Does the Subtalar or Tibiotalar Joint Need Fused in Primary Retrograde Tibiotalocalcaneal Nailing for Fragility Ankle Fractures?

BACKGROUND: As an alternative to traditional open reduction internal fixation of ankle fragility fractures, primary retrograde tibiotalocalcaneal (TTC) nailing has been investigated as a treatment option. These results suggest that this treatment is an acceptable alternative treatment option for these injuries. There are still questions about the need for formal joint preparation at the subtalar or tibiotalar joint when performing primary TTC nailing for fragility fractures. METHODS: In this study, we retrospectively evaluated 32 patients treated with primary retrograde TTC nail without subtalar or tibiotalar joint preparation for a mean of 2.4 years postoperatively. We specifically reviewed the charts for nail breakages at either joint, patients developing subtalar or tibiotalar joint pathology requiring additional treatment, including return to the operating room for formal joint preparation. RESULTS: Fracture union occurred in 100% of patients. There were 3 cases (10.0%) of hardware failure, and 2 of these cases were asymptomatic and did not require any treatment. One patient (3.3%) developed hardware failure with nail breakage at the subtalar joint. This patient developed progressive pain and symptoms requiring revision surgery with formal arthrodesis of the subtalar and tibiotalar joint. CONCLUSIONS: This study shows that retrograde hindfoot nailing without formal subtalar or tibiotalar joint preparation is an acceptable potential treatment option in ankle fragility fractures. Mid-term follow-up demonstrates favorable outcomes without the need for formal joint preparation in this high-risk population. Comparative studies with higher patient numbers and long-term follow-up are needed to confirm the results of this study.Levels of Evidence: Level IV.

Symptomatic rib fracture nonunion: a systematic review of the literature.

INTRODUCTION: Rib fractures commonly occur in trauma patients with varying presentations. Though the literature in recent years has moved toward favoring more early intervention of acute rib fractures, little has been reported on the matter of surgical fixation for symptomatic rib fracture nonunions. MATERIALS AND METHODS: We performed a review of PubMed and Cochrane databases for articles published since 2000. Inclusion criteria were studies with greater than six months of follow-up, while case studies were excluded. A thorough analysis was performed on patient outcomes, complications reported, operative techniques utilized, and fixation systems used, among other parameters reported by the articles. RESULTS: One hundred and thirty-nine studies resulted from our review, and a total of nine studies met our inclusion criteria with a combined total of 182 patients who underwent open reduction and internal fixation for symptomatic rib fracture nonunions. All studies reported a significant reduction of pain with increased satisfaction in the majority of patients. There were a total of 71 postoperative complications, the most common of which included surgical site infections, hardware failure, and hematoma. The most serious complications were insulting injury to the lung parenchyma or pleura; however, these were extremely rare based off the current literature. The use of bone grafting was common with eight of the nine studies mentioning the benefits of grafting. CONCLUSION: Surgical stabilization of rib fracture nonunions appears to be an appropriate treatment alternative, and various techniques and approaches may be used with similar success. Further studies with higher level of evidence are recommended on the subject.

Go with the flow: An experimental analysis with tubing alternative with irrigation.

Background and Aims: Literature regarding alternative tubing for fluid delivery in irrigation and debridement procedures is lacking. The purpose of this study was to compare three different apparatuses with varying quantities of irrigation fluid to assess efficiency of administration and evaluate overall time for fluid administration. Methods: This model was designed to compare available methods of gravity irrigation used in practice. Fluid flow time was measured for three types of tubing: single-lumen cystoscopy tubing, Y-type double-lumen cystoscopy tubing, and nonconductive suction tubing. Irrigation times were assessed for varying volumes of 3, 6, and 9 L to investigate the relationship between bag changes and irrigation time. Bag changes were not conducted for the 3 L trial, but were for 6 and 9 L trials. Dimensions of cystoscopy tubing consisted of 4.95 mm internal diameter and 2.1 m length in both single-lumen and Y-type double-lumen apparatus. Nonconduction suction tubing dimensions were 6.0 mm internal diameter and standard 3.7 m in length. Results: The mean flow time for suction tubing was significantly faster than the cystoscopy tubing for the 3 and 9 L trials (p < 0.001). At 6 L, flow time for the suction tubing and the double lumen cystoscopy tubing were similar, 264 versus 260 s, respectively. At 9 L, the mean flow time for the suction tubing was 80 s faster (410 vs. 491 s) compared with single-lumen cystoscopy and was nearly 30 s faster compared with Y-type cystoscopy tubing. Conclusion: The results of this study provide insight into a faster, widely available, and cost-efficient alternative to commonly used cystoscopy tubing.

