What’s New in Orthopaedic Trauma中文翻译.pdf

The PDF of the article you requested follows this cover page This is an enhanced PDF from The Journal of Bone and Joint Surgery 2009 91 2055 2066 doi 10 2106 JBJS I 00573 J Bone Joint Surg Am Andrew H Schmidt and A Alex Jahangir What s New in Orthopaedic Trauma This information is current as of March 22 2011 Reprints and Permissions Permissions link and click on the Reprints andjbjs orgarticle or locate the article citation on to use material from thisorder reprints or request permissionClick here to Publisher Information www jbjs org 20 Pickering Street Needham MA 02492 3157 The Journal of Bone and Joint Surgery Specialty Update What s New in Orthopaedic Trauma By Andrew H Schmidt MD and A Alex Jahangir MD The treatment of musculoskeletal trauma continues to evolve at a rapid pace with ongoing advances in our understanding of the pathophysiology of trauma and the biology of fracture healing and the soft tissue response to injury the continual introduction of new implants and surgical techniques and clarifi cation of the role of nonoperative treatment of certain injuries The current emphasis on evidence based manage ment continues with the orthopaedic literature containing an increasing number of randomized clinical trials meta analyses and systematic reviews For the purpose of summarizing advances in orthopae dic traumatology within the past year we reviewed all issues of The Journal of Bone and Joint Surgery American Volume and British Volume Journal of Orthopaedic Trauma Journal of Trauma Clinical Orthopaedics and Related Research and Injury Selected articles from other journals were also included Fi nally presentations from the annual meetings of the Ortho paedic Trauma Association OTA and the American Academy of Orthopaedic Surgeons AAOS were reviewed All articles and presentations that represent Level I and II evidence are reviewed herein along with other articles of clinical impor tance in the opinion of the authors Fracture Healing Research on fracture healing can be broadly grouped into two areas biophysical stimulation of fractures and the use of growth factors and other bioactive peptides to promote heal ing With respect to biophysical stimulation several recent studies have evaluated the effect of low intensity pulsed ul trasound therapy and electromagnetic stimulation on fracture healing First an in vitro study demonstrated that alkaline phosphatase activity osteocalcin secretion the expression of osteoblast related genes and the mineralization of human fracture hematoma derived progenitor cells were signifi cantly higher when low intensity pulsed ultrasound was applied to human fracture hematoma1 Two systematic reviews of the use of low intensity pulsed ultrasound for the treatment of acute fractures were published during the last year with somewhat confl icting results One review concluded that low intensity pulsed ultrasound accelerated healing particularly at the sites of acute fractures of the tibia and radius that were treated nonoperatively with cast immobilization2 The second review3 noted that three trials showing a benefi t of low intensity pulsed ultrasound at the sites of fresh fractures were of low quality whereas one study of moderate quality showed no benefi t for the treatment of fresh fractures of the clavicle4 The authors of the latter review noted that the current literature regarding low intensity pulsed ultrasound is of low quality and provides confl icting conclusions and concluded that large clinical trials evaluating patient centric outcomes are needed3 Finally a meta analysis evaluating the use of electromagnetic stimulation in long bone lesions demonstrated that the cur rent evidence neither supports nor refutes the benefi ts of electromagnetic stimulation therapy5 There is great interest in the use of peptides to promote the healing of problematic fractures Two bone morphogenetic proteins are currently available in the United States rhBMP 2 INFUSE Medtronic Sofamor Danek Memphis Tennessee and rhBMP 7 OP 1 Stryker Biotech Hopkinton Massachu setts A third potential source of bioactive proteins is platelet rich plasma which can be obtained from the patient s own blood A randomized clinical study in which rhBMP 7 was compared with platelet rich plasma for the treatment of fracture nonunion demonstrated that patients managed with rhBMP 7 had greater union rates than those managed with platelet rich plasma 86 7 compared with 68 3 p 0 016 6 A series of four cases highlighted the potential devel opment of substantial heterotopic ossifi cation following use of BMPs7 Bone void fi llers are also commonly used Several recent studies demonstrated that calcium phosphate bone cement is superior to autogenous bone graft for the fi lling of subarticular Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies COMSS of the American Academy of Orthopaedic Surgeons Disclosure The authors did not receive any outside funding or grants in support of their research for or preparation of this work One or more of the authors or a member of his or her immediate family received in any one year payments or other benefi ts in excess of 10 000 or a commitment or agreement to provide such benefi ts from a commercial entity Synthes USA Smith and Nephew Inc and Twin Star Medical Inc 2055 COPYRIGHT 2009BYTHEJOURNAL OFBONE ANDJOINTSURGERY INCORPORATED J Bone Joint Surg Am 2009 91 2055 66 ddoi 10 2106 JBJS I 00573 cavitary defects in patients with unstable tibial plateau frac tures resulting in signifi cantly less subsidence and reducing the risk of loss of reduction8 9 Outcomes The Lower Extremity Assessment Project LEAP study group reported several new fi ndings from their large observational study of patients with limb threatening lower extremity trauma10 First the patients had a large number of complica tions including wound infections nonunion wound necrosis and osteomyelitis Nonunion 31 5 and wound infection 23 2 were the most common