RESUMO
Diaphyseal femur fractures are common injuries globally and range in complexity. The most common mechanism worldwide is motor vehicle accidents. Initial evaluation should include Advanced Trauma Life Support protocol and evaluation of the soft tissues, neurovascular examination, and associated injuries. The gold standard for treatment is a closed functional reduction (restoration of length, alignment, and rotation) and fixation with a reamed, statically locked, intramedullary nail. Fracture pattern, associated injuries, and patient factors can increase the difficulty of treatment. Malrotation and limb length discrepancy are not uncommon. Awareness of the problem and knowledge of the how to obtain and verify adequate reduction is critical. Diagnosis of malrotation and/or limb length discrepancy should prompt a detailed discussion of the deformity and treatment options with the patient. Most patients recover remarkably well from diaphyseal femur fractures. They should be followed until union and return to prior functional level with a watchful eye placed on any warning signs of complications such as nonunion and infection.
Assuntos
Fraturas do Fêmur , Fixação Intramedular de Fraturas , Humanos , Fraturas do Fêmur/complicações , Fraturas do Fêmur/cirurgia , Fixação Intramedular de Fraturas/métodos , Consolidação da Fratura , Fêmur , Pinos Ortopédicos , Resultado do TratamentoRESUMO
Patients with complex distal clavicle and acromioclavicular (AC) joint injuries are at risk of loss of reduction, especially when plates are removed postoperatively. The purpose is to review the authors' preferred technique for treatment of distal clavicle and AC joint injuries utilizing combined suture button and plate fixation, aiming to optimize biomechanical strength of fixation and limit loss of reduction after implant removal. Pre-contoured locking plates or hook plates were utilized atop suture buttons to maintain reduction and optimize biomechanical strength. At final follow-up over one year after plate removal and suture button retention in thirteen patients, reduction was maintained to coracoclavicular interval 1.5 ± 1.4 mm less than contralaterally. DASH scores at final follow-up averaged 5.7 ± 2.5 (range: 3.3 - 11.7). Placing suture button fixation prior to and beneath plate fixation in complex AC joint injuries and distal clavicle fractures allows for maintained fixation and prevents loss of reduction after plate removal.
Assuntos
Articulação Acromioclavicular , Fraturas Ósseas , Humanos , Clavícula/cirurgia , Clavícula/lesões , Articulação Acromioclavicular/cirurgia , Articulação Acromioclavicular/lesões , Fraturas Ósseas/cirurgia , Fixação Interna de Fraturas/métodos , SuturasRESUMO
BACKGROUND: Discoid lateral meniscus (DLM) is a morphologic variant in which concomitant articular cartilage defects lead to poor outcomes. The purpose of this study was to quantify the prognostic ability of history, physical examination, and magnetic resonance imaging (MRI) to identify arthroscopically confirmed articular cartilage injury in pediatric and adolescent DLM patients. METHODS: An analysis of 34 consecutive patients (mean, 12.5 y) who underwent surgical treatment for DLM. Patients were grouped based on arthroscopic findings for the presence or absence of articular cartilage injury. All patients underwent standard preoperative history and physical examination, and MRI of their symptomatic knee. Separate discriminant functional analyses were performed using history (age, sex, symptoms lasting >6 mo, traumatic history), physical examination (presence of clunk, extension block, mechanical symptoms), and MRI findings (chondral injury, meniscal degeneration, meniscal morphology) to determine their sensitivity and specificity in prediction of articular cartilage lesions. RESULTS: The sensitivity and specificity of history alone was 71.4% and 75.0%, respectively; physical examination alone was 64.3% and 60%, respectively; and of MRI findings alone was 60% and 66.7%, respectively. A stepwise discriminant functional analysis found that duration of symptoms and extension block were the optimal contributors with a 78.5% sensitivity and 80% specificity. CONCLUSIONS: Preoperative history had the highest sensitivity and specificity compared with physical examination and MRI findings for predicting articular cartilage injury at the time of DLM surgery. These findings may assist in setting expectations for patients with regard to surgical planning and recovery and also to counsel patients with asymptomatic, incidental DLM which factors may risk chondral injury and warrant early return for evaluation. LEVEL OF EVIDENCE: Level II-retrospective prognostic comparative study.