Reverse shoulder arthroplasty for proximal humerus fractures: a comparison of the deltoid split and deltopectoral approaches.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) is a common treatment for three- and four-part proximal humerus fractures. RSA is commonly performed through a deltopectoral (DP) surgical approach; however, a deltoid split (DS) approach has been described. The purpose of this study was to compare the intraoperative and postoperative outcomes of patients undergoing RSA for proximal humerus fractures through a DP and DS approach. MATERIALS AND METHODS: A retrospective study of patients who underwent RSA for proximal humerus fractures at our level 1 trauma center was performed. Patients were evaluated at a minimum 1-year follow-up. Intraoperative outcomes as well as patient-reported outcome measures (PROMs) were analyzed. Postoperative complications, reoperation rates, and radiographic outcomes were evaluated. RESULTS: Sixteen patients were included in the DP group and 13 patients in the DS group. The average follow-up was 28.6 months in the DP group and 21.1 months in the DS group. There were no significant differences in patient demographics or injury characteristics. Operative time was significantly shorter in the DS group (103 min) compared to the DP group (123 min). Tuberosity repair was performed in 81.3% of patients in the DP group and 92.3% of patients in the DS group. No significant differences were found in PROMs at final follow-up. There were no significant differences in postoperative complications. Three patients in the DP group and one patient in the DS group required reoperation. Lastly, 81.8% of patients achieved tuberosity union in the DS group and 66.7% in the DP group; however, this did not reach statistical significance. CONCLUSION: This study demonstrates that RSA for proximal humerus fractures performed through a DS or DP approach may result in similar intraoperative and postoperative outcomes, with no difference in reoperation or complication rates.

Operative fixation of rib fracture nonunions.

INTRODUCTION: Rib fractures are common injuries in trauma patients that often heal without intervention. Infrequently, symptomatic rib fracture nonunions are a complication after rib fractures. There is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe the efficacy of rib fracture nonunion operative fixation with particular focus on surgical technique, healing rates, and complications. MATERIALS AND METHODS: Patients aged ≥ 18 years with symptomatic rib fracture nonunions treated with open reduction and internal fixation (ORIF) with locking plates at a single urban level 1 trauma center were retrospectively reviewed. Pertinent demographic, clinical, radiographic, and surgical data were collected and analyzed. RESULTS: A total of 18 patients met inclusion criteria. The mean time from injury to undergoing ORIF for rib fracture nonunion was just under a year and the number of ribs plated was 2.95 ± 1.16 (1-5 ribs) with bone grafting used in six cases. All patients (100%) showed evidence of healing at an average of 2.65 ± 1.50 months (2-8 months). All patients reported a decrease in pain. No narcotic pain medication was used at an average of 3.88 ± 3.76 weeks (0-10 weeks) post-operatively. Intraoperative and postoperative complications were found in 4 (22.2%) patients. CONCLUSION: This study concluded that operative fixation of symptomatic rib fracture nonunion demonstrated favorable outcomes with reduction in preoperative pain levels, decreased use of narcotic pain medication, minimal complications, and a high rate of fracture union. This described method provides symptomatic relief, reduction in pain, and promotes bony healing of the fracture nonunion without development of major complications. We suggest that operative fixation should be considered as the primary method of treatment of symptomatic rib nonunions.

Intramedullary Screw Fixation Versus Traditional Plating for Distal Fibula Fractures.