complications in the salvage group whereas wound infection 34 was the most common complication in the primary amputation group Furthermore the late amputation group had the highest complication rate 68 mostly due to wound infection Another report indi cated that no injury severity scoring system was predictive of functional recovery in patients with successful limb recon struction after high energy trauma to the lower extremity therefore caution should be employed when using these scores to predict potential recovery from injury11 Finally it was noted that physical function pain and the presence of depression were the factors that were most predictive of patient satisfac tion two years after a high energy lower extremity injury In terestingly no information that was known preoperatively such as patient demographic factors injury type or severity or treatment characteristics could be used to predict patient satisfaction two years after the injury12 Several studies evaluated the impact of musculoskeletal trauma on patients and their families A review of 1290 pa tients with orthopaedic injuries indicated that self reported pain related disability in the week before the injury not fi nishing high school pain at the time of discharge from acute care and being eligible for compensation were predictors of moderate or severe pain six months after the injury13 An other study explored ethnic differences in the risk of post traumatic stress disorder and demonstrated that Hispanic patients who sustained musculoskeletal injury were nearly seven times more likely to demonstrate symptoms of post traumatic stress disorder than were white patients14 Finally a survey of caregivers to patients with musculoskeletal injuries demonstrated that a majority of the caregivers themselves experienced stress fi nancial drain and employment diffi culties emphasizing the importance of referring both pa tients and caregivers to the appropriate services to further improve outcomes15 A study that was performed to evaluate when patients had recovered suffi ciently to drive an automobile after lower extremity fracturesshowed that apatient sbraketravel time an indicator of one s ability to operate the foot controls of a car returned to baseline levels six weeks after weight bearing had begun whichwas typically twelveweeks for patients with long bone injuries and eighteen weeks for those with articular fractures16 Infection Two studies evaluated risk factors for surgical site infection with methicillin resistant Staphylococcus aureus in patients with orthopaedic trauma One study demonstrated that methicillin resistant Staphylococcus aureus carrier status at the time of admission hip fracture and advancing age with a 1 8 increase in relative risk per year were associated with higher rates of such infection17 A large case control study demonstrated that vascular disease chronic obstructive pul monary disease being admitted to an intensive care unit having an open wound and increased age were risk factors for the development of a deep infection with methicillin resistant Staphylococcus aureus at the surgical site18 An interesting study identifi ed evidence of bacterial DNA in 42 of fracture callus specimens without evidence of anyotherdeep tissue colonization actual bacteriawereisolated in 14 of specimens from healing fractures and 35 of specimens from nonhealing fractures19 The bacterial DNAwas very similar to strains commonly found on the skin of the foot Although additional research is needed this fi nding raises the possibility that the source of unexpected infection complicat ing fracture healing and reconstructive orthopaedic proce dures may be the patient s own skin Finally the value of C reactive protein levels in diag nosing infection after internal fi xation was studied20 In all patients C reactive protein levels increased after surgery and peaked on the second postoperative day after which levels decreased In uncomplicated cases C reative protein levels continually decreased whereas in cases complicated by infec tion a secondary elevation in C reative protein level was noted beginning on the fourth postoperative day A C reactive pro tein value of 96 mg L on the fourth postoperative day was found to be predictive of infection20 Polytrauma The timing of fi xation of fractures is an important variable affecting the outcome for patients with polytrauma An ob servational study of patients with multisystem trauma dem onstrated an approximately 50 reduction in mortality risk when defi nitive fi xation of a femoral shaft fracture was delayed at least twelve hours after the injury as compared with treat ment during the fi rst twelve hours after admission21 Also increases in the levels of the proinfl ammatory cytokines interleukin 6 IL 6 and interleukin 8 IL 8 after the fi xation of pelvic and acetabular fractures appear to be related to the magnitude of the operation as the levels were related to the degree of blood loss rather than the duration of surgery itself 22 Greater increases in IL 6 and IL 8 levels were seen in patients who were operatively managed early within one or two days Both of these fi ndings support the current concept that in the setting of multiple trauma optimization of the patient s con dition is an important determinant of outcome and even relatively short delays may allow for better resuscitation of the patient and improved outcome 2056 THEJOURNAL OFBONE therefore in addition to elderly patients with low energy fractures patients with heart failure should have screening and treatment for osteoporosis Unfortunately identifi cation of at risk patients does not mean that treatment is initiated current evidence suggests that many patients are not appropriately referred for screening after fracture A study of 23 146 postmenopausal women who sus tained a hip fracturedemonstrated that only 6 were managed with bisphosphonate treatment after the injury and that only 41 of these patients continued to receive