Long-term sequelae of septic arthritis after tibial plateau fracture fixation: does timing matter?

INTRODUCTION: Septic arthritis following surgical treatment of a tibial plateau fracture is a rare complication, but it does occur, and the impact on long-term function is relatively unknown. The purpose of this study was to determine the long-term sequelae of septic arthritis among patients treated with internal fixation for a tibial plateau fracture and to determine the effect of timing (early or late infection) on the rate of such sequela. MATERIALS AND METHODS: A retrospective comparative study was designed using the trauma database of a single level I academic trauma center. Patients who developed culture-positive septic knee arthritis after internal fixation of a tibial plateau fracture, with 1-year follow-up, were included in the study. The number of debridement procedures required was recorded. Rates of long-term complications and implant removal were identified. Complications rates were compared between patients who developed early (within 30 days of definitive fixation) and late (more than 30 days) septic arthritis. RESULTS: The mean number of debridement procedures per patient was six. Fourteen patients (88%) required implant removal, and thirteen (81%) developed knee arthritis. There was a significantly lower rate of complications in the early septic arthritis group compared to the late group (3 of 6 patients or 50%, vs 10 of 10 patients or 100%; p = 0.036). CONCLUSIONS: Patients who developed septic arthritis following internal fixation of a tibial plateau fracture were likely to endure long-term sequelae. Early infection and detection led to fewer complications. Surgeons treating infectious complications in tibial plateau fracture patients should specifically seek to rule out septic arthritis, anticipate that implant removal may be necessary, and counsel these patients appropriately regarding the anticipated natural history of their condition. LEVEL OF EVIDENCE: III.

Locked Plating versus Nailing for Proximal Tibia Fractures: A Multicenter RCT.

OBJECTIVES: The main 2 forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing (IMN) and locked lateral plating (LLP). The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter, randomized controlled trial. SETTING: 16 academic trauma centers. PATIENTS/PARTICIPANTS: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to IMN, and 47 patients were randomized to LLP. INTERVENTION: IMN or lateral locked plating. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, Bother Index, EQ-5Dindex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number, and complications. RESULTS: Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months postinjury. Similarly, there was no difference in time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support, or complications. CONCLUSIONS: Both IMN and LLP provide for similar outcomes after these fractures. Patients continue to improve over the course of the year after injury but remain impaired even 1 year later. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg.

OBJECTIVE: Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS: Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS: The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION: This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial.

OBJECTIVES: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter randomized controlled trial. SETTING: Twenty academic trauma centers. PATIENTS/PARTICIPANTS: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Are evidence-based protocols which identify vascular injury associated with knee dislocation underutilized?

A concerning number of patients referred to our clinic with knee dislocations have not been thoroughly evaluated for popliteal injury. The objective of this study is to present our experience and attempt to identify possible causes for this trend. Thirty-one consecutive patients with knee dislocations referred over a 1-year period were evaluated. Patients were assigned to either of two groups: Group I included all patients initially evaluated with an evidence-based protocol for identifying clinically significant vascular injury associated with knee dislocation, and Group II included all patients who had not received an evidence-based evaluation. The main outcome measure was delay in the diagnosis of a limb threatening vascular injury (>8 h) within each group. Six out of the 31 patients referred, were evaluated for vascular injury without an evidence-based protocol. These patients were significantly more likely to have had a delay in the diagnosis of their vascular injury beyond 8 h (P = 0.032) and were less likely to have been evaluated at a level I trauma center (P < 0.001). As expected, evidence-based protocols are superior when compared to initial pedal pulse examination alone for identifying surgically significant vascular injury within 8 h. The consequences of a delay in diagnosis beyond 8 h can be catastrophic and one patient in this series required an above-knee amputation. This is not new information, however, a significant number of patients with knee dislocations continue to be evaluated solely by initial pedal pulse examination. Though effective protocols exist, orthopedic surgeons must work to facilitate the implementation of these protocols at their referring institutions.

Failure of fracture plate fixation.