The traditional method of treating fibular fractures in unstable ankle injuries involves open reduction and internal fixation with a plate and screw construct. Less invasive percutaneous fixation techniques with intramedullary fibular screws have been utilized for many years to reduce wound and implant complications while maintaining a stable ankle mortise. However, there have been no direct case-control studies comparing percutaneous intramedullary fibular screw fixation to the traditional open reduction and internal fixation with plates and screws. In our study, we compared radiographic and clinical outcomes for unstable ankle fractures in which the fibula fracture was treated with either a percutaneous intramedullary screw or by open reduction and internal fixation with a plate and screw construct. We retrospectively reviewed 69 consecutive patients from 2011 to 2019 with unstable ankle fractures treated with intramedullary fibular screws and compared them to 216 case-control patients treated with traditional plate and screw construct over the same time period. The average follow-up for the intramedullary screw group was 11.5 months and 15.2 months for the plate and screw group. We collected general demographic data, measured intraoperative and final follow-up talocrural angles, Kellgren-Lawrence osteoarthritis grade, union rates, implant removal rates, infection rates, and American Orthopedic Foot and Ankle Society ankle-hindfoot scores. The intramedullary screw group had a statistically significant lower rate of delayed implant removal (8.7% vs 23.6%) and there was no detectable difference in other measures.

Correlation of Lisfranc Injuries With Regional Bone Density.

Lisfranc injuries present a challenge due to their ubiquity though frequent missed diagnoses. A paucity of data exists associating the contribution of bone density to injury type. This investigation compares the regional bone density between Lisfranc injury types using computed-tomography (CT)-derived Hounsfield units. A retrospective chart review identified patients with gross ligamentous and avulsion-type Lisfranc injuries determined by CT examination of the second metatarsal base and medial cuneiform. Regional bone density was assessed by averaging the Hounsfield units of the first metatarsal base, navicular, cuboid, calcaneus, and talus between 2 reviewers. Density was compared between injury type, isolated concomitant forefoot, and mid/hindfoot fractures. One hundred thirty-four patients were separated into avulsion (n = 85) and ligamentous (n = 49) groups. No statistically significant difference in patient body mass index, age, smoking status, or Quenu and Kuss injury pattern was observed between groups. The regional bone density of the cuboid (p = .03) and talus (p = .04) was greater in the ligamentous group. Lower extremity concomitant mid/hindfoot fracture patients exhibited greater regional bone density in the ligamentous group in all assessed bones (p ≤ .04) except the calcaneus. Ligamentous injuries of the Lisfranc complex are associated with increased regional bone density among patients sustaining concomitant mid/hindfoot fractures. This study expands the utility of regional bone density analysis in foot and ankle trauma.

Outpatient Surgery for Rib Fracture Fixation: A Report of Three Cases.

Rib fractures are common injuries observed in trauma patients that will often heal without operative intervention. However, patients can infrequently have continued pain. Operative fixation of these symptomatic rib fractures has traditionally led to the patient requiring hospital admission for observation and pain control. The purpose of this study was to review three cases of outpatient rib fracture, open reduction and internal fixation (ORIF) surgery. Three patients with symptomatic rib fractures treated with ORIF at a single urban level one trauma center underwent outpatient same-day surgery. Pertinent demographic, clinical, radiographic, and surgical data were collected. All patients had decreased preoperative pain and no complications. This case series demonstrates that outpatient surgery for rib fracture ORIF can be performed safely in a select patient population. Additionally, it has similar efficacy as inpatient operative fixation with the main added benefit being decreased costs to both the patient and the healthcare system. We suggest that outpatient operative fixation of rib fractures should be considered for select patients.

Patients of Obese Representation Require Longer Operative Times: An Evaluation of Acetabular and Pelvic Ring Operative Duration.

