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PURPOSE: To compare a curved drill guide with a straight guide for suture anchor placement into the posterosuperior glenoid from an anterolateral portal with respect to glenoid perforation, drill contact with the suprascapular nerve, and maximum load. METHODS: Ten bilateral pairs of fresh human cadaveric shoulders were randomized to the curved technique on 1 side and the straight technique on the contralateral side. An anterolateral trans-rotator cuff portal was used for placement of anchors at the posterior (11 o'clock right shoulder) and far posterior (10 o'clock right shoulder) positions on the glenoid with a 24-mm drill stop, and the drill tip was marked with ink. Specimens were dissected for glenoid perforation and drill contact with the suprascapular nerve. The maximum load of each anchor was measured using a material testing system. RESULTS: Glenoid perforation occurred in 30% in the curved group and 60% in the straight group overall (P = .01). Ink markings demonstrated a direct hit on the suprascapular nerve in most of the penetrations (13 of 18) but was not significantly different between the curved and straight guides (P = .25). Maximum load of the posterior anchor was greater in the curved group than that in the straight group (199.5 vs 146.7 N, respectively; P = .01). CONCLUSIONS: The curved technique has a lower rate of glenoid perforation and greater maximum load than the straight technique. However, the curved technique can result in glenoid perforation and injury to the suprascapular nerve, and we do not recommend it. CLINICAL RELEVANCE: Placing suture anchors through an anterolateral portal with a curved guide provides a more optimal trajectory with decreased risk of glenoid perforation and superior biomechanical strength than that with the straight guide, but it is not safe.
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Artroscopia/métodos , Manguito Rotador/cirurgia , Escápula/cirurgia , Articulação do Ombro/cirurgia , Âncoras de Sutura , Cadáver , Humanos , Teste de MateriaisRESUMO
HYPOTHESIS: The modified Gartland classification system for pediatric supracondylar fractures is often utilized as a communication tool to aid in determining whether or not a fracture warrants operative intervention. This study sought to determine the interobserver and intraobserver reliability of the Gartland classification system, as well as to determine whether there was agreement that a fracture warranted operative intervention regardless of the classification system. METHODS: A total of 200 anteroposterior and lateral radiographs of pediatric supracondylar humerus fractures were retrospectively reviewed by 3 fellowship-trained pediatric orthopaedic surgeons and 2 orthopaedic residents and then classified as type I, IIa, IIb, or III. The surgeons then recorded whether they would treat the fracture nonoperatively or operatively. The κ coefficients were calculated to determine interobserver and intraobserver reliability. RESULTS: Overall, the Wilkins-modified Gartland classification has low-moderate interobserver reliability (κ=0.475) and high intraobserver reliability (κ=0.777). A low interobserver reliability was found when differentiating between type IIa and IIb (κ=0.240) among attendings. There was moderate-high interobserver reliability for the decision to operate (κ=0.691) and high intraobserver reliability (κ=0.760). Decreased interobserver reliability was present for decision to operate among residents. For fractures classified as type I, the decision to operate was made 3% of the time and 27% for type IIa. The decision was made to operate 99% of the time for type IIb and 100% for type III. SUMMARY: There is almost full agreement for the nonoperative treatment of Type I fractures and operative treatment for type III fractures. There is agreement that type IIb fractures should be treated operatively and that the majority of type IIa fractures should be treated nonoperatively. However, the interobserver reliability for differentiating between type IIa and IIb fractures is low. Our results validate the Gartland classfication system as a method to help direct treatment of pediatric supracondylar humerus fractures, although the modification of the system, IIa versus IIb, seems to have limited reliability and utility. Terminology based on decision to treat may lead to a more clinically useful classification system in the evaluation and treatment of pediatric supracondylar humerus fractures. LEVEL OF EVIDENCE: Level III-diagnostic studies.
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Técnicas de Apoio para a Decisão , Lesões no Cotovelo , Articulação do Cotovelo/diagnóstico por imagem , Fraturas do Úmero/classificação , Adolescente , Criança , Humanos , Fraturas do Úmero/diagnóstico por imagem , Fraturas do Úmero/terapia , Variações Dependentes do Observador , Radiografia , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
Few reports in the literature have been dedicated to young patients with distal fractures of the humerus, and few have addressed subsequent indications to improve range of motion (ROM). This article is a retrospective review of the elbow flexion-extension ROM in 31 patients (age, 12-19 years) who had been treated with open reduction and internal fixation of intercondylar fractures of the distal humerus at a level I trauma center from 1991 through 2013. The ROM of patients who underwent capsulectomy was compared with that of those who did not. Main outcome measures were ROM in degrees and need for capsulectomy. Nine (29%) of the 31 patients had elected to undergo capsulectomy. Eleven did not require capsulectomy. The final flexion-extension arc was improved by 31° compared with the precapsulectomy ROM but did not attain the ROM of those who did not undergo capsulectomy.
