Diagnosing posterior tibial tendon tear with dynamic ultrasound following tibial intramedullary nailing.

Complications following tibial intramedullary nailing include anterior knee pain, malunion, nonunion, and symptomatic/prominent interlocking screws. We report a case of a posterior tibial tendon tear caused by placement of a distal interlocking screw which was detected via dynamic ultrasound. This is a rare and possibly underreported complication which could be the cause of persistent medial sided ankle pain following locked tibial nail placement.

Cost Determinants in the 90-Day Management of Isolated Ankle Fractures at a Large Urban Academic Hospital.

OBJECTIVES: To determine the independent risk factors associated with increasing costs and unplanned hospital readmissions in the 90-day episode of care (EOC) for isolated operative ankle fractures at our institution. DESIGN: Retrospective cohort study. SETTING: Level I Trauma Center. PATIENTS: Two hundred ninety-nine patients undergoing open reduction internal fixation for the treatment of an acute, isolated ankle fracture between 2010 and 2015. INTERVENTION: None. MAIN OUTCOME MEASURES: Independent risk factors for increasing 90-day EOC costs and unplanned hospital readmission rates. RESULTS: Orthopaedic (64.9%) and podiatry (35.1%) patients were included. The mean index admission cost was $14,048.65 ± $5,797.48. Outpatient cases were significantly cheaper compared to inpatient cases ($10,164.22 ± $3,899.61 vs. $15,942.55 ± $5,630.85, respectively, P < 0.001). Unplanned readmission rates were 5.4% (16/299) and 6.7% (20/299) at 30 and 90 days, respectively, and were often (13/20, 65.0%) due to surgical site infections. Independent risk factors for unplanned hospital readmissions included treatment by the podiatry service (P = 0.024) and an American Society of Anesthesiologists score of ≥3 (P = 0.017). Risk factors for increasing total postdischarge costs included treatment by the podiatry service (P = 0.011) and male gender (P = 0.046). CONCLUSIONS: Isolated operative ankle fractures are a prime target for EOC cost containment strategy protocols. Our institutional cost analysis study suggests that independent financial clinical risk factors in this treatment cohort includes podiatry as the treating surgical service and patients with an American Society of Anesthesiologists score ≥3, with the former also independently increasing total postdischarge costs in the 90-day EOC. Outpatient procedures were associated with about a one-third reduction in total costs compared to the inpatient subgroup.

Placing femoral intramedullary nails in severely bowed femurs.

The authors describe a novel technique of anterograde femoral intramedullary nail fixation for hip fracture using the starting guide pin as a blocking screw. This cost-effective technique uses fluoroscopic radiography to ensure the guidewire is within the posterior aspect of the femur on a lateral view, thereby minimizing the risk of anterior cortical femoral fractures.

Percutaneous column fixation and total hip arthroplasty for the treatment of acute acetabular fracture in the elderly.

We used our database of primary total hip arthroplasties to identify those patients who had acetabular fractures fixed with percutaneous screws under the same anesthesia as for the arthroplasty procedure. There were 19 patients with the average follow-up of 22 months. Fourteen patients sustained the fracture secondary to a low-energy trauma, while the remaining patients were involved in a high-energy trauma accident. The mean survival time was calculated to be 2.5 ± 0.6 years for the low-energy group and 4 ± 1.4 years for the high-energy group. We believe that this unique treatment of acetabular fractures has a role in carefully selected patients and provides the necessary reduction and immediate stability of the fracture needed to ensure adequate fit for the acetabular cup in the subsequent THA.

Incidence of orthopedic surgery intervention in a level I urban trauma center with motorcycle trauma.

