

Twenty-seven NZW rabbits were randomly assigned into four groups: resuscitated hemorrhagic shock + fat embolism (HR/FE), resuscitated hemorrhagic shock (HR), fat embolism (FE), and control. Shock was induced via carotid bleeding for one-hour prior to resuscitation. For FE induction, the intramedullary cavity was drilled, reamed and pressurized with a 1–1.5 ml bone cement injection. Four hours later, postmortem bronchoalveolar lavage was performed through the right mainstem bronchus. Analyses of bronchoalveolar lavage fluid (BALF) of interleukin-8 (IL-8) and monocyte chemoattractant protein-1 (MCP-1) were carried out in triplicate and blinded fashion using the ELISA technique.

Our findings suggest that FE by itself does not initiate inflammatory lung injury, as there were no apparent differences between the control and FE cytokine levels. Only the HR/FE animals revealed elevated levels of pro-inflammatory cytokines in BALF. These findings are in agreement with our previous results, which displayed neutrophil activation only in the HR/FE group.

This study was undertaken to assess the contribution of pulmonary fat embolism caused by intramedullary femoral canal pressurization to the development of acute lung injury in the presence of resuscitated hemorrhagic shock. Twenty-seven NZW rabbits were randomly assigned into one of four groups: resuscitated hemorrhagic shock and fat embolism, resuscitated hemorrhagic shock, fat embolism, and control. Fat embolism was induced via intramedullary cavity with a 1–1.5 ml bone cement injection. Only the animals that underwent resuscitated shock and fat embolism displayed amplified neutrophil activation and alveolar infiltration. These findings suggest that the combination of resuscitated shock with fat embolism initiates an inflammatory response, which may play a role in the development of fat embolism syndrome.

The objective of this study was to assess the contribution of pulmonary fat embolism caused by intramedullary femoral canal pressurization to the development of acute lung injury in the presence of resuscitated hemorrhagic shock.

Only the animals that underwent resuscitated shock and fat embolism displayed amplified neutrophil activation and alveolar infiltration.

These findings suggest that the combination of resuscitated shock with fat embolism initiates an inflammatory response, which may play a role in the development of fat embolism syndrome.

CD11b mean channel florescence was only significantly elevated in the HR/FE group at two and four hours post knee manipulation. Moreover, greater infiltration of alveoli by leukocytes was only significantly higher in the HR/FE group as compared to controls.

Twenty-seven NZW rabbits were randomly assigned into one of four groups: resuscitated hemorrhagic shock + fat embolism (HR/FE), resuscitated hemorrhagic shock (HR), fat embolism (FE), and control. Hypovolemic shock was induced via carotid bleeding for one-hour prior to resuscitation. For fat embolism induction, the intramedullary cavity was drilled, reamed and pressurized with a 1–1.5 ml bone cement injection. For evaluation of neutrophil activation, blood was stained with antibodies against CD45 and CD11b and analyzed with a flow cytometer. Animals were mechanically ventilated for four hours post surgical closure. Postmortem thoracotomy was performed, and three stratified random blocks of each lung were processed for histological examination.

Our findings suggest that FE by itself does not cause lung injury, as there were no apparent differences between the control and FE animals. Only the HR/FE animals revealed a higher number of infiltrating neutrophils into alveolar spaces and greater neutrophil activation.

Fracture of the femoral head usually results from high-energy trauma, particularly motor vehicle accidents. These fractures are often associated with poor functional outcomes. SF-36 and MFA scores were obtained for twenty-five femoral head fractures. The mean SF-36 scores was 57.2 (22.6 to 82) and the mean MFA score was 37.6 (10–72). As expected the scores were negatively correlated (−0.587, p=0.005). The presence of an ipsilateral posterior acetabluar wall fracture negatively affected functional outcome. Fragment excision was associated with a higher functional outcome when compared to internal fixation. Posterior surgical approach resulted in higher scores than patients who underwent an anterior procedure.

Fracture of the femoral head is a rare but severe injury. The purpose of this study is to determine the functional outcome of and prognostic factors associated with femoral head fractures.

Acetabular wall fracture, surgical approach, and method of surgical treatment are prognostic factors of functional outcome as measured by the SF-36 and the MFA.

