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BACKGROUND: Limb-threatening lower extremity injuries often require secondary bone grafting after soft tissue reconstruction. We hypothesized that there would be fewer wound complications when performing secondary bone grafting via a remote surgical approach rather than direct flap elevation. METHODS: A retrospective cohort study was performed at a single Level 1 trauma center comparing complications after secondary bone grafting in patients who had undergone previous soft tissue reconstruction after open tibia fractures between 2006 and 2020. Comparing bone grafting via a remote surgical incision versus direct flap elevation, we evaluated wound dehiscence requiring return to the operating room as the primary outcome. Secondary outcomes were deep infection and delayed amputation. RESULTS: We identified 129 patients (mean age: 40 years, 82% male) with 159 secondary bone grafting procedures. Secondary bone grafting was performed via a remote surgical approach in 54% (n = 86) and direct flap elevation in 46% (n = 73) of cases. Wound dehiscence requiring return to the operating room occurred in one patient in the flap elevation group (1%) and none of the patients in the remote surgical approach. The odds of deep wound infection (OR, 1.77; p = 0.31) or amputation (OR, 1.43; p = 0.73) did not significantly differ between surgical approaches. No significant differences were found in complications between the reconstructive surgeon elevating and re-insetting the flap and the orthopaedic trauma surgeon performing the flap elevation and re-inset. CONCLUSION: Direct flap elevation for secondary bone grafting after soft tissue reconstruction for open tibia fractures did not result in more complications than bone grafting via a remote surgical approach. These findings should reassure surgeons to allow other clinical factors to influence the surgical approach for bone grafting.
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Traumatismos da Perna , Lesões dos Tecidos Moles , Humanos , Masculino , Adulto , Feminino , Estudos Retrospectivos , Seguimentos , Retalhos Cirúrgicos , Traumatismos da Perna/cirurgia , Complicações Pós-Operatórias , Lesões dos Tecidos Moles/cirurgia , Extremidade Inferior , Resultado do TratamentoRESUMO
OBJECTIVE: To determine what outcomes are most important to patients after a limb-threatening injury, and if those preferences vary based on the patients' treatment (salvage vs amputation), health, demographics, or time since injury. BACKGROUND: The preferences that motivate the patients' choice of treatment following a limb-threatening injury are poorly understood. Discrete choice experiments (DCEs) are a robust survey methodology to quantify preferences. METHODS: Patients with a history of traumatic limb-threatening injury, January 2010 to December 2020, completed a survey with our DCE and the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. The DCE attributes included recovery time, function, appearance, cost, and time in hospital. We used conditional logit modeling to estimate the relative importance of each attribute on a scale of 0% to 100%, determine willingness to pay for improvements in the included attributes, and assess variation in preferences based on patient characteristics, including PROMIS score. RESULTS: A total of 150 patients completed the survey (104 limb salvage, 46 amputation; mean age, 48±16 years; 79% male). Regaining preinjury function [relative importance=41%; 95% confidence interval (CI), 37%-45%] and minimizing costs (24%; 95% CI, 21%-28%) were of greatest importance. Changes in appearance were least important (7%; 95% CI, 5%-9%). The hierarchy of preferences did not vary between those who had limb salvage or amputation, but patient age, physical and mental health, and income were associated with preference variation. CONCLUSIONS: Patients with limb-threatening injuries most valued gains in function and reduced out-of-pocket costs.
