Augmentation of Fracture Repair: Is Anything Ready for Prime Time?

There continues to be a significant burden of disease associated with the delayed healing of common fractures. Despite a number of trials focused on the augmentation of fracture repair, management remains controversial and evidence regarding cost-effectiveness is lacking. The recent evidence that has challenged traditional thinking regarding management of fracture healing problems will be evaluated.

High-Energy Midfoot Fracture-Dislocations: Staged Treatment With an External Fixator.

The purpose of this study was to analyze the clinical outcomes of patients treated for high-energy midfoot (Lisfranc) injuries with initial temporization of an external fixator before definitive fixation. A retrospective chart review at two level 1 trauma centers was completed. Clinical parameters including demographics and comorbidities were evaluated in addition to hospital and clinical data. Time to full weight bearing took an average of 4.4 months, and with the numbers available no significant difference (p < .05) was found between the open reduction and internal fixation (ORIF) group and the arthrodesis group in regard to length of stay, days from initial reduction with an external fixator to definitive fixation, time to full weight bearing, or return to work. Staged treatment of high-energy Lisfranc injuries with external fixation demonstrated minimal soft tissue complications similar to other series reported in the literature. Definitive stabilization with either ORIF or arthrodesis produced similar results in staged treatment of these injuries. (Journal of Surgical Orthopaedic Advances 28(1):24-30, 2019).

How High Can You Go?: Retrograde Nailing of Proximal Femur Fractures.

There are no data-supported recommendations on how proximal is too proximal for retrograde nailing (RGN). At six level 1 trauma centers, patients with femur fractures within the proximal one-third of the femur treated with RGN were included. This article describes a proximal segment capture ratio (PSCR) and nail segment capture ratio to evaluate RGN of proximal fractures. The study included 107 patients. The average follow-up was 44 weeks. There were two nonunions and three malunions. There was no significant difference between PSCR of 0.3 or less and need for secondary procedures or time to full weight bearing (p>.05). In this study, a smaller (< 0.3) PSCR was not associated with an increased number of complications. A higher Orthopaedic Trauma Association classification was predictive of malunion and increased time to union. These data demonstrate that retrograde nailing is safe and effective for the treatment of supraisthmal femur fractures.

Surgical Exposure Trends and Controversies in Extremity Fracture Care.

Surgical exposures for the management of extremity fractures continue to evolve. Strategies to achieve satisfactory articular reconstitution require surgeons to have an appreciation and understanding of various conventional and contemporary surgical approaches. The recent literature has witnessed a surge in studies on surgical approaches for the fixation of extremity fractures. This increased interest in surgical exposures resulted from not only a desire to enhance outcomes and minimize complications but also a recognition of the inadequacies of traditionally accepted surgical exposures. Contemporary exposures may be modifications or combinations of existing exposures. All surgical exposures require proper surgical execution and familiarity with regional anatomic structures. Exposures, whether conventional or contemporary, must provide sufficient access for reduction and implant insertion. Proper exposure selection can greatly enhance a surgeon's ability to achieve acceptable reduction and adequate fixation. Unique characteristics of both the patient and his or her fracture pathoanatomy may dictate the surgical approach. Patient positioning, imaging access, and concomitant comorbidities (medical, systemic trauma, and regional extremity related) also must be considered. Minimally invasive methods of reduction and fixation are attractive and have merit; however, adherence to them while failing to achieve satisfactory reduction and fixation will not generate a desirable outcome. Surgeons should be aware of several site-specific anatomic regions in which evolving surgical exposures and strategies for extremity fracture management have had favorable outcomes.

Orthobiologics in the augmentation of osteoporotic fractures.

