Comparison of clinical and radiographic outcomes of arthroscopic-assisted percutaneous fixation versus open reduction internal fixation of lateral tibial plateau fractures.

PURPOSE: Treatment for tibial plateau fractures continues to evolve but maintains primary objectives of anatomic reduction of the joint line and a rapid recovery course. Arthroscopic-assisted percutaneous fixation (AAPF) has been introduced as an alternative to traditional open reduction internal fixation (ORIF). The purpose of the study is to compare clinical and radiographic outcomes in patients with low-energy Schatzker type I-III tibial plateau fractures treated with AAPF versus ORIF. METHODS: A retrospective chart review was performed at a level 1 trauma centre to compare outcomes of 120 patients (57 AAPF, 63 ORIF) with low-energy lateral Schatzker type I-III tibial plateau fractures who underwent tibial plateau fixation between 2009 and 2018. Demographic information, injury characteristics, and surgical treatment were recorded. The main outcome measurements included reduction step-off, joint space narrowing, time to weight bearing, and implant removal. RESULTS: There was no difference in age, gender distribution, BMI, ASA, Schatzker classification distribution, initial displacement, blood loss, and reduction step-off between the two groups (p > 0.05). Shorter tourniquet time (74.1 ± 21.7 vs 100.0 ± 21.0 min; p < 0.001), shorter time to full weight bearing (47.8 ± 15.2 vs. 69.1 ± 17.2 days; p < 0.001), and lower rate of joint space narrowing (3.5% vs. 28.6% with more than 1 mm, p < 0.001) were associated with the AAPF cohort, with no difference in pain, knee range of motion, or implant removal rate between the two cohorts. CONCLUSION: AAPF may be a viable alternative to ORIF for the management of low-energy tibial plateau fractures with outcomes not inferior compared to the traditional ORIF method.

Outcomes of arthroscopic-assisted lateral tibial plateau fixation: a systematic review.

PURPOSE: The purpose of this study is to evaluate and summarize the current literature on outcomes of arthroscopic-assisted tibial plateau fixation (AATPF) when applied for only lateral tibial plateau fractures. METHODS: A comprehensive search of nine databases was conducted: ClinicalTrials.gov, Cochrane Library via Wiley, Embase and MEDLINE via Ovid, Global Index Medicus, PubMed, Scopus, SPORTDiscus via EBSCO, and Web of Science Core Collection. The study was performed in concordance with PRISMA guidelines. Studies eligible for inclusions included Schatzker I-III lateral tibial plateau fractures with a minimum of 6-month follow-up. Data extraction was performed by two authors independently using a predesigned form. RESULTS: A total of 17 studies, 7 prospective and 10 retrospective, including 565 patients (age 15-82 years old) treated with AATPF were included in this review with follow-up ranging from 6 to 138 months. All 10 studies that used categorical functional outcomes demonstrated excellent/very good or good outcomes in > 90% of patients. When compared to patients managed with the traditional open reduction internal fixation (ORIF), patients treated with AATPF had statistically significantly better range of motion mean difference [5.21° (95% CI - 2.50 to 12.92, p < 0.0001)], lower blood loss [66.19 mL (95% confidence interval (CI) 32.54-99.84 mL, p < 0.0001)], shorter hospital stay [- 1.41 days (95% CI - 3.39 to 0.58 days, p < 0.0001)], better Hospital Special Surgery score [11.31 (95% CI 6.49-16.12, p < 0.0001)], and higher Rasmussen radiographic score [1.26 (95% CI - 0.72 to 3.23, p < 0.0001)]. CONCLUSION: AATPF is a promising treatment of lateral tibial plateau fractures with some advantages over the traditional ORIF. LEVEL OF EVIDENCE: Therapeutic Level III.

Extremity War Injuries VIII: sequelae of combat injuries.

