Orthopaedics is an ever evolving specialty underpinned by evidence-based medicine. It is important that potential Orthopaedic ST3 candidates are familiar with the seminal orthopaedic papers that underpin clinical practice. This post will breakdown the key orthopaedic papers that you should know for the Orthopaedic ST3 interview (Table 1).
Table 1. Key Orthopaedic Papers To Know For The Orthopaedic ST3 Interview
|Neck of Femur Fractures
|Tibial Plateau Fractures
|Distal Radius Fractures
|Proximal Humerus Fractures
Ankle Fractures (Fractures of the ankle. II Combined experimental surgical and experimental-roentgenologic investigations. Lauge-Hansen N. Arch Surg 1950; 60: 957-85.)
Lauge-Hansen introduced a systematic and comprehensive classification system for ankle fractures based on the sequence of events leading to the injury. Lauge-Hansen identified specific injury mechanisms and described the various fracture patterns associated with each mechanism. The study utilised fresh lower limb specimens from patients undergoing amputation. Deforming forces were then applied by hand leading to fractures of the ankle. The specimens underwent radiological investigation and dissected to determine the pattern of bone and ligamentous injuries.
The classification system proposed by Lauge-Hansen is based on two key components: the position of the foot at the time of injury (supination or pronation) and the direction of the applied force (abduction, adduction, external rotation, or internal rotation). By combining these elements, Lauge-Hansen created a framework that allowed orthopaedic surgeons to categorize ankle fractures more precisely, enhancing both communication and treatment strategies.
The Lauge-Hansen classification has become a cornerstone in the education and understanding of ankle fractures, serving as a valuable tool for orthopaedic surgeons in their clinical practice and research endeavors. As a result, Lauge-Hansen’s work has had a lasting impact on the field of orthopaedics, contributing to improved diagnostic accuracy, treatment planning, and overall patient care in the realm of ankle injuries. Definitely, one to know for the clinical station of the Orthopaedic ST3 Interview.
Open Fractures Classification (Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analysis. Gustilo RB, Anderson JT. J Bone Joint Surg Am 1976; 58-A: 453-58.)
A key paper to know for the Orthopaedic ST3 Interview included a paper by Gustilo and Anderson, which underpins the classification of open fractures. This study was a combined retrospective and prospective study. Fractures were classified within the study into Type 1, Type 2 and Type 3. Type 3 fractures were subsequently stratified into type IIIA, IIIB and IIIC in a later paper by Gustilo (Problems in the management of type III open fractures: a new classification of type III open fractures).
Open fracture washout
The paper by Owens, White, and Wenke, titled “Comparison of irrigation solutions and devices in a contaminated musculoskeletal wound survival model,” published in the Journal of Bone and Joint Surgery (American volume) in January 2009, investigates the effectiveness of different irrigation solutions and devices in a model simulating contaminated musculoskeletal wounds. Owen’s work in Goat models underpins the use of low pressure irrigation and volume of fluid used during the washout of open fractures.
Compartment syndrome (Compartment monitoring in tibial fractures: The pressure threshold for decompression. McQueen MM, Court-Brown CM. J Bone Joint Surg Br 1996; 78-B: 99-104.)
Compartment syndrome is a clinical scenario faced by Orthopaedic ST3 interview candidates. The paper by McQueen and Court-Brown established that a Delta-P of less than 30mmHg warrants surgical decompression. The study was a prospective cohort study, which was undertaken over 2 years and 7 months. 116 patients were included, of which 3 developed compartment syndrome.
Neck of Femur Fractures (Low-Angle Fixation in Fractures of the Femoral neck. Garden RS. J Bone Joint Surg Br 1961; 43B: 647-63).
The Garden’s classification is commonly used to describe intra-capsular neck of femur fractures and is essential knowledge for those preparing for their Orthopaedic ST3 interview. It was first described by Garden in the study entitled “Low-Angle Fixation in Fractures of the Femoral neck”. Garden proposed stages, which have become the Garden’s classification. These stages were proposed as they correlate with the rate of non-union after fixation.
Tip-Apex Distance in Hip Fractures (The Value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. J Bone Joint Surg AM 1995; 77: 1058-64.)