Many orthobiologic adjuvants are available and widely utilized for general skeletal restoration. Their use for the specific task of osteoporotic fracture augmentation is less well recognized. Common conductive materials are reviewed for their value in this patient population including the large group of allograft adjuvants categorically known as the demineralized bone matrices (DBMs). Another large group of alloplastic materials is also examined-the calcium phosphate and sulfate ceramics. Both of these materials, when used for the proper indications, demonstrate efficacy for these patients. The inductive properties of bone morphogenic proteins (BMPs) and platelet concentrates show no clear advantages for this group of patients. Systemic agents including bisphosphonates, receptor activator of nuclear factor κß ligand (RANKL) inhibitors, and parathyroid hormone augmentation all demonstrate positive effects with this fracture cohort. Newer modalities, such as trace ion bioceramic augmentation, are also reviewed for their positive effects on osteoporotic fracture healing.

Advances in the understanding and treatment of musculoskeletal infections.

Musculoskeletal infections are a challenging treatment problem for orthopaedic surgeons. Despite advances in aseptic techniques and improved chemotherapeutic options, there has not been a substantial decrease in the incidence of musculoskeletal infections for the past quarter century. Understanding how microbes gain a foothold in tissue and bone and establish a chronic infectious state is imperative to the successful treatment of bone and soft-tissue infections. The methodic establishment of microbes in a sessile state in a mature biofilm represents the basis for instituting a chronic microbial defense system and sustainability in a host. To properly eradicate such infections requires a stepwise treatment algorithm of meticulous and thorough débridement, dead-space management, and soft-tissue and bone reconstruction. A comprehensive understanding of the reconstruction ladder combined with a detailed treatment plan from the initial staging of an infection through final reconstruction can cure an infection and achieve good functional results for patients.

Complex trauma to the shoulder girdle, including the proximal humerus, the clavicle, and the scapula: current concepts in diagnosis and treatment.

Fractures to the shoulder girdle are common injuries in an aging population. Many techniques and theories lie behind the treatment of such injuries. Knowledge and understanding of current concepts for diagnosing and treating proximal humeral, clavicular, and scapular fractures and the theory behind them will help surgeons make informed decisions with regard to patient care.

Ipsilateral proximal femur and shaft fractures treated with hip screws and a reamed retrograde intramedullary nail.

BACKGROUND: Although not common, proximal femoral fractures associated with ipsilateral shaft fractures present a difficult management problem. A variety of surgical options have been employed with varying results. QUESTIONS/PURPOSES: We investigated the use of hip screws and a reamed retrograde intramedullary (IM) nail for the treatment of this combined fracture pattern in terms of postoperative alignment (malunion), nonunion, and complications. METHODS: Between May 2002 and October 2011, a total of 95 proximal femoral fractures with associated shaft fractures were treated at three participating Level 1 trauma centers; all were treated with hip screw fixation (cannulated screws or sliding hip screws) and retrograde reamed IM nails. The medical records of these patients were reviewed retrospectively for alignment, malunion, nonunion, and complications. Followup was available on 92 of 95 (97%) of the patients treated with hip screws and a retrograde nail. Forty were treated with a sliding hip screw, and 52 were treated with cannulated screws. RESULTS: There were five proximal malunions in this series (5%). The union rate was 98% (90 of 92) for the femoral neck fractures and 91.3% (84 of 92) for the femoral shaft fractures after the initial surgery. There were two nonunions of comminuted femoral neck fractures after cannulated screw fixation. There was no difference in femoral neck union or alignment when comparing cannulated screws to a sliding hip screw. Four open comminuted femoral shaft fractures went on to nonunion and required secondary surgery to obtain union, and one patient developed symptomatic avascular necrosis. CONCLUSIONS: The treatment of ipsilateral proximal femoral neck and shaft fractures with hip screw fixation and a reamed retrograde nail demonstrated a high likelihood of union for the femoral neck fractures and a low risk of malunion. Comminution and initial displacement of the proximal femoral fracture may still lead to a small incidence of malunion or nonunion, and open comminuted femoral shaft fractures still may progress to nonunion despite appropriate surgical management. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

End-stage hindfoot arthrosis: outcomes of tibiocalcaneal fusion using internal and Ilizarov fixation.