There is currently no consensus on the management of femoral head fractures and treatment practices have evolved on the basis of a limited series of studies. Functional outcome following femoral head fracture has been evaluated using Epstein’s criteria in several studies, however, only one study has been conducted using a validated outcome measure.

Twenty-five femoral head fractures in twenty-four patients were identified from the trauma and orthopaedic databases of two major trauma centres. The patient with bilateral femoral head fractures was not included in the analysis. After obtaining informed consent, the patients’ medical records were reviewed. Functional outcome was assessed using two validated, patient-based outcome measures, the Short Form (SF)-36 and the Musculoskeletal Functional Assessment instrument (MFA). The average age of the patients was 36.8 (std. dev. 11.1) and the mean length of follow-up was 41.4 months (minimum twelve months). Three factors were identified using non-parametric analysis that significantly affected the functional outcome scores:

The presence of an ipsilateral posterior acetabluar wall fracture negatively affected functional outcome (p=0.08).

5207 patients treated for a calcaneous fracture in Ontario between 1993–1999 were identified from population datasets and were reviewed to evaluate regional practice variation and complication rates for operatively and non-operatively managed calcaneous fractures. There was considerable geographic variation in treatment. Individuals in some parts of Ontario were almost eight times more likely to receive operative treatment than others. The majority of calcaneous fractures in Ontario are treated non-operatively, however the large observed practice variation suggests that there is disagreement among treating clinicians. Primary subtalar fusion has a high risk of post-operative infection and should therefore be considered very cautiously.

The purpose of this study was to evaluate regional practice variation and complication rates for operatively and non-operatively managed calcaneous fractures.

The majority of calcaneous fractures in Ontario are treated non-operatively, however the large observed practice variation suggests that there is disagreement among treating clinicians. Primary subtalar fusion has a high risk of post-operative infection and should therefore be considered very cautiously.

Given the observed regional variation in management of calcaneous fractures more work needs to be done to address this issue.

5207 fractures of the calcaneous in Ontario between 1993–1999were identified from population datasets. Regional variations in treatment and complication rates were computed. Multiple linear regression was used to identify factors associated with complications.

There was considerable geographic variation in treatment. Individuals in some parts of Ontario were almost eight times more likely to receive operative treatment than others. General surgeons or general practitioners definitively treated 30% of patients (almost all closed). Overall rate of complications was low, however there was a 13.4 percent infection rate following immediate subtalar fusion. Infection was 5.3% following ORIF and 0.6% following closed treatment. Infection risk was increased in multiple trauma patients and those with open fractures. Subsequent subtalar fusion rates (within the study period) were higher in multiple trauma patients, but were not associated with treatment (open or closed). Amputation was 22.5 times more likely following open calcaneous fractures but the overall amputation rate was only 0.17%. No relationship between surgeon experience and the rate of complications following operative treatment was identified.

The purpose of this study was to determine the effect of positioning (lateral vs. supine) on pulmonary pathophysiology following pulmonary contusion and fat embolism in a canine model of polytrauma. Platelet and neutrophil activation were assessed using flow-cytometry. There were no significant differences between groups in CD62P and CD11/18 MCF (markers of platelet and neutrophil activation, respectively) following fat embolism. However, only animals in the lateral position displayed significant increases in both measures as compared to baseline values. Lateral positioning may exert an early effect on proinflammatory and coagulation activation, and may play a role in the development of acute lung injury.

It has previously been suggested that acute lung injury can be influenced by patient positioning, be it lateral or supine. The purpose of this study was to determine the effect of positioning on pulmonary pathophysiology associated with concomitant pulmonary contusion and fat embolism in a canine model of polytrauma.

Twelve dogs were randomly assigned to one of two surgical positioning groups, lateral and supine. The dogs were subjected to pulmonary contusion by application of force between 200–250 N/m² for thirty seconds in three areas of one lung. Two hours later, fat embolism was induced via reaming of the ipsilateral femur and tibia and cemented nailing. Two hours later, the dogs were sacrificed. For flow-cytometric evaluation of platelet and neutrophil activation, venous blood samples were stained with fluorescence-conjugated antibodies against CD62P and CD11/18, respectively.

There were no significant differences between the groups in CD62P and CD11/18 mean channel fluorescence (MCF) following pulmonary contusion and fat embolism. However, only animals in the lateral positioning group displayed significant increases in CD62P and CD11/18 MCF at two hours following fat embolism as compared to baseline values.