The 2013 Extremity War Injury symposium focused on the sequelae of combat-related injuries, including posttraumatic osteoarthritis, amputations, and infections. Much remains to be learned about posttraumatic arthritis, and there are few circumstances in which a definitive arthroplasty should be performed in an acutely injured and open joint. Although the last decade has seen tremendous advances in the treatment of combat upper extremity injuries, many questions remain unanswered, and continued research focusing on improving reconstruction of large segmental defects remains critical. Discussion of infection centered on the need for novel methods to reduce the bacterial load following the initial débridement procedures. Novel methods of delivering antimicrobial therapy and anti-inflammatory medications directly to the wound were discussed as well as the need for near real-time assessment of bacterial and fungal burden and further means of prevention and treatment of biofilm formation and the importance of animal models to test therapies discussed. Moderators and lecturers of focus groups noted the continuing need for improved prehospital care in the management of junctional injuries, identified optimal strategies for both surgical repair and/or reconstruction of the ligaments in multiligamentous injuries, and noted the need to mitigate bone mineral density loss following amputation and/or limb salvage as well as the necessity of developing better methods of anticipating and managing heterotopic ossification.

Minimally invasive versus open sacroiliac joint fusion: are they similarly safe and effective?

BACKGROUND: The sacroiliac joint has been implicated as a source of chronic low back pain in 15% to 30% of patients. When nonsurgical approaches fail, sacroiliac joint fusion may be recommended. Advances in intraoperative image guidance have assisted minimally invasive surgical (MIS) techniques using ingrowth-coated fusion rods; however, how these techniques perform relative to open anterior fusion of the sacroiliac joint using plates and screws is not known. QUESTIONS/PURPOSES: We compared estimated blood loss (EBL), surgical time, length of hospital stay (LOS), and Oswestry Disability Index (ODI) between patients undergoing MIS and open sacroiliac joint fusion. METHODS: We retrospectively studied 63 patients (open: 36; MIS: 27) who underwent sacroiliac joint fusion with minimum 1-year followup at our institution from 2006 to 2011. Of those, 10 in the open group had incomplete records. All patients had sacroiliac joint dysfunction confirmed by image-guided intraarticular anesthetic sacroiliac joint injection and had failed nonoperative treatment. Patients were matched via propensity score, adjusting for age, sex, BMI, history of spine fusion, and preoperative ODI scores, leaving 22 in each group. Nine patients were not matched. We reviewed patient medical records to obtain EBL, length of surgery, LOS, and pre- and postoperative ODI scores. Mean followup was 13 months (range, 11-33 months) in the open group and 15 months (range, 12-26 months) in the MIS group. RESULTS: Patients in the open group had a higher mean EBL (681 mL versus 41 mL, p < 0.001). Mean surgical time and LOS were shorter in the MIS group than in the open group (68 minutes versus 128 minutes and 3.3 days versus 2 days, p < 0.001 for both). With the numbers available, mean postoperative ODI scores were not different between groups (47% versus 54%, p = 0.272). CONCLUSIONS: EBL, surgery time, and LOS favored the MIS sacroiliac fusion group. With the numbers available, ODI scores were similar between groups, though the study size was relatively small and it is possible that the study was underpowered on this end point. Because the implants used for these procedures make assessment of fusion challenging with available imaging techniques, we do not know how many patients' sacroiliac joints successfully fused, so longer followup and critical evaluation of outcomes scores over time are called for. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Minimal Clinically Important Difference (MCID) for the Short Musculoskeletal Function Assessment (SMFA) in Severe Lower Extremity Trauma: Pooled Data from 7 Multicenter, Prospective Clinical Trials.

BACKGROUND: The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures. METHODS: Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes. RESULTS: A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing. CONCLUSIONS: A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Documentation of outcomes for sacroiliac joint fusion: does prior spinal fusion influence the outcome?