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Articulação do Cotovelo/cirurgia , Fraturas do Úmero/cirurgia , Liberação da Cápsula Articular , Amplitude de Movimento Articular/fisiologia , Adolescente , Criança , Articulação do Cotovelo/fisiopatologia , Feminino , Seguimentos , Humanos , Fraturas do Úmero/fisiopatologia , Masculino , Estudos Retrospectivos , Adulto JovemRESUMO
PURPOSE: This study examines donor site morbidity associated with the medial femoral trochlea (MFT) when used as a donor site for vascularized osteochondral flaps for reconstruction of challenging carpal defects such as proximal pole scaphoid nonunion and advanced Kienböck disease. METHODS: The retrospective study population included all patients who had undergone MFT flap harvest for scaphoid or lunate reconstruction. Chart review, patient questionnaires, and validated knee function assessment tools were used: International Knee Documentation Committee Subjective Knee Form scores ranged from 0 (maximal disability) to 100 (no disability). Western Ontario and McMaster Universities osteoarthritis index scores ranged from 0% (no disability) to 100% (maximal disability). Magnetic resonance imaging and radiographs were obtained on the donor knee on the majority of patients. RESULTS: Questionnaire response rate was 79% (45 of 57 patients). Average patient age was 35 ± 11 years (range, 19-70 years). Average postoperative follow-up was 27 ± 17 months (range, 9-108 months). The indication for MFT flap reconstruction was scaphoid nonunion in 30 patients and Kienböck disease in 15 patients. All 45 patients had a stable knee on examination. Magnetic resonance and radiographic imaging obtained on 35 patients exhibited no pathological changes. Average duration of postoperative pain was 56 ± 59 days (range, 0-360 days); average duration until patients reported the knee returning to normal was 90 ± 60 days (range, 14-360 days). Forty-three of 44 patients would have the same surgery again if needed; overall satisfaction with the surgery was rated as 5 ± 1 (range, 2-5) on a scale from 0 (no satisfaction) to 5 (maximal satisfaction). Average International Knee Documentation Committee score was 96 ± 9 (range, 56.3-100) and the average Western Ontario and McMaster Universities score was 6% ± 16% (range, 0%-68%). CONCLUSIONS: Medial femoral trochlea osteochondral flap harvest results in minimal donor site morbidity in the majority of patients. Symptoms are time limited. Intermediate-term follow-up demonstrates excellent results in subjective outcome measures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
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Ossos do Carpo/cirurgia , Fraturas não Consolidadas/cirurgia , Articulação do Joelho/fisiologia , Osteonecrose/cirurgia , Retalhos Cirúrgicos , Coleta de Tecidos e Órgãos/efeitos adversos , Sítio Doador de Transplante , Adulto , Idoso , Ossos do Carpo/lesões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Amplitude de Movimento Articular , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Many patient care procedures are routinely performed by orthopaedic residents while not directly supervised by attending physicians. However, resident competence to perform these procedures is often presumed and not confirmed by objective measures. The purpose of this study was to formally evaluate 3 basic pediatric orthopaedic procedures commonly performed without attending supervision. METHODS: All orthopaedic residents (n=20) were asked to complete 3 procedures (placement and removal of a short arm cast, aspiration of a knee joint, and compartment pressure checks of a leg) under direct attending supervision. Attending faculty developed a checklist for each procedure, listing the appropriate steps required and criteria with which to assess the final results. Scores were calculated, including means and SDs. Change in score by postgraduate year level was determined by simple linear regression. RESULTS: The mean score for short arm cast application and removal was 6.2 of a total possible score of 8, with an average 1.1 increase in score per year of training (P<0.001). Uneven cast padding and lack of full thumb motion were the most common reasons for losing points. Knee joint aspiration had an average score of 6.2 of 7, with an average increase in score of 0.3 per year of training (P=0.046). Lack of equipment preparation and not donning gloves in a sterile manner were the most common reasons for losing points. Measure of leg compartment pressures had an average score of 9.7 of 12, with an average increase in score of 0.5 per increase in year of training (P=0.087). Injecting an inappropriate amount of fluid and not recording measurements were the most common reasons for losing points. CONCLUSIONS: The ability of a resident to appropriately perform certain procedures without direct supervision improves with advancing level of training. The most junior residents might not appropriately be placing short arm casts, aspirating knee joints, or checking compartment pressures of the leg. LEVEL OF EVIDENCE: Level IIDiagnostic.