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Traumatismos da Perna , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Feminino , Amputação Cirúrgica , Gastos em Saúde , Extremidade InferiorRESUMO
PURPOSE: The purposes of this study were to identify the relative frequency of Monteggia fracture patterns and to investigate the required frequency of open reduction of the proximal radiocapitellar joint. METHODS: We identified 121 Monteggia fractures at a Level I trauma center from 1996 to 2015 and included 119 in this study. These fractures were identified using a database search for the appropriate International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes as well as individual surgeons' logs. Two fellowship-trained hand surgeons reviewed the identified patients' x-rays and operative notes. Each fracture was classified using Bado's original description, excluding transolecranon and Monteggia variants. RESULTS: Bado I lesion represented 68% (81 of 119) of Monteggia fractures. Annular ligament incarceration preventing radial head reduction occurred in approximately 17% (14 of 81) of this Bado type. Revision fixation of the ulna was not necessary (none of 119 cases) and functional range of motion (average arc, 117°) was recovered in most patients. The reoperation rate of 20% (23 of 119) was related to the severity of the presenting injury and hardware prominence. CONCLUSIONS: Most radial head dislocations associated with Monteggia fractures occur anteriorly and will reduce with anatomic plating of the ulna. In cases where the radial head fails to reduce, entrapment of the annular ligament can be expected and open reduction is required. Revision fixation of the ulna to achieve reduction of the radial head is uncommon in our experience. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.
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Ligamentos Articulares/cirurgia , Fratura de Monteggia/cirurgia , Adolescente , Adulto , Idoso , Placas Ósseas , Feminino , Fixação Interna de Fraturas , Humanos , Ligamentos Articulares/fisiopatologia , Masculino , Pessoa de Meia-Idade , Fratura de Monteggia/classificação , Amplitude de Movimento Articular , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Ulna/cirurgia , Adulto JovemRESUMO
OBJECTIVE: The purpose of this retrospective case series was to examine the AO Foundation and Orthopaedic Trauma Association (AO/OTA) 13-C3 distal humeral fractures treated with open reduction-internal fixation (ORIF) in patients older than 70 years. METHODS: During an 8-year period, 21 patients older than 70 years with AO/OTA 13-C3 distal humeral fractures were treated with ORIF performed by 2 senior upper extremity traumatologists. There were 16 patients with >1 year of follow-up, with a mean age of 78 (70-84) years. RESULTS: At a mean follow-up of 4 years (1-8 years), all 16 patients demonstrated radiographic signs of bone union. Three patients underwent reoperations, including irrigation and débridement for postoperative infections (n = 2) and removal of implant for symptomatic olecranon intramedullary screw (n = 1). The mean postoperative total arc of ulnohumeral motion was 97° (80°-145°), including a mean flexion of 117° (106°-126°) and flexion contracture of 20° (14°-26°). The mean pronation was 69° (55°-85°), and supination was 78° (74°-9°0). The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 19 (standard deviation, 6.9; confidence interval, 15.4-22.8), and the mean Mayo Elbow Performance Score was 91 (standard deviation, 8.2; confidence interval, 86-95). CONCLUSIONS: ORIF remains a reliable option for treatment of AO/OTA 13-C3 distal humeral fractures in elderly patients. Excellent clinical outcomes can be achieved with preservation of motion and arm function through anatomic reduction, rigid internal fixation, and early mobilization.
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Parafusos Ósseos , Articulação do Cotovelo/cirurgia , Fixação Interna de Fraturas/métodos , Fraturas do Úmero/cirurgia , Amplitude de Movimento Articular/fisiologia , Idoso , Idoso de 80 Anos ou mais , Articulação do Cotovelo/diagnóstico por imagem , Feminino , Humanos , Fraturas do Úmero/diagnóstico , Masculino , Reoperação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
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
Purpose: As stakeholders seek to improve patient outcomes while maintaining cost-effectiveness in an increasingly expensive healthcare system, metrics such as patient satisfaction are becoming more important. This present study sought to identify factors associated with and independently predictive of better surgical satisfaction two years following hand and wrist surgery. Methods: Patients undergoing hand and wrist surgery at an urban outpatient institution were enrolled preoperatively into a surgical registry and assessed two years postoperatively. Patient satisfaction with surgery was measured at two years postoperatively with the Surgical Satisfaction Questionnaire (SSQ-8). Bivariate analysis determined associations between postoperative satisfaction and patient demographics, injury specifiers, medical history, and multiple patient-reported outcomes (PROs). Multivariable analysis determined independent predictors of two-year postoperative satisfaction following hand and wrist surgery. Results: Better surgical satisfaction was associated with having never smoked, no preoperative opioid use, lack of an accompanying legal claim, lack of a workers compensation claim, no clinical history of depression/anxiety, less comorbidities, and higher preoperative expectations.Various PROs relating to function, pain, activity, and general health at both baseline and two years demonstrated associations with postoperative satisfaction. Multivariable analysis confirmed that never smoking, lack of a legal claim, and better preoperative Brief Michigan Hand Questionnaire scores were independently predictive of better surgical satisfaction two years following hand and wrist surgery. Conclusion: At two years following hand and wrist surgery, better patient satisfaction was best predicted by never smoking, no related legal claim, and better baseline Brief Michigan Hand Questionnaire scores. Level of evidence: III.