Assuntos
Cartilagem Articular/lesões , Imageamento por Ressonância Magnética , Anamnese , Meniscos Tibiais/cirurgia , Exame Físico , Lesões do Menisco Tibial/diagnóstico , Adolescente , Artroscopia/métodos , Criança , Feminino , Humanos , Artropatias/patologia , Masculino , Meniscos Tibiais/diagnóstico por imagem , Prognóstico , Estudos Retrospectivos , Sensibilidade e Especificidade , Avaliação de Sintomas , Lesões do Menisco Tibial/classificação , Lesões do Menisco Tibial/complicações , Lesões do Menisco Tibial/cirurgiaRESUMO
OBJECTIVES: This study evaluated the relationship between obesity and postoperative complications in patients undergoing ankle open reduction internal fixation (ORIF). DESIGN: Retrospective cohort study. SETTING: PearlDiver-Mariner All-Payor Database. PATIENT SELECTION CRITERIA: Patients who underwent ankle ORIF from 2010 to 2021 and had a minimum of 2 years of follow-up were identified using Current Procedural Terminology, ICD-9, and ICD-10 codes. OUTCOME MEASURES AND OUTCOMES: Patients were stratified by body mass index into nonobese, obese, morbidly obese, and super-obese groups. Complication rates, including 90-day readmissions, infection, and post-traumatic osteoarthritis, were compared between obesity groups. Patients were additionally compared with a 1:1 matched analysis that controlled for demographics and comorbidities. RESULTS: A total of 160,415 patients undergoing ankle ORIF from 2010 to 2021 were identified. The cohort consisted mostly of females (64.8%) and the average age was 52.5 (SD 18.4) years. There were higher rates of 90-day readmissions, UTIs, DVT/PE, pneumonia, superficial infections, and acute kidney injuries in patients with increasing levels of obesity (P < 0.001). There were increased odds of nonunion and post-traumatic arthritis in the matched analysis at 2 years in the obesity group [OR: 2.36, 95% confidence interval (CI): 1.68-3.31, P < 0.001; OR: 2.18, 95% CI: 1.77-2.68, P < 0.001, respectively]. CONCLUSIONS: Postoperative medical complication rates in patients undergoing ankle ORIF, including infection, are higher in obese patients, even in the 1:1 matched analysis that controlled for demographic and comorbidity factors. Rates of nonunion and post-traumatic arthritis were higher in obese patients, as well. As such, it is important for surgeons to provide appropriate education regarding the risks after ankle ORIF in patients with obesity. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas do Tornozelo , Fixação Interna de Fraturas , Obesidade , Complicações Pós-Operatórias , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fraturas do Tornozelo/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Obesidade/complicações , Adulto , Fixação Interna de Fraturas/efeitos adversos , Idoso , Redução Aberta , Estudos de CoortesRESUMO
CASE: A 15-year-old adolescent boy sustained both talar and navicular extrusions after a dirt-bike accident. The talus and navicular were discarded during initial debridement because of contamination. Given extensive soft-tissue injury and bone loss, the patient's family opted for transtibial amputation, as described by Ertl, over limb salvage. Simultaneous osteomyoplastic reconstruction and acute targeted muscle reinnervation were performed. CONCLUSION: Transtibial amputation is a viable treatment option for total talar and navicular extrusions, particularly if an optimal functional outcome is unachievable with limb salvage. Simultaneous osteomyoplastic reconstruction and acute targeted muscle reinnervation can potentially decrease neuroma formation and phantom limb pain.