Recent literature has determined that operative times for the obese population are greater for both elective and nonelective orthopedic procedures. If time allotted for a given surgical procedure is used as a measure of procedural difficulty, then consideration can be given for using an additional coding modifier (i.e., Modifier 22) for the increased skill and effort associated with longer procedures. A retrospective chart review was conducted on all patients who underwent surgical treatment for an acute fracture about the pelvis at an urban level-1 trauma center from October 1, 2010 through October 31, 2018. After allowing for both inclusion and exclusion criteria, 102 patients with acetabular fractures and 55 patients with pelvic ring injuries were included in this investigation. The obese population within the acetabular fracture cohort demonstrated significantly longer mean times for the duration of surgery, total time in spent in the operating room, and duration under anesthesia (P values of 0.038, 0.05 and 0.035, respectively). Similar results were observed with the pelvic ring injury cohort, with significantly longer procedural times (P = 0.019), total time in the operating room (P = 0.034), and total duration under anesthesia (P = 0.0395). A trend towards a greater risk of infection was found in obese patients (7%) when compared with nonobese patients (1.6%) within the acetabular fracture subset (P = 0.093). Operative duration for acetabular fractures and pelvic ring injuries is significantly longer in the obese population. Furthermore, this indicates that a Modifier 22 may be justified for the surgical treatment of these injuries in the obese and morbidly obese patient populations.

The Intercalary Fragment in Posterior Malleolus Fractures: Characterization and Significance.

Methods of fixation in ankle fractures involving the posterior malleolus have become increasingly scrutinized. With the increase in computed tomography (CT), an intercalary fracture fragment (ICF) adjacent to the posterior malleolus has been oft described. Treatment of the ICF remains controversial and the purpose of this study was to evaluate radiographic and clinical outcomes in patients who had direct reduction and fixation of this fragment compared to those where the ICF was not fixed. This retrospective study included 249 trimalleolar and posterior pilon ankle fractures grouped into those who had the ICF reduced and fixed (n = 74) and those where the ICF was not directly addressed (n = 175). CT scans were evaluated for size and location of the ICF. Demographic, radiographic and intraoperative variables were collected and analyzed. The group which had the ICF reduced and fixed had decreased Kellgren-Lawrence scores (p = .001). There was also a higher rate of repeat surgery in the group who had the ICF fixed, although not meeting statistical significance. There were no differences in size or location of the ICF fragment between groups. We did identify similarities with other studies in regard to size and posterolateral location of the ICF between groups. However, based on worsening radiographic outcomes of the group where the ICF was reduced and fixed, we do not necessarily recommend universal treatment of this fragment. The surgeon's goal should always be a concentric articular reduction and treatment of the ICF should be considered on a case-by-case basis.

Excessively long interfragmentary screws for posterior wall acetabular fractures can predict intra-articular penetration.

BACKGROUND: The fixation of posterior wall acetabular fractures often utilizes interfragmentary screws with varying length. Intricate pelvic anatomy and overhanging greater trochanter make obtaining proper screw trajectory difficult. A large measurement may represent aberrant trajectory and breach of the articular surface. This study aims to identify a preferred maximum screw length that avoids intra-articular penetration. HYPOTHESIS: We hypothesized that a screw measured 40 millimeters or longer has a high likelihood of being intra-articular. PATIENTS AND METHODS: A retrospective review included CT scans of 151 consecutive patients collected at a level-1 trauma center was analyzed by two observers. On axial imaging, a straight line was measured at the largest extraarticular portion of the posterior wall simulating ideal screw placement. Another line was measured tangent to the articular surface simulating longest possible extraarticular screw. Measurements were taken at 2-millimeter increments. RESULTS: The intra-class correlation coefficient between both observers was excellent (0.75-1.00) for most recorded values. The maximum mean length for straight line measured (m=32.18mm, SD=3.74) which was smaller than the mean length for tangent line (m=38.44, SD=4.29). Exploratory multivariate logistic regression analyses demonstrated increased height, age, and acetabular version were associated with larger measurements greater than 40mm (p<0.05). DISCUSSION: This study demonstrates that most acetabular posterior walls cannot accommodate a 40 millimeter lag screw. If the measured drill hole is greater than this length, then careful reconsideration of the screw trajectory is warranted to ensure the screw is not intra-articular. Older and taller patients may be able to accommodate longer screws. LEVEL OF EVIDENCE: III.

Pelvic Shadowing as a Diagnostic Predictor of Orthopedic Pathology in Orthopedic Trauma Patients.