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Introduction: Opioid overprescribing has caused a substantial increase in opioid related deaths and billions of dollars in additional healthcare costs. Orthopaedic surgeons commonly prescribe opioids in the perioperative period; however, research has shown preoperative opioid use may be associated with worse postoperative outcomes. Despite this body of evidence, there are few studies investigating the association between preoperative opioid use and two-year outcomes after hand surgery. Materials and methods: This study evaluated two-year postoperative patient-reported outcomes in patients who used opioids prior to hand surgery, and those who did not. Patients completed pre and postoperative questionnaires including Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the Brief Michigan Hand Questionnaire (BMHQ), and other questionnaires related to pain, function, and satisfaction. 342 patients undergoing upper-extremity surgery were enrolled into a prospective orthopaedic surgery outcome registry, and 69.9% completed the follow-up surveys. Preoperative opioid use and its association to patient outcome scores was analyzed through bivariate analysis. Significant associations were further tested by multivariable analysis to determine independent predictors. Results: Preoperative opioid use was associated with worse two-year PROMIS Fatigue (p â< â.01), PROMIS Anxiety (p â< â.01), PROMIS Depression (p â< â.01), SSQ-8 (p â= â.01), BMHQ (p â= â.01), NPS Hand (p â< â.01) and MODEMS met expectations (p â= â.03). No significant differences were observed in patient-reported outcome change scores. Multivariable analysis demonstrated that preoperative opioid use was predictive of worse two-year PROMIS Fatigue (p â< â.01), PROMIS Anxiety (p â< â.01), PROMIS Depression (p â= â.02), BMHQ (p â= â.01), SSQ-8 (p â< â.01), NPS Hand (p â= â.02) and MODEMS met expectations (p â< â.01). Conclusion: Preoperative opioid use was associated with worse patient-reported outcomes two years after elective hand surgery. There was no significant difference in the improvement from baseline between the two groups. Clinically significant differences were observed in follow-up PROMIS Anxiety, BMHQ and NPS - Hand scores. Clinically significant change scores were noted in both groups for PROMIS PF, PROMIS PI, PROMIS SS, BMHQ, and NPS - Hand.