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Artrodese/educação , Moldes Cirúrgicos , Competência Clínica , Síndromes Compartimentais/cirurgia , Internato e Residência , Articulação do Joelho/cirurgia , Ortopedia/educação , Artrodese/métodos , Síndromes Compartimentais/fisiopatologia , Humanos , Articulação do Joelho/fisiopatologia , PressãoRESUMO
BACKGROUND: Mobile imaging, such as viewing radiographs as text messages, is increasingly prevalent in clinical settings. The purpose of this study was to determine whether remote diagnosis of pediatric elbow fractures using smartphone technology is reliable. In addition, this study aimed to determine whether the assessment regarding the decision for operative treatment is affected by evaluation of images on a mobile device as opposed to standard picture archiving and communication system (PACS). METHODS: Standard anteroposterior and lateral radiographs of 50 pediatric elbow trauma cases were evaluated by 2 fellowship-trained pediatric orthopaedic surgeons and 2 senior orthopaedic residents. Raters were asked to classify the case as any of 6 diagnoses: supracondylar humerus, lateral condyle, medial epicondyle, radial neck fracture, positive posterior fat pad sign, or normal pediatric elbow. Raters were asked to choose operative or conservative treatment. After 1 week, photographs of the same images were taken from a standardized distance from a computer monitor with an iPhone 5 camera and transmitted by multimedia messaging to each rater. The same questions were again posed to raters. Interobserver and intraobserver reliabilities were calculated by Cohen κ-statistics with bootstrapped 95% confidence intervals. RESULTS: Intraobserver reliability of classification of injuries on PACS compared with smartphone images was excellent, with an overall κ of 0.91. Treatment decision also demonstrated excellent intraobserver reliability (PACS vs. smartphones) with a κ of 0.86 for all raters. CONCLUSIONS: Diagnosis of pediatric elbow injuries can be made equally reliably based on either PACS or transmitted multimedia messaging images taken with an iPhone camera from a computer screen and viewed on a smartphone. Treatment decisions can also be made reliably based on either image modality. CLINICAL RELEVANCE: Using smartphones to transmit and display radiographs, which is common in current clinical practice, is effective and reliable for diagnosis and treatment planning of pediatric elbow injuries.
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Articulação do Cotovelo/diagnóstico por imagem , Fraturas do Úmero/diagnóstico por imagem , Fraturas do Rádio/diagnóstico por imagem , Consulta Remota/métodos , Smartphone , Criança , Tomada de Decisão Clínica , Humanos , Fraturas do Úmero/terapia , Variações Dependentes do Observador , Cirurgiões Ortopédicos , Planejamento de Assistência ao Paciente , Pediatria , Radiografia , Fraturas do Rádio/terapia , Reprodutibilidade dos Testes , Lesões no CotoveloRESUMO
BACKGROUND: Heterotopic ossification (HO) develops after nearly 2/3 of traumatic blast amputations in the contemporary battlefield. This phenomenon has potentially devastating consequences for servicemen and women and its pathophysiology warrants further investigation using a previously developed animal blast model. QUESTIONS/PURPOSES: We asked, what is the (1) severity (quantity) and (2) type (location) of HO bone formation after a hindlimb blast amputation with two distinct blast media. We hypothesized that a more "war-relevant" blast medium could be a more accurate model and potentially intensify the development of HO. METHODS: Using a Sprague-Dawley rat model, the pathophysiology of ectopic bone formation in a traumatic hindlimb blast amputation was evaluated. Twenty-four animals underwent blast amputations and closure based on a previously established experimental model. Half the amputations were subjected to blasted sand and the other 1/2 to blasted water. Serial orthogonal radiography was performed on each animal until euthanasia at 24 weeks to track the development of HO. Heterotopic bone severity and type were assessed by three independent graders at each time using a novel grading scale to assess quantity and quality of HO. RESULTS: All animals had radiographic evidence of HO develop. No differences were observed in ectopic bone development between sand and water blasting regarding severity or type at any time. Animals that received water and sand blasting had moderate HO develop at 24 weeks (median, 2.0 and 2.5 weeks, respectively; range, 1-3 weeks; difference of medians, 0.5; p=0.67). At the time of euthanasia, 10 animals that were water blasted had Type 3 HO compared with 11 in the sand-blasted group (p=1.00). CONCLUSIONS: Our study showed a clear development of HO after hindlimb blast amputation in a Sprague-Dawley rat model; however, no difference was observed in HO development based on the type of blast media. This suggests it is the blast mechanism that induces ectopic bone development, regardless of the blasted medium. The grading scale we developed for our animal-model study provided a reliable means of assessing HO severity and type. CLINICAL RELEVANCE: We anticipate that future investigations will elucidate similarities between service members' wartime extremity injuries and the animal model used in our study, and with focused future research this model may have beneficial therapeutic implications as the pathophysiology of HO development is further understood.