BACKGROUND: This study summarizes orthopedic injuries sustained in motorcycle collisions in patients presenting to a Level I trauma center. METHODS: We performed a retrospective review of orthopedic injuries in motorcycle trauma victims brought into the emergency department. Of 2,634 presenting cases, 151 were identified as involving motorcycle collisions. Variables included age, gender, mechanism of injury, type and location of injury, concomitant injuries, length of hospitalization, number of orthopedic procedures during primary admission, and subsequent readmission. RESULTS: A total of 71.5% of patients required orthopedic consultation. Average age was 35.0 years, with men injured at a ratio of 8:1. The most common mechanism of injury was motorcycle versus automobile (n=48). A total of 206 fractures in 108 patients were discovered. The most common site of fracture involved the lower extremities. Open reduction with internal fixation was performed on 110 fractures (69 patients) during primary admission. Fifty-seven patients (52.8%) sustained open fractures requiring emergent orthopedic intervention. Fifty-three patients had various concomitant complications. Two patients died during initial hospitalization. Average hospitalization for patients without orthopedic consultation was 11.9 days versus 13.8 days with orthopedic consultation. The average number of orthopedic procedures performed on patients was 1.6. CONCLUSIONS: Motorcycle collisions frequently involve patients in their working prime, thus placing substantial burden on the individual and society. Although these patients must continue to receive Level I trauma care, strengthened prevention and improved education efforts are warranted.

Surgical outcomes after traumatic open knee dislocation.

The purpose of this study is to describe the types of injuries and surgical treatments associated with open knee dislocations and to present the functional outcomes of these patients. Between 2001 and 2005, the medical records of patients that sustained traumatic open knee dislocations at our Level 1 Trauma Center were retrospectively reviewed. Initial surgical intervention was performed in all patients including placement of spanning external fixator, repair of vascular injuries if necessary, and irrigation and debridement of the open wounds. Ligamentous reconstruction was delayed until after limb salvage. The Short Form-12 was the primary outcome measure. Seven patients (five male, two female) had a mean age of 31.9 years (range 22-44) at the time of injury (five right, two left). Motorcycle accident was the most common cause (57%). Follow-up was a mean 27.6 months. The PCL was damaged in all patients. Three patients underwent angiography for absent/diminished pulses on initial exam with two requiring operative intervention. Three patients had associated common peroneal nerve injury (one iatrogenic). Ten (10.7) operative procedures were performed per patient (range 5-18) with an average of 6.6 debridements (range 2-11). Infection rate was 43% with one patient undergoing amputation for infection. Good to excellent results were found in 33% of patients. Most patients (86%) report some residual symptomatic or functional deficit. Due to the injury complexity in open traumatic knee dislocations, the surgical treatment is extensive and challenging. While infection rates are high, aggressive, individualized treatment can lead to satisfactory outcome although full return to activity is difficult to achieve using current treatment methods.

Pelvic fractures in professional cyclists: a report of 3 cases.

BACKGROUND: Professional riders demonstrate increased risk factors for such injuries including both extensive time on the bike in addition to a possible underlying osteopenia secondary to the nonimpact nature of the sport. HYPOTHESIS: Nonoperative management of stable, nondisplaced pelvic fractures in professional cyclists offers excellent results. STUDY DESIGN: Case series. METHODS: Three cases of professional cyclists with pelvic fractures were reviewed. RESULTS: All 3 cyclists were able to return to professional competition and remain symptom free. CONCLUSION: Accurate early diagnosis of pelvic fractures, with the aid of computed tomography, is crucial. Early nonweightbearing with a progression to weightbearing as tolerated and early return to stationary training are appropriate. Accurate diagnosis and careful nonoperative management of stable, nondisplaced pelvic fractures in professional cyclists offers excellent results. CLINICAL RELEVANCE: Accurate diagnosis of pelvic fractures in high-demand athletes with few complaints and no obvious findings on plain film radiographs. Control of weightbearing and competitive status to prevent injury progression. Gauged return to competition at professional level.

Percutaneous fixation of the medial condyle in bicondylar tibial plateau fractures: novel use of the 3.5-mm medial distal tibia plate.

Internal fixation for fractures involving the medial tibial plateau is a controversial topic. Surgical options include buttress plating with antiglide plate, T-shaped proximal tibia plates, external fixation, and isolated screw fixation. Operative management is often complicated by soft-tissue concerns. In this article, we describe a percutaneous surgical technique in which a 3.5-mm medial distal tibia plate, originally designed for distal tibial shaft or pilon fractures, is used in osteosynthesis of the medial tibial plateau. Use of this implant reduces soft-tissue dissection and thereby decreases risk for soft-tissue infection or slough while preventing medial column collapse and varus deformity of the knee. Orthopedic surgeons should consider this novel hardware application as an option for osteosynthesis in certain bicondylar tibial plateau fractures.