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BACKGROUND: To determine if the use of a narrower elastic tourniquet compared to a standard pneumatic tourniquet reduces operative blood loss in the operative fixation of humeral shaft fractures. METHODS: This retrospective cohort study was performed at a level I trauma center and included 134 patients, aged 18 to 90 years, with a humeral shaft fracture treated with open reduction internal fixation (ORIF) from January 2007 through June 2018. The primary variable of interest was the application of a HemaClear™ elastic tourniquet versus a standard pneumatic tourniquet during the fixation of a humeral shaft fracture. The primary outcome was estimated blood loss (EBL) during the humerus ORIF surgery as recorded in the operative record. The secondary outcomes were total tourniquet time and operative time. The primary purpose of the study was to compare the above outcomes between the two tourniquet types. RESULTS: Estimated blood loss was 42% lower (95% CI: 11% to 73%, p < 0.01) in the elastic tourniquet group when compared to the standard pneumatic tourniquet group. The use of the elastic tourniquet was also associated with a 67% increase (95% CI: 35% to 100%, p < 0.01) in tourniquet time compared to the standard pneumatic tourniquet. No difference in the total operative time between the two groups (difference, -3%; 95% CI: -21 to 14, p = 0.72) was observed. CONCLUSION: Elastic tourniquet use was associated with 42% less blood loss in the fixation of humeral shaft fractures compared to use of a traditional pneumatic tourniquet, although this may be of unclear clinical importance given the relatively low estimated blood loss in this cohort. The potential benefit of reduced blood loss associated with the narrower elastic tourniquet is likely caused by the increased tourniquet time, without a change in overall operative time.
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Fixação Interna de Fraturas , Fraturas do Úmero , Humanos , Estudos Retrospectivos , Torniquetes , Fraturas do Úmero/cirurgia , Úmero/cirurgia , Resultado do TratamentoRESUMO
OBJECTIVES: To evaluate the presence of financial distress and identify risk factors for financial toxicity in patients after tibial shaft fracture. DESIGN: A cross-sectional analysis. SETTING: Level I trauma center. PATIENTS: All patients within 4 years after tibial shaft fracture (open, closed, or fracture that required flap reconstruction). INTERVENTION: Injury-related financial distress. MAIN OUTCOME MEASUREMENTS: Financial distress related to the injury, as reported by the patient in a binary question. Financial toxicity using the LIMB-Q, scored from 0 to 100, with higher scores indicating more financial toxicity. RESULTS: Data were collected from 142 patients after tibial shaft fracture [44% closed (n = 62), 41% open (n = 58), and 15% flap (n = 22)]. The mean age was 44 years (SD 17), 61% were men, and the mean time from injury was 15 months. Financial distress was reported by 64% of patients (95% confidence interval, 56% to 72%). Financial toxicity did not differ by fracture severity ( P = 0.12). Medical complications were associated with a 14-point increase in financial toxicity ( P = 0.04). Age older than 65 years (-15 points, P = 0.03) and incomes of $70,000 or more ($70,000-$99,999, -15 points, P = 0.02; >$100,000, -19 points, P < 0.01) protected against financial toxicity. CONCLUSION: We observed financial distress levels more than twice the proportion observed after cancer. Medical complications, lower incomes, and younger age were associated with increased financial toxicity. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Tíbia , Fraturas da Tíbia , Masculino , Humanos , Adulto , Idoso , Feminino , Estudos Transversais , Estresse Financeiro , Fraturas da Tíbia/cirurgia , Fatores de Risco , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Introduction Studies have shown a link between patients' preoperative expectations and their postoperative satisfaction. However, limited studies exist concerning patient factors associated with higher preoperative expectations in the hand surgery population. This study analyzed preoperative expectation scores of patients undergoing hand surgery and aimed to determine associated patient characteristics. Materials and Methods A total of 418 elective hand surgery patients aged 15 years and older enrolled in a prospectively collected orthopaedic registry from June 2015 to December 2018 were analyzed. Patients were administered preoperative questionnaires including six Patient-Reported Outcome Measurement Information System domains and other activity and pain scales. Expectation scores were measured using the six domains of the Musculoskeletal Outcomes Data Evaluation and Management System expectations questionnaire. Bivariate and multivariable analyses were conducted to identify independent predictors of higher expectations. Results Overall, patients had high expectations (≥ 80.0) of their hand surgery. Higher mean expectation scores were seen with females, college graduates, better baseline health status, and fewer prior hand surgeries ( p < 0.05 for all). No significant associations were found among the Common Procedural Terminology codes and expectations. Multivariable analysis confirmed that college degree ( p = 0.023) and less pain ( p = 0.008) were predictive of higher baseline expectations. Conclusion In sum, more educated patients with less pain at baseline and better baseline health status have higher expectations of their hand surgery. Hand surgeons can use these results to help focus their preoperative counseling and expectation management.