Our findings suggest that lateral positioning, autoregulation and preferential blood flow to the contused non-dependent lung may render lung tissue more susceptible to congestion and lead to activation of both platelets and neutrophils. Lateral positioning may have an early effect on activation of the inflammatory and coagulation cascades and may be significant in the development of posttraumatic acute lung injury.

Little is known about the psychological morbidity associated with orthopaedic trauma. Our study aimed to determine the extent of psychological symptoms and whether patient psychological symptoms were predictive of outcomes following orthopaedic trauma. Overall, trauma patients experienced higher intensity of psychological symptoms than population norms. Psychological symptoms, patient age, and ongoing litigation predicted functional outcomes. Patients may benefit from early interventions by social workers and psychologists to process their psychological states post injury.

Little is known about the psychological morbidity associated with orthopaedic trauma.

Our study aimed to determine the extent of psychological symptoms and whether patient psychological symptoms were predictive of outcomes following orthopaedic trauma.

All patients attending ten orthopaedic fracture clinics at three University-affiliated Hospitals were approached for study eligibility. All consenting patients would be requested to complete a baseline assessment form, a 90-item symptom checklist-90R (SCL-90R), and the Short-Form–36. The SCL-90R constitutes nine dimensions (Somatization, Obsessive-compulsive, Interpersonal sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation, Psychoticism) and three global indices (Global severity index, Positive symptom distress index, positive symptom total). We conducted regression analyses to determine predictors of quality of life among study patients.

Of two hundred and fifteen patients, 59% were male at a mean age of 44.5 years. Over half of patients had lower extremity fractures. Trauma patients experienced greater psychological symptoms than population norms. Overall, trauma patients experienced higher intensity of psychological symptoms than population norms. Patient functional outcomes were predicted by patient age, ongoing litigation, and Positive Symptom Distress. This model predicted 21% of the variance in patient function. Patient somatization was an important psychological symptom resulting in increasing intensity of symptoms. Smoking, alcohol, open fracture, surgeons’ perception of technical outcome, level of education, and time since injury were not predictive in this model.

Psychological symptoms, patient age, and ongoing litigation predicted functional outcomes. Patients may benefit from early interventions by social workers and psychologists to process their psychological states post injury.

Funding: This study was funded in part by research grants from AO North America and Regional Medical Associates, McMaster University. Dr. Bhandari was funded, in part, by a 2004 Detweiler Fellowship, Royal Colleges of Physicians and Surgeons of Canada. Dr. Busse is funded by a Canadian Institutes of Health Research Fellowship Award.

This study investigated the effect presence, method, and timing of fixation of femoral shaft fractures have on the morbidity and mortality of patients with pulmonary contusion.

In the multiply-injured patient with femoral shaft fractures, early (< 24 hours) fracture stabilization with closed, reamed, statically-locked intramedullary nailing has been shown to decrease morbidity and mortality. Controversy exists as to whether such treatment compromises the outcome in patients that have significant co-existing pulmonary injury. This study is the first to specifically investigate the sub-group of patients that have pulmonary contusion.

A retrospective review of patients presenting to a Level One trauma center from 1990 to 2002 with pulmonary contusion identified three hundred and twenty-two cases. Patient characteristics of age, sex, GCS, ISS, AIS, presence of femoral shaft fracture, method and timing of treatment of femoral shaft fracture, and presence of other pulmonary injuries were recorded, as were the outcomes of pulmonary complications (acute lung injury (ALI), ARDS, fat embolism syndrome, pulmonary embolism, and pneumonia), days on ventilatory support, days in the intensive care unit and ward, and death.

There were no significant differences in the patient characteristics between groups with and without femoral shaft fracture. Except for an increased likelihood of the femoral shaft fracture group having ALI (RR 1.11), there were no significant differences in outcomes between the femur fracture/non-femur fracture groups. As well, there were no significant differences in outcomes between the groups that had fracture fixation before or after twenty-four hours or had the fracture fixed with or without intramedullary nailing.

The presence, method, and timing of treatment of femoral shaft fractures do not increase the morbidity or mortality of trauma patients that have pulmonary contusion.