End-stage post-traumatic pantalar arthrosis from ankle, pilon, and talus fractures has often been complicated by infection, bone loss, and a soft tissue deficit. Patients can present with neuropathy, diabetes, tobacco use, and previously failed arthrodesis. Fusion in this population has been challenging, with nonunion rates up to 30%, often leading to amputation. We reviewed the results of a standardized protocol that combined simultaneous internal fixation with the Ilizarov technique to achieve fusion in high-risk patients. With institutional review board approval, a retrospective review of the patients treated with simultaneous internal fixation and an Ilizarov frame was undertaken. The records and radiographs allowed identification of the comorbidities and the presence or absence of successful fusion. Complications were acknowledged and treated. Fifteen patients had undergone the procedure. The mean follow-up period was 27.9 (range 9 to 67) months. Thirteen patients (86.67%) had had previous fusion failure. Twelve patients (80%) had developed post-traumatic arthrosis, 5 (33.33%) of whom had open injuries. All patients had 1 comorbidity, and 10 (66.67%) had multiple, including rheumatoid arthritis, diabetes (types 1 and 2), and smoking. Four patients (26.67%) presented with deep infection and bone loss. Union was achieved in 11 (73.33%), with 12 (80%) patients experiencing profound pain relief. Seven patients (46.67%) required symptomatic hardware removal. Three patients (20%) eventually underwent below-the-knee amputation for recalcitrant nonunion. Statistically significant correlations were found between smoking and wound infection and revision and between nonunion and amputation. Our results have indicated that combined internal fixation with Ilizarov application can provide a strong surgical option for the management of end-stage, pantalar arthritis. More studies are needed to compare the cohort outcomes and gait analysis in these patients with those who have chosen below-the-knee amputation.

CD271 as a marker for mesenchymal stem cells in bone marrow versus umbilical cord blood.

CD271 has been applied to isolate mesenchymal stem cells (MSCs) from bone marrow and other tissues. Umbilical cord blood is a unique resource of stem cells and endothelial progenitor cells. Isolation of MSCs from umbilical cord blood, however, has been inefficient and inconsistent. This study was designed to examine the potential application of CD271 as a marker for the isolation of MSCs from umbilical cord blood. CD271+ cells were isolated from umbilical cord blood and bone marrow using CD271 antibody-conjugated microbeads, and characterized in osteogenic, chondrogenic and adipogenic differentiation. CD271+ cells from umbilical cord blood were slow to proliferate compared with those isolated from bone marrow. While CD271+ cells from bone marrow differentiated into osteogenic, chondrogenic and adipogenic lineages, there were no sound indications of differentiation by CD271+ cells from umbilical cord blood under the same differentiation conditions applied to the CD271+ cells from bone marrow. The study also found that bone marrow CD271+ cells remarkably upregulated the expression of chondrogenic genes under chondrogenic differentiation induction. When implanted into bone defects in mice, CD271+ cells from bone marrow regenerated significant bone, but the counterparts in umbilical cord blood formed little bone in the bone defects. In conclusion, CD271 is an efficient marker for MSC isolation from bone marrow but has failed to isolate MSCs from umbilical cord blood. CD271+ cells in bone marrow are particularly chondrogenic. The property of CD271+ cells is unique but varies from different tissues.

Management of aseptic nonunions and severe bone defects: let us get this thing healed!

Effective nonunion and bone defect management requires consideration of multiple potential contributing factors including biomechanics, biology, metabolic, and patient factors. This article reviews these factors as well as several potential nonunion or bone defect treatments including bone grafts, bone graft substitutes, the induced membrane technique, and distraction osteogenesis. A summary of these concepts and guidelines for an overall approach to management are also provided.

Evolution of orthopaedic reconstructive care.