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Amputação Traumática/etiologia , Traumatismos por Explosões/etiologia , Membro Posterior/lesões , Ossificação Heterotópica/etiologia , Amputação Traumática/diagnóstico por imagem , Amputação Traumática/fisiopatologia , Amputação Traumática/cirurgia , Animais , Traumatismos por Explosões/diagnóstico por imagem , Traumatismos por Explosões/fisiopatologia , Traumatismos por Explosões/cirurgia , Modelos Animais de Doenças , Membro Posterior/diagnóstico por imagem , Membro Posterior/fisiopatologia , Masculino , Ossificação Heterotópica/diagnóstico por imagem , Ossificação Heterotópica/fisiopatologia , Radiografia , Ratos Sprague-Dawley , Índice de Gravidade de Doença , Fatores de TempoRESUMO
PURPOSE: The purpose of this study was to compare the risk of injury to the suprascapular nerve during suture anchor placement in the glenoid when using an anterosuperior portal versus a rotator interval portal. METHODS: Ten bilateral fresh human cadaveric shoulders were randomized to anchor placement through the anterosuperior portal on one shoulder and the rotator interval portal on the contralateral shoulder. Standard 3 × 14 mm suture anchors were placed in the glenoid rim (1 o'clock, 11 o'clock, and 10 o'clock positions for the right shoulder). The suprascapular nerve was dissected. When glenoid perforation occurred, the distance from the anchor tip to the suprascapular nerve, the distance from the glenoid rim to the suprascapular nerve, and the drill-hole depth at each entry site were recorded. RESULTS: All far-posterior anchors perforated the glenoid rim when using the anterosuperior or rotator interval portal. The distance from the far-posterior anchor tip to the suprascapular nerve averaged 8 mm (range, 3.4 to 14 mm) for the anterosuperior portal and 2.1 mm (range, 0 to 5.5 mm) for the rotator interval portal (P ≤ .001). CONCLUSIONS: Using an anterosuperior or rotator interval portal results in consistent penetration of 1 o'clock and 2 o'clock posterior anchors and might place the suprascapular nerve at risk of iatrogenic injury. Based on closer proximity of the anchor tip to the suprascapular nerve, the risk of injury is significantly greater with a rotator interval portal. CLINICAL RELEVANCE: Using a rotator interval portal for suture anchor placement in the posterior aspect of the glenoid rim can lead to a higher likelihood of suprascapular nerve injury.