Failure of fracture fixation after plating often leads to challenging surgical revision situations. Careful analysis of all patient and fracture variables is helpful in both determining the causes of the fixation failure and maximizing the success of subsequent interventions. Biologic and mechanical factors must be considered. Biologic considerations include traumatic soft-tissue injury and atrophic fracture site. Common mechanical reasons for failure include malreduction, inadequate plate length or strength, and excessive or insufficient construct stiffness. Reliance on laterally based implants in the presence of medial comminution may be a cause of fixation failure and subsequent deformity, particularly with conventional nonlocking implants. Management of dead space with cement or beads has been effective in conjunction with staged approaches. An antibiotic cement rod in the diaphysis may provide fracture stabilization. Locking full-length constructs should be considered for osteoporotic fractures.

Acute Exertional Compartment Syndrome of Bilateral Upper Extremities After a Push-up Contest.

Acute exertional compartment syndrome (AECS) involving the upper extremity is a rare form of compartment syndrome that occurs after physical activity. Despite its infrequent occurrence, AECS has devastating sequelae, including muscle necrosis and nerve injury. It is imperative to promptly evaluate for AECS in any patient who has notable pain and sensory changes in the context of recent physical activity because of the dire consequences of a missed diagnosis. A 34-year-old man presented to the emergency department with excruciating pain and diffuse paresthesias in his bilateral arms and forearms after participating in a push-up contest. He also had pain with passive stretch of his triceps. Because of these physical examination findings and uncontrollable pain, a clinical diagnosis of AECS was made and was managed with fasciotomies. Postoperatively, the patient's pain and paresthesias slowly resolved, and he was eventually able to return to work at full capacity as a construction worker. This example of AECS of bilateral upper extremities emphasizes that it is a condition that, although rare, is real and must be taken seriously. With appropriate clinical suspicion, a prompt diagnosis can be made, and potentially devastating consequences can be avoided.

Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns.

OBJECTIVES: Bicondylar tibial plateau fracture management remains therapeutically challenging, partly because of multiplanar articular comminution. This study was performed to evaluate the frequency and morphologic characteristics of the posteromedial fragment in this injury pattern. DESIGN: Retrospective chart and radiographic review. SETTING: Urban Level 1 university trauma center. PATIENTS: Fifty-seven patients sustaining 57 Orthopedic Trauma Association (OTA) C-Type bicondylar tibial plateau fractures formed the study group. MAIN OUTCOME MEASURE: Between May 2000 and March 2003, 170 OTA C-Type bicondylar tibial plateau fractures were identified using an orthopaedic database. One hundred and forty-six fractures had computed tomographic (CT) scans performed prior to definitive fixation and were reviewed using the Picture Archiving and Communication System (PACS). Sixty-six (45.2%) injuries had fractures that involved the medial articular surface. Nine with suboptimal CTs were excluded, leaving 57 injuries for review. Forty-two patients demonstrated coronal plane posteromedial fragments. Morphologic evaluation of the posteromedial fragment included articular surface area, maximum posterior cortical height (PCH), and sagittal fracture angle (SFA). RESULTS: Forty-two of 57 injuries (74%) demonstrated a posteromedial fragment that comprised a mean of 58% of the articular surface of the medial tibial plateau (range, 19%-98%) and a mean of 23% of the entire tibial plateau articular surface (range, 8%-47%). Mean posteromedial fragment height was 42 mm (range, 16-59 mm), and mean sagittal fracture angle was 81 degrees (range, 33 degrees to 112 degrees). Six patients demonstrated fracture patterns not accurately identified by the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fracture classification system. CONCLUSIONS: A posteromedial fragment was observed in nearly one third of the bicondylar plateau fractures evaluated. The morphologic features of this fragment may have clinical implications when using currently available laterally applied fixed-angle screw/plate implants to stabilize these injuries. Alternate or supplementary fixation methods may be required when managing this injury pattern.

The use of surgical drains in orthopedics.

The use of postsurgical drains have a long history in thoracic and abdominal surgery. In orthopedics these devices have been used to decrease local edema, lessen the potential for hematoma or seroma formation, and to aid in the efflux of infection. However, the role of postoperative surgical drains in clean, elective cases has not been firmly established. In fact, most studies fail to show a statistical difference in outcome between drained and undrained patients. Despite the paucity of clinical evidence demonstrating any benefit supporting their use, drains continue to be placed after elective orthopedic procedures.