The patterns and severity of injury sustained by service members have continuously evolved over the past 10 years of combat in Iraq and Afghanistan. The 2010 surge of combat troops into Afghanistan, combined with a transition to counterinsurgency tactics with an emphasis on dismounted operations, resulted in increased exposure of US service members to improvised explosive devices and a new pattern of injury termed dismounted complex blast injury. This constellation of injuries typically includes multiple extremity injuries, high bilateral transfemoral amputations, amputated or mangled upper extremities, open pelvis fractures, and injury to the perineal and/or genital regions. These polytraumatized patients frequently present with head, abdominal, and genitourinary injuries, as well. Traditional methods of reconstruction must be optimized because tissue availability may be limited.

Reprioritization of research for combat casualty care.

Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.

Technical considerations for the management of segmental osseous defects with an internal bone transport nail.

INTRODUCTION: Traditionally, distraction osteogenesis has been accomplished with an external fixator. All internal transport utilizing magnetic intramedullary nails is a newer technique for bone reconstruction. The Precice Bone Transport Nail is a new implant that allows for noninvasive transport via a magnetically driven motor. AREAS COVERED: This report describes the function of the Bone Transport Nail along with the technical considerations on how to successfully manage bone defects with this new technology. Appropriate use of the nail, preoperative planning, intraoperative considerations, and postoperative management are discussed in detail. EXPERT OPINION: The Precice Bone Transport Nail utilizes the technology of the original Precice nail to provide an all-internal option for reconstruction of intercalary defects. This obviates the need for an additional plate with a standard Precice nail when performing bone transport and allows for a less invasive option that decreases operating room time. It provides a more cosmetic result than external fixation and avoids the risks of pin tract infection. Preoperative planning is essential to appropriate execution of the operative procedure and to perform a successful transport. A thorough understanding of the nail design and limitations are a prerequisite as this implant is significantly different from a standard intramedullary nail.

Treatment of posttraumatic equinus deformity and concomitant soft tissue defects of the heel.

BACKGROUND: To evaluate the operative method and clinical outcome for the treatment of posttraumatic equinus deformity and concomitant soft tissue defect of the heel. METHODS: Between June 2006 and May 2010, seven cases of posttraumatic equinus deformity and concomitant unstable scar or ulcer of the heels were treated by using a hinged Ilizarov apparatus and reversed sural fasciocutaneous island flap transfer. Achilles tendon lengthening was also done in all patients. The average duration of follow-up was 21 months. The sizes of sural flaps were from 7 cm × 6 cm to 10 cm × 9 cm. Two weeks after the flap transfer, distraction of the Ilizarov fixator was initiated to gradually correct the equinus position of the foot. RESULTS: Results were evaluated by using the following criteria: (1) the degree of active dorsiflexion of the ankle, (2) the total active range of motion of the ankle, and (3) walking ability and flap durability. For active dorsiflexion of the ankle, the results were good in three patients and fair in four patients. For range of active motion of the ankle, the results were good in five patients and fair in two patients. For walking ability and flap durability, the results were good in six patients and fair in one patient. CONCLUSION: This study showed that posttraumatic equinus deformity accompanied by soft tissue defect of the heel can be treated effectively with Achilles tendon lengthening, reversed sural fasciocutaneous island flap transfer, and a hinged Ilizarov technique.

A radiographic zone-based approach to predict meniscus injury in lateral tibial plateau fracture.