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Artroscopia/métodos , Traumatismos dos Nervos Periféricos/etiologia , Escápula/inervação , Lesões do Ombro , Âncoras de Sutura , Idoso , Idoso de 80 Anos ou mais , Artroscopia/efeitos adversos , Cadáver , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Ortopédicos , Distribuição Aleatória , Risco , Medição de Risco , Manguito Rotador , SegurançaRESUMO
The objective of our investigation was to explore risk factors associated with primary closure of type IIIA tibial fractures resulting in subsequent flap coverage. A retrospective study identified 278 patients with acute type IIIA open tibial fractures who underwent primary closure at a single center during an 8-year period. Treatment factors, including the number of debridements before closure, duration of external fixation, and timing of wound closure, were reported. The primary outcome was complication requiring unplanned operation of the study injury resulting in flap coverage. Fifty-five (20%) patients underwent flap coverage following complication after attempted primary closure. Patients who required a flap experienced a 42% complication rate after delayed flap coverage. The limb salvage rate was 95% for the study population. Three significant complication predictors were identified: 3 or more debridements before closure (odds ratio [OR], 29.8; 95% CI, 5.9-150.1; P<.001), wound closure more than 2 days after injury (OR, 9.8; 95% CI, 1.6-60.2; P=.01), and external fixation more than 14 days (OR, 7.3; 95% CI, 1.6-34.6; P=.01). Patients who had 3 or more debridements before closure had a 70.7% chance of having a complication resulting in a flap (29 of 41) compared with only a 6.8% chance of complication for those who had 2 or fewer debridements (14 of 205; P<.001). Risk factors for complication after primary closure of type IIIA open tibial fractures include number of debridements, wound closure after 2 days, and external fixation use for more than 14 days. Wounds requiring 3 or more debridements failed 70.7% after closure, suggesting alternative approaches should be considered in more severe cases. [Orthopedics. 2024;47(2):108-112.].
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Fraturas Expostas , Fraturas da Tíbia , Humanos , Estudos Retrospectivos , Tíbia , Resultado do Tratamento , Fixação Interna de Fraturas/métodos , Fraturas da Tíbia/complicações , Fatores de Risco , Fraturas Expostas/cirurgia , Fraturas Expostas/complicaçõesRESUMO
INTRODUCTION: Cluster randomized crossover trials are often faced with a dilemma when selecting an optimal model of consent, as the traditional model of obtaining informed consent from participant's before initiating any trial related activities may not be suitable. We describe our experience of engaging patient advisors to identify an optimal model of consent for the PREP-IT trials. This paper also examines surrogate measures of success for the selected model of consent. METHODS: The PREP-IT program consists of two multi-center cluster randomized crossover trials that engaged patient advisors to determine an optimal model of consent. Patient advisors and stakeholders met regularly and reached consensus on decisions related to the trial design including the model for consent. Patient advisors provided valuable insight on how key decisions on trial design and conduct would be received by participants and the impact these decisions will have. RESULTS: Patient advisors, together with stakeholders, reviewed the pros and cons and the requirements for the traditional model of consent, deferred consent, and waiver of consent. Collectively, they agreed upon a deferred consent model, in which patients may be approached for consent after their fracture surgery and prior to data collection. The consent rate in PREP-IT is 80.7%, and 0.67% of participants have withdrawn consent for participation. DISCUSSION: Involvement of patient advisors in the development of an optimal model of consent has been successful. Engagement of patient advisors is recommended for other large trials where the traditional model of consent may not be optimal.
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OBJECTIVES: To determine whether knowledge-based deficiencies are adequately addressed at the AO North America Basic Principles of Fracture Management course. DESIGN: Pretest, posttest. SETTING: Eighteen national trauma courses. PARTICIPANTS: Two thousand one hundred forty-nine learners. INTERVENTION: Pre- and postcourse 20-item tests of basic fracture knowledge, including 14 trauma topics. MAIN OUTCOME MEASURES: Deficiencies were defined as <60% correct answers on the precourse test. Postcourse knowledge gaps were defined as <75% correct responses. RESULTS: Deficiencies were noted in 7 of the 14 topics on the precourse test. All topics with deficiencies on the precourse test were shown to have statistically significant improvement in postcourse test scores. All topics without deficiencies were shown to have statistically significant improvement in postcourse test scores. The average overall precourse test score was 63% (95% confidence interval, 61%-65%), and the average overall postcourse test score was 81% (95% confidence interval, 79%-83%). The pretest to posttest difference was statistically significant (P < 0.05). The control questions, covering material that was not discussed in the course, did not have statistically significant improvement in scores. CONCLUSIONS: Residents are entering residency programs with limited knowledge of fracture care, and significant gaps remain at the junior level at the time of course participation, suggesting that supplemental fracture courses play an important role in resident education. Validation of short-term learning is possible through a pretest and posttest technique, and it can guide design changes, as opposed to relying on satisfaction surveys alone.