Assuntos
Procedimentos de Cirurgia Plástica , Tálus , Masculino , Adolescente , Humanos , Amputação Cirúrgica , Tálus/diagnóstico por imagem , Tálus/cirurgia , Salvamento de MembroRESUMO
BACKGROUND: Posterior hamstring harvest has been described in the adult population in a limited fashion, but no study is available describing the use of posterior hamstring harvest in an active pediatric and adolescent cohort. At times, surgeons may be faced with a challenging anterior harvest due to patient anatomic characteristics, particularly the anatomic features and size of the pes tendons. Clinicians need to have multiple harvest approaches at their disposal. Complications with hamstring harvest such as premature graft transection are more problematic in this population due to higher failure rates with allograft tissue. The posterior harvest via its more proximal location may allow for easier tendon identification, visualization of the accessory attachments, and longer preserved tendon length if transection error occurs when the anterior approach is avoided based on surgical technique, patient anatomic characteristics, and surgeon and patient preference. PURPOSE: To describe the technique of a posterior hamstring harvest in pediatric and adolescent patients and to analyze complications. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study was a retrospective review of a consecutive series of pediatric and adolescent patients who underwent posterior hamstring harvest. During surgery, the patient's leg was abducted and externally rotated to expose the posteromedial aspect of the knee. A 2-cm incision was made overlying the palpable medial hamstring at the popliteal crease. The posterior hamstring tendons were first harvested proximally with an open tendon stripper and distally with a closed stripper. Preoperative, intraoperative, and postoperative findings and complications were analyzed. RESULTS: A total of 214 patients (mean ± SD age, 15.7 ± 4.1 years; range, 8.0-19.8 years) underwent posterior harvest, with a mean ± SD follow-up of 1.83 ± 1.05 years. No complications occurred in our series related to graft harvest-no graft transections, neurovascular injuries, secondary procedures for wound healing or closure, cosmetic concerns, or limitations in return to activity due to the posterior incision. CONCLUSION: The posterior hamstring harvest is a safe and reliable technique to harvest autograft tendon in pediatric and adolescent anterior cruciate ligament reconstructions. The posterior technique entailed no complications related to harvest. No patients expressed any cosmetic concerns about their incision or had limitations in return to sport due to the posterior harvest.
RESUMO
BACKGROUND: It is unclear whether patients can be taken off suppressive antibiotics with infected retained instrumentation. This study aimed to retrospectively analyze the perioperative course and antibiotic regimen that led to the clinical intervention of patients with infected spinal instrumentation. METHODS: Consecutive adult patients with spine instrumentation who suffered surgical site infections (SSI) requiring debridement were retrospectively analyzed. The patients were grouped into 4 cohorts based on their clinical intervention: removal of instrumentation, reinstrumentation, retention of instrumentation with continued antibiotic suppression, and retention of instrumentation with no antibiotic suppression. Patient factors, infection factors, debridement, and antibiosis were compared. RESULTS: Of the 67 patients with SSI after spine surgery and instrumentation, 19 (28%) had their instrumentation removed, 6 (9%) had their instrumentation exchanged, 25 (37%) had their instrumentation retained and were on antibiotic suppression, and 17 (25%) had their instrumentation retained without any suppression. Those who had their instrumentation removed had a later presentation of their infection averaging 85 days (range 6-280 days) postoperatively. There was an earlier presentation for those who retained their implants, with suppression averaging 19 days (range 9-39) and no suppression averaging 29 days (range 6-90 days) post operatively (P < .001). CONCLUSIONS: None of the patients with retained instrumentation without suppression had recurrence of infections after long-term follow-up. Lifelong antibiotic suppression may not be required with SSI that present early after early aggressive debridement. Patients with infections detected later are difficult to treat without removal of their original instrumentation. CLINICAL RELEVANCE: This study presents the outcomes of surgical and antibiotic factors in patients with infected spinal instrumentation.