Purpose: Endoprosthetic reconstruction of the distal femur is the preferred approach for patients undergoing resection of bone sarcomas. The traditional How-medica Modular Resection System, using a press-fit stem (HMRS or Kotz prosthesis, Stryker Orthopaedics, Mahwah, New Jersey, USA) has shown good long-term clinical success, but has also been known to incur complications such as stem fracture. The Restoration stem, as a part of the new Global Modular Resection System (GMRS, Stryker Orthopaedics, Mahwah, NJ, USA), is currently proposed for this same application. This stem has a different geometry and provides the advantage of decreased risk of fracture of the component. The goal of this study was to compare the HMRS and Restoration press-fit stems in terms of initial mechanical stability.

Methods: Six matching pairs fresh frozen adult femora were obtained and prepared using a flexible canal reamer and fitted with either a Restoration or HMRS press-fit stem distally. All constructs were mechanically tested in axial compression, lateral bending, and torsion to obtain mechanical stiffness. Torque-to-failure was finally performed to determine the offset force required to clinically fail the specimen by either incurring damage to the femur, the stem, or the femur-stem interface.

Results: Restoration press-fit stems results were: axial stiffness (average=1871.1 N/mm, SD=431.2), lateral stiffness (average=508.0 N/mm, SD=179.6), and torsional stiffness (average=262.3 N/mm, SD=53.2). HMRS stems achieved comparable levels: axial stiffness (average=1867.9 N/mm, SD=392.0), lateral bending stiffness (average=468.5 N/mm, SD=115.3), and torsional stiffness (average=234.9 N/mm, SD=62.4). For torque-to-failure, the applied offset forces on Restoration (average=876.3 N, SD=449.6) and HMRS (aver-age=690.5 N, SD=142.0) stems were similar. There were no statistical differences in performance between the two stem types regarding axial compression (p=0.97), lateral bending (p=0.45), or torsional stiffnesses (p=0.07). Moreover, no differences were detected between the groups when tested in torque-to-failure (p=0.37). The mechanism of torsional failure for all specimens was “spinning” (i.e. surface sliding) at the femur-stem interface. No significant damage was detected to any bones or stem devices.

Conclusions: These results suggest that the Restoration and HMRS press-fit stems may be equivalent clinically in the immediate post-operative situation. Funding: Commerical funding Funding Parties: Stryker Orthopaedics

Fifty-five patients undergoing isolated acetabular revisions in fifty-seven hips were available for review. In thirty-three of fifty-seven hips there was no significant acetabular deficiency; of the remaining twenty-four hips twenty underwent allograft reconstruction and four autogenous bone grafting. Mean follow-up was four years with a range of three to seven years; there have been no femoral loosening, and three further surgical procedures for hip instability. All acetabular components at last review were soundly fixed with the exception of one patient who underwent excision arthroplasty at twelve months for deep infection.

The purpose of this study was to review the functional outcome and the fate of the femoral stem and revised acetabular component following isolated ace-tabular revision.

Findings of the current study demonstrate that isolated acetabular revision does not compromise the final functional nor radiographic outcome in acetabular revision in appropriately selected patients; the fate of the femoral component is not adversely influenced by this procedure.

There is no need to remove the femoral component at the time of acetabular revision if the femoral component is well fixed and stable by pre- and intra-operative assessment.

Prospectively entered data on fifty-seven hips (fifty-five patients) who have undergone isolated acetabular revision without femoral revision was available for review. All patients were assessed pre-operatively and post-operatively on an annual basis by means of physical examination, x-ray, SF-36 and WOMAC questionnaires.

In thirty-three of fifty-seven hips there was no significant acetabular deficiency; of the remaining twenty-four hips, one had a segmental defect, thirteen had a cavitary defect and ten had a combined segmental and cavitary defect. Osteolysis existed in the proximal femur of two hips.

Bone grafting in twenty-four hips consisted of morselized allograft in nine; combined structural and morselized allograft used in eleven and autogenous bone used in four acetabular defects. Autogenous bone grafting was done in two femoral osteolytic lesions.

Mean follow-up was four years with a range of three to seven years. The mean duration of arthroplasty prior to revision was fourteen years (range four to twenty-three years).

There were no nerve palsies, vascular injuries or intra-operative fractures in this patient group. All ace-tabular components at latest review were soundly fixed with the exception of one patient who underwent excision arthroplasty at twelve months for deep infection. Twenty-one of the twenty-four hips with bone grafting demonstrated positive radiographic signs of incorporation; the remaining threehips have a stable interface but no evidence of bone ingrowth. Three of the fifty-seven hips presented with hip dislocations after revision arthroplasty; two were managed by closed reduction; the third by open reduction and soft tissue repair.