OBJECTIVES: There is limited data regarding meniscal injury and it's association to fracture location and articular impaction/displacement (AID) in tibial plateau fractures. The purpose of this study was to predict lateral meniscal injury in tibial plateau fractures, based on location and extent of AID as visualized on pre op CT images. DESIGN: Retrospective review study. SETTING: Level I academic trauma center. PATIENTS: We retrospectively reviewed lateral tibia plateau fracture patients that were treated operatively using CPT codes 27535 and 27536. Two hundred patients were identified. Inclusion criteria were lateral tibia plateau fracture, age of 18 years or older, and documented direct examination of lateral meniscus integrity intraoperatively. Seventy patients met inclusion criteria. INTERVENTION: The injured lateral tibial plateau was divided into four quadrants on pre-operative CT and maximum AID was measured. The zone of fracture was defined as the location of largest AID (Image-1). All patients had an arthrotomy at the time of surgery to evaluate the integrity of the meniscus. Intra operative data regarding meniscal integrity and preoperative CT data were analyzed. Logistic regression was used to estimate what effect zone and amount of AID had on predicting the meniscal injury. Receiver operating characteristic (ROC) analysis was performed to determine cut off points for high sensitivity/specificity. MAIN OUTCOME MEASUREMENTS: Amount and area of depression in the lateral tibial plateau as relates to meniscal injury. RESULTS: Mean age was (45.1 ± 12.9) years. Twelve had Schatzker type I and 58 had type II fractures. Twenty-two patients had meniscus injury (MI) and forty-eight patients did not have a meniscus injury (NMI). Mean AID for MI was 12.48 mm ± 7.17 mm and 6.4 mm ± 4.3 mm for NMI (p<0.01). In MI group, largest AID was in Posterolateral (PL) zone(17.58 mm ± 8.9 mm) followed by Anteromedial (AM) zone (13.3 mm ± 7.2 mm) and Anterolateral (AL) zone (9.4 mm ± 5.8 mm). In NMI group largest AID was in AL zone (8.52 mm ± 2.6 mm) followed by AM zone (8.04 mm ± 5.4 mm) and PL zone (7.75 mm ± 2.35 mm). Patients with PL zone involvement had a lower meniscus tear rate compare to other zones. Logistic regression revealed that for every 1 mm increase in AID there is a 21% increase chance of meniscus tear (p<0.01). Comparison of the zones indicated that for the same AID, AL and AM zone fractures have 7.3 and 5.6 times increase risk of meniscus tear, respectively, as compared to PL zone (p<0.05). ROC analysis revealed that AID of 4.3 mm as a cut off point provides 100% sensitivity for diagnosis of meniscus tear. CONCLUSION: With 1 mm increase in AID there is a 21% increase in chance of meniscal tear. With the same AID, AL and AM zone fractures have a significantly higher chance of having a meniscal tear. AID of 4.3 mm provides 100% sensitivity to predict meniscal tear in lateral tibia plateau fracture. These values are useful in predicting pre op meniscal tear without MRI.

Permanent reduction plate and intramedullary nailing of open tibia fractures: Do we need to take them out?

INTRODUCTION: Provisional reduction plating has been advocated as a reduction aid for tibial shaft fractures. Concerns regarding soft tissue stripping, infection, wound complications and nonunion have been postulated. Recent studies investigating reduction plating present patient cohorts where plates are removed or left to the discretion of the surgeon. This study aims to identify a cohort of open tibial shaft fractures treated with intramedullary nailing aided by permanent reduction plating. Our hypothesis is that permanent reduction plating in conjunction with intramedullary nailing of open tibia fractures does not increase risk of nonunion, infection or time to fracture union compared to intramedullary nailing alone. METHODS: An IRB approved retrospective study was performed using trauma registry data from January 2014 to June 2018 at a Level 1 trauma center. Open AO/OTA 41A/42 A-C/43A tibial shaft fractures treated with intramedullary nail alone (IM) or intramedullary nail and permanent reduction plates (PP) were included in patients over 18 years of age with at least six month follow up or until fracture union. Patient demographics, fracture characteristics, mechanism of injury, medical comorbidities, and length of follow up were recorded along with time to union, incidence of nonunion and treatment for documented or suspected infections. RESULTS: During the study period, 389 patients underwent tibial intramedullary nailing with 162 identified as open fractures. 91 patients met inclusion criteria with 39 in the PP group and 52 in IM group. Statistical analysis revealed no difference between the two groups except more AO/OTA 42A fractures were noted in the IM group. Average follow up was 8.0 and 10.2 months for PP and IM respectively. Nonunion occurred in 2 PP group patients and 7 in the IM group (p = 0.29). Time to union was 5.5 months for PP group and 6.1 months for IM group (p = 0.39) with 4 infections in the PP group and 10 infections in IM group (p = 0.38). CONCLUSION: Despite the small sample size, this study suggests that permanent reduction plating, in the setting of open tibia fractures, does not delay time to fracture union or increase risk of nonunion or infection.