Open diaphyseal long bone fractures: a reduction method using devitalized or extruded osseous fragments.

Open diaphyseal and meta-diaphyseal fractures of the lower extremity remain therapeutically challenging. Currently accepted treatment methods consist of a thorough irrigation and debridement of nonviable tissue combined with locked intramedullary nailing. Although exact reduction parameters remain controversial, achievement of a satisfactory reduction becomes increasingly difficult with fracture comminution and overt bone loss. We describe the simple technique of using multiple associated devitalized tibial bone fragments to obtain an accurate reduction prior to intramedullary nailing. This technique can be extended to other long bone fractures.

Simultaneous ipsilateral posterior knee and hip dislocations: case report, including a technique for closed reduction of the hip.

In isolation, dislocations of the hip and knee require emergent reduction to minimize the risks of serious complications, including vascular and neurologic injury, osteonecrosis of the femoral head, and loss of motion and function. With simultaneous dislocation of the ipsilateral hip and knee, as in the situation of hip dislocation with concomitant femoral shaft fracture, reduction of the hip may prove difficult because of the inability to control the femoral segment. In this setting, general anesthesia is commonly required. We present the case of a patient who sustained an ipsilateral hip and knee dislocation who underwent closed reduction of the knee in the emergency department but required general anesthesia and the insertion of Schanz pins in the femur to reduce the hip dislocation.

Dead Space Management After Orthopaedic Trauma: Tips, Tricks, and Pitfalls.

UNLABELLED: Dead space is defined as the residual tissue void after tissue loss. This may occur due to tissue necrosis after high-energy trauma, infection, or surgical debridement of nonviable tissue. This review provides an update on the state of the art and recent advances in the management of osseous and soft tissue defects. Specifically, our focus will be on the initial dead space assessment, provisional management of osseous and soft tissue defects, techniques for definitive reconstruction, and dead space management in the setting of infection. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Provisional plating of Type III open tibia fractures prior to intramedullary nailing.

Intramedullary nailing of tibial shaft fractures is the preferred treatment of most displaced, unstable tibial shaft fractures. In open tibia fractures, direct exposure of the fracture segments for irrigation and debridement is required prior to fracture stabilization. We propose a method of provisional stabilization using commonly available implants placed through the associated traumatic open wound prior to intramedullary nailing. This technique, particularly helpful to surgeons operating with limited assistance, employs a temporarily applied 3.5-mm dynamic compression plate or limited contact dynamic compression plate implant secured with unicortical screws, allowing reaming and intramedullary nailing of a reduced, stabilized tibia fracture.

Puerperal diastasis of the pubic symphysis. A case report.

BACKGROUND: Puerperal diastasis of the symphysis pubis is an uncommon intrapartum complication. Patients often respond to conservative measures. A small percentage of patients will develop chronic pain and require surgical treatment, which involves debridement or fusion of the symphysis pubis. CASE: A 33-year-old woman, gravida 1, para 0, with an uncomplicated prenatal course developed acute-onset anterior pubic pain during an otherwise normal delivery. This anterior pubic pain radiated to the left buttock and thigh. The pain persisted postpartum and was exacerbated by any movement. Radiographs confirmed pubic symphysis diastasis. The patient responded to conservative management and was essentially pain free by 10 weeks postpartum. CONCLUSION: The diagnosis should be considered in a patient with an acute onset of pain during delivery that does not improve postpartum.

Entrapped posteromedial structures in pilon fractures.