PURPOSE: The purpose of this prospective case series (level II) was to determine the clinical outcomes of anterior SIJ fusion, comparing the outcomes of patients who had prior spinal fusions at any level compared to patients who have not. METHODS: This prospective study included 25 patients who underwent SIJ fusion with anterior plate fixation. All patients had failed non-operative treatment, had a positive Patrick test, and positive response to intra-articular SIJ injections with greater than 50 % pain relief. Patients had follow-up at 3, 6, 9 and 12 months where they completed Oswestry disability index (ODI) and Short Musculoskeletal Functional Assessment (SMFA) surveys. Outcome data are available for 19 patients who completed pre-operative and 12-month follow-up surveys. Their average time of the final follow-up was 1.1 years (range 10-33 months). RESULTS: Significant improvements between pre-operative and the final follow-up in ODI (p = 0.007) and SMFA (p = 0.01) were observed; the ODI assessed outcomes in patients who had previous spinal fusion surgery were significantly worse than those that did not at the final follow-up (p = 0.04). CONCLUSION: Patients who have not undergone prior spinal fusion surgery, regardless of age, gender, and BMI have better outcomes following anterior SIJ fusion.

Intramedullary Nail and Plate Combination Technique for Peri-Implant Both-Bone Forearm Fractures.

A 35-year-old female patient with cerebellar ataxia presented with a right periprosthetic both-bone forearm fracture after a ground-level fall. Her surgical history was significant for multiple both-bone forearm fractures treated by open reduction and internal fixation. Subsequent treatment with a combination of intramedullary nailing and plate fixation for each bone provided successful fracture union while allowing immediate return to weight-bearing and range of motion. This case report demonstrates that intramedullary nailing and plate fixation of both-bone forearm fractures provides complete protection of the radius and ulna in recurrent, peri-implant both-bone forearm fractures. This technique is a valuable treatment option in the setting of a patient at risk for recurrent injury of the forearm.

Arthroscopically Assisted Percutaneous Screw Fixation of Tibial Plateau Fractures.

Tibial plateau fractures account for approximately 1% to 2% of fractures in adults1. These fractures exhibit a bimodal distribution as high-energy fractures in young patients and low-energy fragility fractures in elderly patients. The goal of operative treatment is restoration of joint stability, limb alignment, and articular surface congruity while minimizing complications such as stiffness, infection, and posttraumatic osteoarthritis. Open reduction and internal fixation with direct visualization of the articular reduction or indirect evaluation with fluoroscopy has traditionally been the standard treatment for displaced tibial plateau fractures. However, there has been concern regarding inadequate visualization of the articular surface with open tibial plateau fracture fixation, contributing to a fivefold increase in conversion to total knee arthroplasty2. In addition, the risk of wound complications and infection has been reported to be as high as 12%3,4. Knee arthroscopy with percutaneous, cannulated screw fixation provides a less invasive procedure with excellent visualization of the articular surface and allows for accurate reduction and fracture fixation compared with traditional open reduction and internal fixation techniques1. Recent studies of arthroscopically assisted percutaneous screw fixation of tibial plateau fractures have reported excellent early clinical and radiographic outcomes and low complication rates3,5,6. Description: This technique involves the use of both arthroscopy and fluoroscopy to facilitate reduction and fixation of the tibial plateau fracture. Through a minimally invasive technique, the depressed articular joint surface is targeted with use of preoperative computed tomography (CT) scans and intraoperative biplanar fluoroscopy. Reduction is then directly visualized with arthroscopy and fixation is performed with use of fluoroscopy. Lastly, restoration of the articular surface is confirmed with use of arthroscopy after definitive fixation. Modifications can be made as needed. Alternatives: The traditional method for fixation of displaced tibial plateau fractures is open reduction and internal fixation. Articular reduction can be visualized directly with an open submeniscal arthrotomy and an ipsilateral femoral distractor or indirectly with fluoroscopy. Rationale: Visualization of the articular surface is essential to achieve anatomic reduction of the joint line. Inspection of the posterior plateau is difficult with an open surgical approach. Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture may allow for improved restoration of articular surfaces through enhanced visualization. Less soft-tissue dissection is associated with lower morbidity and may result in less damage to the blood supply, lower rates of infection and wound complications, faster healing, and better mobility for patients. In our experience, this technique has been successful in patients with severe osteoporosis and comminution of depressed fragments. If total knee arthroplasty is required, we have also observed less damage to the blood supply and fewer surgical scars with use of this surgical technique. Expected Outcomes: Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture facilitates anatomical reduction through a less invasive approach. Patients undergoing this method of tibial plateau fracture fixation are able to engage earlier in rehabilitation2. Studies have shown early postoperative range of motion, excellent patient-reported outcomes, and minimal complications7,8. Important Tips: Arthroscopically assisted fixation can be applied to a variety of tibial plateau fractures; however, the minimally invasive approach is best suited for patients with isolated lateral tibial plateau fractures (Schatzker I to III) and a cortical envelope that can be easily restored. The cortical envelope refers to the outer rim of the tibial plateau. Fracture pattern and ligamentotaxis determine the cortical envelope, which can be evaluated on preoperative CT scans. In our experience, even depressed segments with a high degree of comminution may be treated with use of this technique with satisfactory results.Articular depression should be targeted with use of a preoperative CT scan and intraoperative fluoroscopy and arthroscopy.The surgeon should be careful not to "push up" in 1 small area; rather, a "joker" elevator or bone tamp should be utilized, moving anterior to posterior, which can be frequently assessed with arthroscopy.The intra-articular pressure of the arthroscopy irrigation fluid should be low (≤45 mm Hg or gravity flow), and the operative extremity should be monitored for compartment syndrome throughout the procedure. Acronyms and Abbreviations: ACL = anterior cruciate ligamentK-wires = Kirschner wiresORIF = open reduction and internal fixationAP = anteroposteriorCR = computed radiography.