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Internato e Residência , Ortopedia , Competência Clínica , Currículo , Humanos , América do Norte , Inquéritos e QuestionáriosRESUMO
The quality of Bankart repair may be compromised by the presence of glenoid perforation during suture anchor placement. The purpose of this study was to compare the rate of glenoid perforation and biomechanical strength of antero-inferior suture anchors placed with a curved vs a traditional straight technique through an anteroinferior portal. Ten bilateral pairs of fresh human cadaveric shoulders were randomized to either a curved or a straight suture anchor insertion technique. An anteroinferior portal was used to place a 1.5-mm soft anchor in the anteroinferior glenoid (5:30 position for right shoulders). Anatomic dissection was performed, and the maximum load of each anchor was measured using a materials testing system. The overall rate of glenoid perforation by the anteroinferior anchor was 50%. The rate of glenoid perforation was 40% in the straight group and 60% in the curved group (P=.41). The median maximum load was 86 N in the straight group and 137 N in the curved group (P=.23). The median maximum load of the anchors that did perforate the glenoid was 102 N and of those that did not was 118 N (P=.72). The mode of failure was suture anchor pullout in all except one specimen. The curved guide was not superior to the traditional straight guide in terms of the rate of glenoid perforation or the maximum load of the suture anchors. Anterior cortical perforation of the glenoid during anteroinferior suture anchor placement is common with both techniques. [Orthopedics. 2019; 42(2):e242-e246.].
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Artroscopia/instrumentação , Lesões de Bankart/cirurgia , Âncoras de Sutura , Idoso , Artroscopia/métodos , Cadáver , Dissecação , Feminino , Cavidade Glenoide/lesões , Cavidade Glenoide/cirurgia , Humanos , Masculino , Desenho de Prótese , Escápula/cirurgia , Articulação do Ombro/cirurgia , Técnicas de SuturaRESUMO
STUDY DESIGN: A retrospective review (2001-2014) was conducted using prospectively collected data at a level I trauma center. OBJECTIVE: We sought to determine the incidence and characteristics of complications occurring secondary to therapeutic anticoagulation in adult spine trauma patients. SUMMARY OF BACKGROUND DATA: Numerous studies have assessed prophylactic anticoagulation after spine surgery, but none has investigated the risks of therapeutic doses of anticoagulation for treatment of postoperative thromboembolic events. METHODS: Patients were included if they sustained a postoperative thromboembolic event (deep venous thrombosis, pulmonary embolism, or myocardial infarction). Patients were excluded if anticoagulation was subtherapeutic. Of 1712 patients, 62 who received therapeutic anticoagulation and 174 propensity-matched control patients who did not receive therapeutic anticoagulation were included in the study. RESULTS: Initial anticoagulation was obtained by heparin infusion (51%), low-molecular-weight heparin (LMWH, 46%), and warfarin (3%). Complications requiring unplanned reoperation occurred in 18% of anticoagulated patients and 10% of nonanticoagulated patients (Pâ=â0.17). The reoperation rate after heparin infusion was 31% and after LMWH was 6.5% (Pâ=â0.02). Epidural hematoma occurred in 3% and 1% of anticoagulated and nonanticoagulated patients, respectively. Multivariate logistic regression analysis of the two groups showed a trend toward increased risk of reoperation in the anticoagulation group. Analysis of the heparin infusion subgroup separate from the LMWH subgroup compared with the control group showed an increased risk of reoperation for any complication (odds ratio, 3.57; Pâ=â0.01) and for bleeding complications (odds ratio, 43.1; Pâ=â0.01). CONCLUSION: This is the first study to quantify complications secondary to postoperative therapeutic anticoagulation in spine patients. Postoperative spine trauma patients who underwent therapeutic anticoagulation experienced an unplanned reoperation rate of 18%, including a 3% incidence of spinal epidural hematoma. Therapeutic anticoagulation using heparin infusion seems to drive the overall rate of reoperation (31%) compared with LMWH. LEVEL OF EVIDENCE: 3.