Extra-capsular fixation of neck of femur fractures is a component of the self-assessment scoring for orthopaedic ST3 interviews. When performing a DHS surgeons aim for a tip-apex distance of less than 25mm. This 25mm value originates from a retrospective cohort study performed by Baumgaertner. 193 patients were included in the study. A logistic regression model showed TAD to be the strongest predictor of screw cut out. It was also shown that none of the cases with a of TAD <25mm cut-out.
Calcaneal fracture (UK HEEL Fracture Trial)
The HEEL (UK Heel Fracture Trial) was a study comparing two treatments for a specific type of heel fracture: closed, displaced, intra-articular calcaneal fractures. These fractures affect the joint surface of the heel bone and can be debilitating.
- Main outcome: No overall benefit of surgery compared to non-operative treatment in terms of pain and function at two years after injury.
- Subgroup analysis: Some groups of patients, such as those with severe deformities or younger individuals, seemed to do slightly better with surgery. However, these benefits were statistically significant but might not be clinically significant in real-world practice.
- Limitations: Relatively small sample size and one surgeon performing most surgeries, potentially limiting generalizability of findings.
- Overall: The HEEL trial challenged the previously held belief that surgery was always the best option for these fractures. It suggests that, for many patients, non-operative treatment can be just as effective, with fewer risks and complications. However, careful evaluation and consideration of individual patient factors are still crucial for guiding treatment decisions.
Tibial Plateau Classification (The tibial plateau fracture. The Toronto experience 1968-1975. Shatzker J, McBroom R, Bruce D. Clin Orthop Relat Res 1979; 138: 94-104)
The aim of this study was to characterise the nature of tibial plateau fractures and to determine the ideal treatment (conservative vs. operative) for a variety of different fracture patterns. 94 patients were included in the trial. The classification system used in this article to describe included patients is still commonly used today.
SWIFFT Trial Summary: Cast vs. Surgery for Broken Wrist Bones
The SWIFFT (Scaphoid Waist Internal Fixation for Fractures Trial) was a large, well-designed study that compared two treatments for a common type of wrist fracture:
- Early surgery with internal fixation: Using screws or pins to hold the broken bone fragments together.
- Cast immobilization: Wearing a below-elbow cast for six weeks to allow the bone to heal naturally.
Patients: 439 adults with a minimally displaced fracture of the scaphoid waist were included in the study. The main findings were:
- No significant difference in long-term outcomes: The SWIFFT trial found little difference in pain, grip strength, or wrist movement between the surgery and cast groups after one year. Both treatments offered similar relief from symptoms and restoration of function.
- Surgery did not provide clear benefits: While some patients in the surgery group had faster resolution of pain and earlier return to work, these benefits were often small and not consistent across all individuals.
- Cast may be preferred in many cases: Given the potential risks and complications of surgery (pain, stiffness, infection), the study suggests that cast immobilization is a safe and effective treatment option for most people with this type of fracture.
DRAFFT Trial – Distal Radius Fractures
DRAFFT (Distal Radius Acute Fracture Fixation Trial):
- Compared K-wire fixation with locking-plate fixation for dorsally displaced fractures.
- Found no significant difference in wrist function or quality of life at one year, but K-wire fixation was quicker and less invasive.
- Concluded that both treatments are effective, with K-wire being a suitable alternative for selected patients.
DRAFFT 2 (Distal Radius Acute Fracture Fixation Trial 2):
- Compared surgical fixation with K-wires and cast + manipulation to casting alone for dorsally displaced fractures.
- Found no significant difference in wrist function or quality of life at one year, but 12% of the cast group required surgery later due to bone displacement.
- Concluded that casting is as effective as surgery for most patients, with surgery reserved for those with high risk of bone displacement.
PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) Trial Summary
The PROFHER trial was a landmark study comparing two treatment options for displaced proximal humerus fractures (upper arm fractures) in adults:
- Surgery: Open reduction and internal fixation (ORIF) to reposition and stabilize the broken bone fragments with plates and screws.
- Non-surgical treatment: Immobilization with a sling and physiotherapy to promote healing without surgery.
- No significant difference in overall patient-reported outcomes: After two years, both surgical and non-surgical groups reported similar levels of pain, function, and quality of life.
- Subgroup analysis: Some patient groups, like those with severe fractures or younger individuals, seemed to do slightly better with surgery in terms of pain and range of motion. However, these benefits were small and may not be clinically significant for everyone.
- Cost-effectiveness: Non-surgical treatment was significantly cheaper due to fewer complications and shorter hospital stays.