Adjusting for Variation in Patient-Reported Outcome Measures Is Needed to Improve Care After Total Knee Arthroplasty.

INTRODUCTION: Limited quantitative information exists about the patient and surgeon factors driving variation in patient-reported outcome measure (PROM) scores, limiting the use of these data in understanding and improving quality. The overall goal of this study was to learn how to adjust PROM scores to enable both individual and group quality improvement. METHODS: Observational study in which preoperative Oxford Knee Score (OKS) and Patient Reported Outcomes Measurement System (PROMIS)-10 measures were prospectively obtained through patient survey from 1,173 of 1,435 possible patients before total knee arthroplasty and from 810 of the 1,173 patients at 12 months postoperatively (response rates = 81.7% and 69.0%). Regression analyses identified the relative contribution of patient and surgeon risk factors to OKS change from baseline to 12 months. Variation in patient scores and surgeon performance was described and quantified. Adjusted outcomes were used to calculate an observed and expected score for each surgeon. RESULTS: (1) Moderate variation was observed in pre-/post-OKS change among the surgeons (n = 16, mean change = 15.5 ± 2.2, range = 12.1-21.1). Forty-five percent of the variance in OKS change was explained by the factors included in our model. (2) Patient preoperative OKS and PROMIS physical score, race, and BMI were markedly associated with change in OKS, but other patient factors, surgeon volume, and years of experience were not. (3) Eight surgeons had observed scores greater than expected after adjustment, providing an opportunity to learn what strategies were associated with better outcomes. DISCUSSION: Traditional age/sex adjustment of patient mix would have had no effect on mean PROM scores by surgeon. An adjustment model that includes the factors found to be markedly associated with outcomes will allow care systems to identify individual surgeon care management strategies potentially important for improving patient outcomes.

Moderators' summary: perceived performance differences. limb salvage versus amputation in the lower extremity (session II).

Severe extremity trauma is a significant cause of morbidity and disability; these injuries are often considered for amputation. Two studies have shown few differences between amputation and limb salvage outcomes. Functional limitations that result from loss of muscle needed to cover bone and provide limb function are a major factor in the decision to amputate a salvaged limb. Several studies have reported successful management of muscle loss with soft-tissue transfer. Extracellular matrix scaffolds and muscle regeneration using stem cells are promising technologies. However, no single strategy has proved to be effective in the management of limb pain following extremity trauma; a multimodal approach is required for best results. Additional knowledge gaps exist, such as the effect of occupational and physical therapy on the outcome of severe limb injury, factors such as peer visitation and social support networks, and the effect of sex, cultural differences, and patient personality.