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Anticoagulantes/efeitos adversos , Infarto do Miocárdio/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Embolia Pulmonar/epidemiologia , Traumatismos da Coluna Vertebral/epidemiologia , Trombose Venosa/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Feminino , Heparina/administração & dosagem , Heparina/efeitos adversos , Heparina de Baixo Peso Molecular/administração & dosagem , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/tratamento farmacológico , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/tratamento farmacológico , Estudos Prospectivos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/tratamento farmacológico , Estudos Retrospectivos , Traumatismos da Coluna Vertebral/diagnóstico , Traumatismos da Coluna Vertebral/cirurgia , Trombose Venosa/diagnóstico , Trombose Venosa/tratamento farmacológico , Adulto JovemRESUMO
Successful replantation of distal digital segments necessitates the establishment of sufficient outflow to minimize congestion and progressive tissue necrosis. In cases where only arterial anastomosis is feasible, an artificial outlet must be provided to maintain physiological requirements until microvenous circulation regenerates. This can be accomplished using any number of "exsanguination techniques" designed to facilitate egress through ongoing passive blood loss. Although reportedly effective, these measures are imprecise and carry a substantial risk of infection, scarring, and/or uncontrolled hemorrhage. Herein, we describe a preemptive alternative for provisional venous drainage, whereby direct catheterization of a distal arterial branch is used to enhance the precision of outflow management following artery-only digital replantation. The establishment of intravascular access, using the technique described, permits remote manipulation of the microcirculatory environment through timed administration of heparinized saline and regulated removal of controlled volumes of blood.
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OBJECTIVES: Although most clavicular fractures are amenable to nonoperative management, metadiaphyseal fractures are considerably more complex, with rates of suboptimal healing as high as 75% when treated nonoperatively. The poor results are ascribed to the deforming forces on the distal clavicle from the surrounding muscles and the weight of the arm. It recently has been noted that some operative fixations of these fractures are also failing when a standard superiorly placed plate is used. We hypothesized that anterior plating, when compared with superior plating, improves the strength and durability of the construct by redirecting the axis of the major deforming force across rather than in line with the screws of the construct. METHODS: Six pairs of fresh-frozen human cadaveric clavicles with the scapula attached by the coracoclavicular ligaments were osteotomized just medial to the ligaments and plated with a standard 3.5-mm limited-contact dynamic compression plate. Specimens were potted and mounted on a materials testing system machine, preserving the anatomic relationship of the clavicle and scapula. They were then loaded through the coracoclavicular ligaments to mimic the weight of the arm pulling inferiorly. Each specimen was loaded with 375 N at 1 Hz for 2000 cycles. Sequential loading was then applied at 25-N intervals until failure. Statistical analysis was performed using a Wilcoxon signed-rank test. RESULTS: The superiorly plated specimens failed after fewer cycles and with lower force than the anteriorly plated specimens. The median number of cycles to failure was 2082 for anterior plated specimens and 50 for superiorly plated (P = 0.028). The median load to failure was 587.5 N in the anterior group and 375 N in the superior group (P = 0.035). The median stiffness was 46.13 N/mm for anterior and 40.45 N/mm for superior (P = 0.375) plates. CONCLUSIONS: Anteriorly plated distal third clavicular fractures have superior strength and durability compared with fractures plated superiorly when using a physician-contoured, 3.5-mm, limited-contact, dynamic compression plate in this cadaver model.
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Placas Ósseas , Clavícula/lesões , Clavícula/cirurgia , Fixação Interna de Fraturas/instrumentação , Fraturas Ósseas/fisiopatologia , Fraturas Ósseas/cirurgia , Idoso , Idoso de 80 Anos ou mais , Parafusos Ósseos , Cadáver , Clavícula/fisiopatologia , Simulação por Computador , Análise de Falha de Equipamento/métodos , Feminino , Fixação Interna de Fraturas/métodos , Fricção , Humanos , Masculino , Modelos Biológicos , Falha de Prótese , Ajuste de Prótese/métodos , Implantação de Prótese/métodos , Estresse Mecânico , Resultado do Tratamento , Suporte de CargaRESUMO
AIM: The aim of this study was to investigate the effects of compartment syndrome and timing of fasciotomy wound closure on surgical site infection (SSI) after surgical fixation of tibial plateau fractures. Our primary hypothesis was that SSI rate is increased for fractures with compartment syndrome versus those without, even accounting for confounders associated with infection. Our secondary hypothesis was that infection rates are unrelated to timing of fasciotomy closure or fixation. MATERIALS AND METHODS: We conducted a retrospective cohort study of operative tibial plateau fractures with ipsilateral compartment syndrome (n=71) treated with fasciotomy at our level I trauma center from 2003 through 2011. A control group consisted of 602 patients with 625 operatively treated tibial plateau fractures without diagnosis of compartment syndrome. The primary outcome measure was deep SSI after ORIF. RESULTS: Fractures with compartment syndrome had a higher rate of SSI (25% versus 8%, p<0.001). The difference remained significant in our multivariate model (odds ratio, 7.27; 95% confidence interval, 3.8-13.9). Delay in timing of fasciotomy closure was associated with a 7% increase per day in odds of infection (95% confidence interval, 0.2-13; p<0.05). CONCLUSIONS: Tibial plateau fractures with ipsilateral compartment syndrome have a significant increase in rates of SSI compared with those without compartment syndrome (p<0.001). Delays in fasciotomy wound closure were also associated with increased odds of SSI (p<0.05).