Introduction The Throckmorton sign, or John Thomas sign, is a well-established orthopedic eponym, anecdotally used in orthopedic surgery to correlate the direction of male genitalia, observed on a pelvic radiograph, with the laterality of an associated orthopedic pathology. In earlier studies, the direction of pelvic shadowing on X-ray has been neither a credible nor a reliable predictor of fracture laterality. Given this small body of evidence, we sought to further investigate the relationship between peri-trochanteric hip fracture laterality and male genitalia lie. Method A single-center retrospective chart review was conducted of 397 consecutive male patients who received pelvic radiographs performed upon entry to an urban level 1 trauma center. Exclusion criteria included age less than 18 years or a prior history of pelvic or urological surgery. Of this cohort, 360 patients met the inclusion criteria and underwent investigation. Results The study population had an average age of 42 years (range: 18-91 years). Statistical analysis yielded a 4.24 relative risk with pelvic shadowing laterality and respective peri-trochanteric hip fracture sidedness. Additionally, there was a 4.63 and 9.88 relative risk of tibial shaft fractures and distal radius fractures having a concomitant positive Throckmorton Sign, respectively. Conclusion Pelvic shadowing can be used as an additional diagnostic tool in predicting peri-trochanteric hip fracture sidedness in a trauma bay setting.

Split-Thickness Skin Grafting: A Primer for Orthopaedic Surgeons.

Soft-tissue defects pose a unique challenge to the treating orthopaedic surgeon. Such defects are commonly encountered after orthopaedic injuries or infection, and the management of these wounds varies significantly. Skin grafting has gained popularity in the management of such soft-tissue defects due to its ability to provide coverage, re-epithelialize, and have a relatively high success rate. One of the most frequently used types of skin graft in orthopaedics is the split-thickness skin graft (STSG). Understanding the proper indications, technique, and management of the STSG foreshadows its success or failure. This review focuses on the indications, technique, alternatives, and complications surrounding the utilization of the STSG in the management of orthopaedic injuries.

Use of 3D Navigation Versus Traditional Fluoroscopy for Posterior Pelvic Ring Fixation.

Unstable pelvic ring disruption is most commonly treated with closed reduction and percutaneous screw fixation. Traditional methods involve screw placement under fluoroscopic imaging, but with recent technologic advances, intraoperative 3D navigation can now be used to help with the insertion of sacroiliac screws. Various cadaver studies have shown that placement of sacroiliac screws under 3D navigation is more accurate than placement under traditional fluoroscopic guidance. This retrospective review of 134 patients evaluated the clinical use of 3D navigation vs traditional fluoroscopy for sacroiliac screw insertion at an urban level I trauma center. Analysis of surgical data showed a significantly longer imaging time with the conventional method compared with the more experimental 3D navigation (204.06 seconds vs 66.90 seconds, P<.01). Further, a significantly larger radiation dose to both the patient and the staff was seen with traditional fluoroscopy (80.1 mGy for each) compared with that of 3D navigation (39.0 mGy and 25.1 mGy, respectively). No statistically significant difference was seen for outcome or follow-up variables between the 2 extrapolated groups. These variables included length of hospital stay, infection, nerve injury, and hardware breakage. The authors advocate that 3D navigated sacroiliac screws are safe and effective for pelvic ring stabilization; this method may be especially applicable in certain difficult imaging situations, such as morbid obesity, bowel gas interference, and overlapping pelvic structures that make the sacral corridor difficult to discern with traditional 2D fluoroscopy. Safe placement of transiliac-transsacral screws (P<.01) occurred with 3D navigation, and there was a statistically significant increase in adequate screw placement in multiple sacral segments compared with single-level stabilization (P<.01). [Orthopedics. 2021;44(4):229-234.].

A Modern "Nightstick Fracture" Induced by Contemporary Ballistics During the George Floyd Protests.