OBJECTIVES: To analyze a patient cohort who sustained a tibial pilon fracture and report the incidence of interposed posteromedial soft tissue structures. DESIGN: Retrospective cohort review. SETTING: Regional Level 1 Trauma Center. PATIENTS/PARTICIPANTS: About 394 patients with 420 pilon fractures treated between January 2005 and November 2011. INTERVENTION: Each patient's preoperative radiographs and computed tomography (CT) images were reviewed. The axial and reconstructed images were used in bone and soft tissue windows to identify any posteromedial soft tissue structures incarcerated within the fracture. MAIN OUTCOME MEASUREMENTS: Medical charts reviewed for the presence of preoperative neurologic deficit, separate posteromedial incision, and whether attending radiology CT interpretation noted the interposed structure. RESULTS: 40 patients with 40 fractures (9.5%) had an entrapped posteromedial structure. The tibialis posterior tendon was interposed in 38/40 fractures (95%) and the posterior tibial neurovascular bundle in 4/40 fractures (10%). Preoperative neurologic deficit occurred in 5/40 patients (12%). A posteromedial incision was used in 11/40 fractures (27%). The attending radiology CT interpretation noted the interposed structure in 8/40 fractures (20%). CONCLUSIONS: In addition to the osseous injuries, CT imaging can demonstrate the posteromedial soft tissue structures. In our series, the tibialis posterior tendon was commonly incarcerated. In some cases, removal of the entrapped structure(s) may not be possible through the more commonly used anterolateral and anteromedial surgical approaches, and a separate posteromedial exposure may be required. Failure to recognize the presence of an interposed structure could lead to malreduction, impaired tendon function, neurovascular insult, and the need for further surgery. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Opportunities for knowledge translation in the decade of road traffic safety.

The United Nations has identified road traffic safety as an important objective for the decade 2011-2020. It has implemented a 5-tiered program: improving health care services, improving management of road safety, improving road network safety, improving vehicular safety, and improving road safety legislation. A small body of practical research has been generated by the medical and surgical (including orthopaedic) communities regarding the road traffic safety, but a substantial amount of work remains to be performed. This article will review published research in each of the 5 tiers of the Decade of Action for Road Traffic Safety and will identify areas where research is insufficient or absent, such that new research programming and funding can be developed.

The realities of relationship failure.

Young surgeons and their spouses experience a myriad of stresses in the first few years of practice. Issues related to job search, moving to a new community, learning one's craft, time management, changes to spouse's career, child rearing, and the ever blurring line between work time and free time may all contribute to a decline in a couple's relationship. Recognizing these issues as obstacles to a healthy relationship and working to stay attuned to each other's emotional needs is of paramount importance. Some couples experiencing problems benefit from couples counseling, although many will ultimately go on to split and divorce. Going through a divorce can be an extremely consuming process, which may leave a person emotionally and financially depleted. Efforts to maintain other supports systems and to limit excessive work responsibilities may allow for a smoother passage through this commonly difficult period of life.

Fluoroscopically guided hip capsulotomy: effective or not? A cadaveric study.

OBJECTIVE: The purpose of this study was to examine the efficacy of a fluoroscopically guided hip capsulotomy. METHODS: Ten fresh-frozen paired cadaveric hips were injected under fluoroscopic guidance with saline sufficient to generate an intra-articular pressure greater than 58 mmHg. The pressure was monitored continuously using a percutaneous transducer. A limited lateral approach to the proximal femur was performed by one of two senior orthopaedic trauma surgeons. Using a scalpel under fluoroscopic guidance, each surgeon made one attempt at an anterior capsulotomy. Changes in intra-articular pressure were recorded throughout the procedure. The specimens were then dissected to measure the extent of each capsulotomy as well as the distance from the capsulotomy to nearby neurovascular structures. RESULTS: A rapid and substantial decrease in intra-articular pressure was seen in all hips. The mean intra-articular pressure postcapsulotomy was 8.4 mmHg. The capsulotomies averaged 15.1 mm in length. None of the attempts at capsulotomy lasted longer than 90 seconds. The average distance between capsulotomy and the lateral-most branch of the femoral nerve was 19.5 mm. The femoral artery was on average 40.3 mm from the capsulotomy. There was no correlation between the side on which capsulotomy was performed and its extent or proximity to neurovascular structures. CONCLUSIONS: Fluoroscopically guided hip capsulotomy through a small lateral incision appears to be a safe, effective, and expedient method, which may substantially reduce intra-articular pressure after minimally displaced femoral neck fractures.