The purpose of this study was to evaluate trabecular bone response to four different synthetic graft materials (CaSO₄ and CaSO₄ – HA/TCP composites) as compared to autograft in a canine defect model. The group with the highest HA/TCP proportion (and the lowest CaSO4 proportion) had the greatest amount of residual graft material and total mineralized material (p< 0.05). Increasing the proportion of HA/TCP reduces the rate of dissolution, and appears to have little effect on bone formation. This study suggests that a range of composites could be created to match the spectrum of resorption rates demanded by clinical applications.

Calcium sulfates and phosphates have become popular clinically for use as bone graft substitutes, however, their in-vivo performance has not been well characterized. The purpose of this study was to evaluate trabecular bone response to four synthetic graft materials (CaSO₄ and CaSO₄ – HA/TCP composites) as compared to autograft in a canine defect model.

Both 100% CaSO₄ and the 3 CaSO₄– HA/TCP formulations showed good bone formation. The group with the highest proportion of HA/TCP lasted longer than the other formulations, suggesting increased HA/TCP proportions reduce the rates of dissolution, without compromising bone formation in the current model.

Results suggests that a range of composites could be created to match the spectrum of resorption rates demanded by clinical applications.

In this REB-approved RCT, bilateral humeral and femoral cylindrical defects were filled with one of four types of pellets with varying proportions of CaSO₄ – HA/TCP, autograft bone, or left unfilled. After sacrifice at six or twelve weeks, defect sites were evaluated histologically for tissue and inflammatory response, area fractions of residual graft material, and bone ingrowth in the defects.

The area of the defect occupied by residual graft material in the group with the highest percentage of HA/TCP was greater than in other composite groups (p< 0.0006). At twelve weeks, this group contained more total mineralized material (graft material + bone) (p< 0.005). The extent of new bone formation was not different among the composite groups at either time-point, but all showed more bone formation than the empty defect.

Funding: This study was funded by a research grant from Stryker Howmedica, Matwah, NJ.

Revision hip arthroplasty does not bring to the patient the same degree of benefit as the primary operation. We compared two hundred and thirteen patients undergoing revision arthroplasty with five hundred and forty-seven patients undergoing primary total hip replacement. The complication rate in the revision arthroplasty group was approximately twice as high in the primary group (p< .05) primarily as a result of postoperative dislocation. Both groups of patients had a statistically significant improvement between their pre- and postoperative WOMAC and SF-36 physical scores; however, there was also a statistically significant difference in outcome when the two groups were compared, with primary patients having significantly improved WOMAC and SF-36 physical scores.

To compare the outcomes between primary and revision total hip arthroplasty patients at one institution with regard to demographics, complication rates and functional outcome.

Revision hip arthroplasty does not bring to the patient the same degree of benefit as does the primary operation. The reason for this is multi-factorial and includes a higher complication rate and lower functional outcome.

Further study of the problems associated with revision total hip replacement especially focused on complication rates would appear to be warranted.

All patients were entered prospectively in a database and were assessed by means of physical examination, radiographs, SF-36 and WOMAC questionnaires. Patients were followed for a minimum of two years with a range of two to five years. Patients were seen on an annual basis.

Five hundred and forty-seven patients underwent primary total hip replacement and two hundred and thirteen patients underwent revision total hip replacement. 53.4% of patients undergoing primary and 52% of patients undergoing revision arthroplasty were female. Mean age at primary hip replacement 61.8 years, revision hip replacement 67.1 years. Post-operative complication rate was 7.6% in primary patients and 14.7% in revision patients (p< .05); there was no statistically significant difference between the two groups with regard to intra-operative fracture, implant loosening or postoperative infection; there was a statistically significant difference in terms of dislocation with 0.8% of primary arthroplasties and 5.6% of revision patients sustaining at least one dislocation following their surgery (p< .01). Both groups of patients had a statistically significant improvement between their pre- and post-operative WOMAC and SF-36 physical scores (p< .0001); however, there was also a statistically significant difference in outcome when the two groups were compared with primary patients having significantly improved WOMAC scores (p< .0001) and significantly improved SF-36 physical scores (p< .0001).