the medication at twelve months25 A prospective study demonstrated that more patients were managed with pharmacologic treatment of os teoporosis when the assessment was initiated by the ortho paedic surgeon and follow up was conducted in a specialized orthopaedic osteoporosis clinic than was the case when pa tients were referred to their primary care physician for oste oporosis management 58 compared with 29 26 Finally a cost decision model showed that tertiary care centers that hire an osteoporosis coordinator to identify patients with fragility fractures and to coordinate their care could reduce the inci dence of hip fractures and could save the hospital money if as few as 350 patients were managed annually27 Pediatric Fractures Recent studies have recommended early defi nitive fi xation of supracondylar humeral fractures in children A systematic re view of Gartland type III supracondylar fractures demon strated that the rate of failure of closed reduction and conversion to open reduction was signifi cantly higher 23 compared with 11 when treatment was delayed by more than twelve hours28 Furthermore a review of children with closed low energy supracondylar fractures without vascular compromise who subsequently had development of com partment syndrome demonstrated that 90 of the patients had severe swelling of the elbowat the time of presentation and that all had a mean delay of twenty two hours before treat ment emphasizing that early reduction reduces the risk of subsequent compartment syndrome29 Clavicular Fractures Whetheror not to repairclavicular fractureshas been a topicof interest in previous years with the focus on identifying which fractures and patients benefi t from surgery Two studies evaluated outcomes following intramedullary nail fi xation of the clavicle with a titanium elastic nail inserted through the medial aspect of the clavicle The fi rst study was a retrospective review of thirty one cases in which there was a 100 union rate and excellent cosmetic and functional results although protrusion of the nail occurred in seven cases requiring shortening of the nail in fi ve patients30 Open reduction was required in half of the cases and the nails were removed from all but two of the patients The second study was a randomized clinical trial of sixty adult patients in which titanium elastic nailing was compared with nonoperative management31 All fractures in the titanium elastic nailing group healed whereas the nonoperative group had a 10 nonunion rate Two pa tients in the nonoperative group underwent subsequent sur gery to correct a symptomatic malunion Outcome and disability scores favored the titanium elastic nailing group even at the time of the two year follow up although the greatest differences were seen in the fi rst eighteen weeks Finally pa tients in the titanium elastic nailing group had less shortening and were more satisfi ed with their cosmetic appearance and the overall outcome Proximal Humeral Fractures A matched control series of displaced greater tuberosity frac tures defi ned as those with 5 mm of displacement that were treated operatively revealed a 100 union rate with 80 of the patients having a good to excellent functional outcome score these results were signifi cantly better than those for patients who had been managed nonoperatively32 A retro spective study of forty elderly patients with three and four part proximal humeral fractures demonstrated that open reduction and internal fi xation with a locked plate was associated with better clinical results as compared with a technically optimal hemiarthroplasty and the authors noted that it should be considered as a viable option for the treatment of these frac tures33 A retrospective series emphasized the technical diffi culties and complications encountered in association with the use of angular stable locking plates34 Although the patients in that series had a 95 rate of fracture union only half of the patients had a good or excellent result 33 had failure of reduction and fi xation and 21 had development of humeral head osteonecrosis The majority of these complications oc curred in patients older than sixty fi ve years of age with type C fractures 2057 THEJOURNAL OFBONE the mean age of the patients was sixty eight years and the mean duration of follow up was 3 7 years Most injuries were four part fractures or fracture dislocations Complications related to tuberosity healing occurred in 11 of the cases Although most patients had no or mild pain most had marked limitation of function with an average Constant score of 57 Humeral Shaft and Elbow A prospective randomized trial comparing antegrade with retrograde locked intramedullary nailing of midshaft humeral fracturesdemonstrated that both techniques resulted in similar rates of union38 Antegrade nailing resulted in a longer time for the recovery of shoulder function whereas retrograde nailing resulted in a longer time for the recoveryof elbow function the eventual functional outcome in both groups was similar A prospective randomized trial of patients older than sixty years of age who had a displaced comminuted distal humeral fracture demonstrated that patients who were man aged with semiconstrained total elbow arthroplasty had su perior outcome scores a reduced reoperation rate comparable range of motion and more predictable outcomes as compared with those managed with open reduction and internal fi xation supporting the use of primary total elbow arthroplasty in pa tients with such fractures39 Distal Radial Fractures The ideal treatment of unstable distal radial fractures is still under investigation with closed treatment closed reduction and percutaneous pin fi xation external fi xation either bridging or nonbridging and open reduction and internal fi xation all considered to be reasonable treatment options A study of the practice patterns of younger American ortho paedic surgeons as indicated by case lists submitted to the American Board of Or