A 28-year-old male presented to the emergency department with an isolated ulnar shaft fracture secondary to a ballistic injury with a wooden pellet gun. This injury is also known as a "nightstick fracture," which is a common eponym in orthopedic surgery used to describe a fracture of the ulnar shaft. The eponym gained its title for the injury commonly seen when in a defensive position while being attacked with a wooden club. It is widely accepted that this infamous injury was popularized in the 1960s as a sequela of the many race-related riots across the United States. This case details how the nightstick fracture is still prevalent as a result of political protesting today, despite modern-day methods of non-lethal riot control.

Effect of Early Weight Bearing on Outcomes After Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures.

Current practice allows early weight bearing of unstable ankle fractures after fixation. This study offers a unique comparison of early weight bearing (EWB) vs late weight bearing (LWB) in operatively stabilized trimalleolar ankle fractures. The goal of this study was to evaluate union rates, clinical outcomes, and complications for patients who were managed with EWB vs LWB. The authors performed a retrospective review of 185 patients who underwent surgical stabilization for trimalleolar ankle fracture. Fixation of the posterior malleolus and weight bearing status were determined by surgeon preference. For this study, EWB was defined as 3 weeks or less and LWB was defined as greater than 3 weeks. Patients were evaluated for fracture union and implant failure. Complications and clinical outcomes included ambulatory status, infection rate, and return to surgery. The EWB group included 47 (25.4%) patients, and the LWB group included 138 (74.6%) patients. Of the 7 nonunions, 1 (14.3%) occurred in the EWB group and 6 (85.7%) in the LWB group. A total of 72 (38.9%) posterior malleolar fractures were operatively stabilized, and stabilization did not affect union rates. Syndesmotic fixation was required for 12.5% of patients, despite posterior malleolar stabilization. Syndesmotic fixation increased the union rate 2.5 times. Deep infection and open fracture decreased union. No difference was seen between groups in implant failure, union rate, infection, or return to the operating room. No deleterious effect of EWB in operatively treated trimalleolar ankle fractures was found for union, implant failure, infection, or reoperation. Syndesmotic fixation may offer an advantage over posterior malleolar fixation, with improved union rates. [Orthopedics. 2021;44(3):160-165.].

Improved Outcomes Using a Fibular Strut in Proximal Humerus Fracture Fixation.

Proximal humerus fractures, although common, have high rates of failure after open reduction and internal fixation. The use of a fibular allograft has been explored as a means to decrease complications, particularly varus collapse and the need for revision surgery. The authors performed a retrospective review of 133 proximal humerus fractures managed surgically with locking plates (n=72) or locking plates with fibular allograft intramedullary struts (n=61). Demographic, intraoperative, and postoperative variables were collected and analyzed. The fibular allograft group was more likely to be older (P<.01), be female (P=.04), and have a history of osteoporosis (P=.01). No differences were noted in the proportions of 2-, 3-, or 4-part fractures between groups. Average follow-up was 28 weeks. Medial calcar length was longer in the locking plate only group (P=.04); however, this group demonstrated a decreased head shaft angle (P=.01) and a trend toward increased rates of varus collapse (P=.06). No significant differences were found regarding other radiographic complications, irrespective of fracture complexity. A notable decrease in fluoroscopy time was seen with strut use (P=.04), but operative time and blood loss were similar between groups. A significant decrease in revision surgery rate was found with use of an allograft strut (P=.05). Using a strut appears to preserve the radiographic head shaft angle and decrease the risk of fracture collapse in 2-, 3-, and 4-part fractures, without increasing surgical time or morbidity. Use of an intramedullary strut appears to reduce the need for revision surgery, particularly in 3- and 4-part fractures. [Orthopedics. 2020;43(5):262-268.].

Masquelet Technique for Chest Wall Reconstruction: A Case Report.

CASE: A 33-year-old man with recurrent intrathoracic scapular dislocation due to previous trauma-related chest wall resection successfully underwent the 2-stage induced membrane technique commonly known as the Masquelet technique; this procedure effectively created 2 new ribs that resolved his symptoms. CONCLUSIONS: Techniques for chest wall reconstruction for bone loss are quite limited, and these often consist of filling defects with a layered patch; this often cannot withstand the cyclical respiratory motion. Use of the induced membrane technique appears to carry potential when used in the chest wall, and this report describes a technique by which this procedure can be reliably performed.