Assuntos
Síndromes Compartimentais/cirurgia , Fasciotomia/métodos , Fixação Interna de Fraturas/métodos , Fraturas Expostas/cirurgia , Infecção da Ferida Cirúrgica/cirurgia , Fraturas da Tíbia/cirurgia , Síndromes Compartimentais/etiologia , Síndromes Compartimentais/patologia , Feminino , Seguimentos , Fraturas Expostas/complicações , Fraturas Expostas/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/patologia , Fraturas da Tíbia/complicações , Fraturas da Tíbia/patologia , Resultado do TratamentoRESUMO
BACKGROUND: Medial epicondyle fractures in pediatric patients might be associated with an occult elbow dislocation and neurovascular damage. METHODS: A single case of a medial epicondyle fracture presenting with brachial artery transection was reviewed. Presentation, clinical course, and early outcome are reported. RESULTS: A 14-year-old patient presenting with an apparently isolated medial epicondyle fracture was found to have examination and diagnostic test findings consistent with brachial artery transection. His injury was explored and repaired acutely, resulting in acute return of perfusion. Final follow-up revealed 0° to 130° of flexion-extension arc of motion and full pronation and supination with normal sensory and motor function of the hand. CONCLUSIONS: Pediatric medial epicondyle fractures should alert the clinician to the possibility of an occult dislocation of the elbow, and a full neurovascular assessment should be performed. Early recognition and repair of a vascular injury associated with this fracture can lead to a good outcome.
Assuntos
Artéria Braquial/lesões , Fraturas Fechadas/complicações , Fraturas do Úmero/complicações , Adolescente , Artéria Braquial/diagnóstico por imagem , Artéria Braquial/cirurgia , Fraturas Fechadas/cirurgia , Humanos , Fraturas do Úmero/cirurgia , MasculinoRESUMO
Supplemental perioperative oxygen (SPO) therapy has been proposed as one approach for reducing the risk of surgical site infection (SSI). Current data are mixed regarding efficacy in decreasing SSI rates and hospital inpatient stays in general and few data exist for orthopaedic trauma patients. This study is a phase III, double-blind, prospective randomized clinical trial with a primary goal of assessing the efficacy of 2 different concentrations of perioperative oxygen in the prevention of SSIs in adults with tibial plateau, pilon (tibial plafond), or calcaneus fractures at higher risk of infection and definitively treated with plate and screw fixation. Patients are block randomized (within center) in a 1:1 ratio to either treatment group (FiO2 80%) or control group (FiO2 30%) and stratified by each study injury location. Secondary objectives of the study are to compare species and antibacterial sensitivities of the bacteria in patients who develop SSIs, to validate a previously developed risk prediction model for the development of SSI after fracture surgery, and to measure and compare resource utilization and cost associated with SSI in the 2 study groups. SPO is a low cost and readily available resource that could be easily disseminated to trauma centers across the country and the world if proved to be effective.
Assuntos
Infecções Bacterianas/economia , Fraturas Ósseas/economia , Fraturas Ósseas/cirurgia , Oxigenoterapia/economia , Oxigenoterapia/métodos , Infecção da Ferida Cirúrgica/economia , Infecção da Ferida Cirúrgica/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções Bacterianas/epidemiologia , Infecções Bacterianas/prevenção & controle , Terapia Combinada/economia , Terapia Combinada/métodos , Terapia Combinada/estatística & dados numéricos , Relação Dose-Resposta a Droga , Feminino , Fraturas Ósseas/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/administração & dosagem , Oxigenoterapia/estatística & dados numéricos , Assistência Perioperatória/economia , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Infecção da Ferida Cirúrgica/diagnóstico , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto JovemRESUMO
Carpal tunnel syndrome is the most common peripheral nerve compression syndrome. Treatment options include wrist-neutral bracing, corticosteroid injections, operative release of the transverse carpal ligament, and symptom-relief options. Endoscopic carpal tunnel release may give patients a faster recovery compared with traditional open release, but there are no ultimate differences in outcome among the various surgical options.