Serious adverse events and 30-day hospital readmission rate following elective total knee arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Elective total knee arthroplasty (TKA) is a common surgery which has evolved rapidly. However, there are no recent large systematic reviews of serious adverse event (SAE) rate and 30-day readmission rate (30-dRR) or an indication of whether surgical methods have improved. METHODS: To obtain a pooled estimate of SAE rate and 30-dRR following TKA, we searched Medline, Web of Science, Cochrane Library, and Google Scholar databases. Data were extracted by two authors following PRISMA guidelines. Eligibility criteria were defined prior to a comprehensive search. Studies were eligible if they were published in 2007 or later, described sequelae of TKA with patient N > 1000, and the SAE or 30-dRR rate could be calculated. SAEs included return to operating room, death or coma, venous thromboembolism (VTE), deep infection or sepsis, myocardial infarction, heart failure or cardiac arrest, stroke or cerebrovascular accident, or pneumonia. RESULTS: Of 248 references reviewed, 28 are included, involving 10,153,503 patients; this includes 9,483,387 patients with primary TKA (pTKA), and 670,116 patients with revision TKA (rTKA). For pTKA, the SAE rate was 5.7% (95% CI 4.4-7.2%, I2 = 100%), and the 30-dRR was 4.8% (95% CI 4.3-5.4%, I2 = 100%). For rTKA, the SAE rate was 8.5% (95% CI 8.3-8.7%, I2 = 77%), while the 30-dRR was 7.2% (95% CI 6.4-8.0%, I2 = 81%). Odds of 30-dRR following pTKA were about half that of rTKA (OR 0.57, 95% CI 0.53-0.62%, p < 0.001, I2 = 45%). Of patients who received pTKA, the commonest SAEs were VTE (1.22%; 95% CI 0.83-1.70%) and genitourinary complications including renal insufficiency or renal failure (1.22%; 95% CI 0.83-1.67%). There has been significant improvement in SAE rate and 30-dRR since 2010 (χ2 test < 0.001). CONCLUSIONS: TKA procedures have a relatively low complication rate, and there has been a significant improvement in SAE rate and 30-dRR over the past decade.

The induced membrane technique for bone defects: Basic science, clinical evidence, and technical tips.

The clinical management of large bone defects continues to be a difficult clinical problem to manage for treating surgeons. The induced membrane technique is a commonly employed strategy to manage these complex injuries and achieve bone union. Basic science and clinical evidence continue to expand to address questions related to the biology of the membrane and how interventions may impact clinical outcomes. In this review, we discuss the basic science and clinical evidence for the induced membrane technique as well as provide indications for the procedure and technical tips for performing the induced membrane technique.

Bone void fillers.

For this technology overview, the tools of evidence-based medicine were used to summarize information on the effectiveness and clinical outcomes related to the usage of bone void fillers- specifically, synthetic graft materials. Comprehensive literature searches were conducted to address five key questions, which the task force that prepared the report posed as follows. Question 1 addressed the use of synthetic bone void fillers alone. Question 2 was designed to determine whether synthetic bone void fillers could successfully serve as graft extenders and eliminate the need for iliac crest bone graft. Questions 3, 4, and 5 addressed the use of allografts as a comparison with synthetic fillers because clinical results with allografts are perceived as being much closer to autografts in these areas of the spine.