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BACKGROUND: The purpose of this study was to identify preoperative factors associated with worse postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores 2 years after hand and wrist surgery. We hypothesized that older age, more comorbidities, increased substance use, and lower socioeconomic status would correlate with worse 2-year PROMIS PI scores. METHODS: This study was a retrospective review of prospectively acquired data on 253 patients. Surveys were administered within 1 week of surgery and 2 years postoperatively. Bivariate and multivariable analyses were conducted to identify significant predictors of worse 2-year PROMIS PI scores and change in PROMIS PI scores. RESULTS: Older age, higher body mass index, more comorbidities, lower preoperative expectations, more prior surgeries, unemployment, smoking, higher American Society of Anesthesiologists (ASA) score, and multiple other socio-demographic factors were correlated with worse 2-year PROMIS PI scores (P ≤ .018). Similar factors were also correlated with less improvement in 2-year PROMIS PI scores (P ≤ .048). Worse scores on all preoperative patient-reported outcome measures correlated with worse 2-year PROMIS PI scores (P ≤ .007). Multivariable analysis identified smoking history, less frequent alcohol consumption, worse preoperative PROMIS social satisfaction and Numeric Pain Scale whole body scores, and higher ASA scores as independent predictors of worse 2-year PROMIS PI. The same factors in addition to better baseline PROMIS PI were predictive of less improvement in 2-year PROMIS PI. CONCLUSION: Numerous preoperative factors were predictive of worse postoperative 2-year PROMIS PI and less improvement in 2-year PROMIS PI for patients undergoing hand and wrist surgery.
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We describe a 28-year-old man who sustained an open IIIB left ankle fracture dislocation with heel pad avulsion. The patient underwent formal angiography of the left lower extremity, followed by free tissue transfer of a rectus abdominis flap several days later. Intraoperatively, a thrombus was identified in the deep inferior epigastric artery above the femoral artery access site requiring thrombectomy. Histologic analysis estimated the thrombus age at 12 to 72 hours, raising concern that the thrombus was induced during angiogram instrumentation. Donor and recipient site-specific risks of arterial instrumentation (including invasive diagnostics) should be considered when planning free tissue transfer.
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BACKGROUND: Radial head fractures are often associated with poor outcomes. Both open reduction and internal fixation (ORIF) and radial head arthroplasty (RHA) might be considered in operative cases. This study aimed to compare long-term patient-reported functional outcomes among patients with operatively treated radial head fractures. METHODS: A cross sectional study conducted at a Level I trauma center was used to identify patients with a radial head fracture who underwent ORIF or RHA between 2006 and 2018, and agreed to complete a survey in 2020. The primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. RESULTS: Seventy-six patients participated in the study. No significant differences in outcomes were observed between groups. QuickDASH scores were similar for both groups (ORIF: mean = 15.7, SD = 18.4; RHA: mean = 22.8, SD = 18.6; mean difference = 0.2 [-9.0 to 9.3], P = .97). Nineteen (37%) ORIF patients and 12 (48%) RHA patients reported a need for pain medication (adjusted odds ratio [OR] = 0.8 [0.3-2.4], P = .70). Thirteen (25%) ORIF patients and 6 (24%) RHA patients required additional surgery (adjusted OR = 1.7 [0.5-6.2], P = .39). A subgroup analysis of multi-fragmentary fractures revealed similar findings. CONCLUSION: Patient-reported outcomes, which included a subgroup analysis of multi-fragmentary fractures, were similar between ORIF and RHA groups at an average of 7.5 years from surgery. Reconstructing the radial head might not result in worse outcomes than RHA when both options are employed according to the best judgment of the operating surgeon.
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BACKGROUND: The objectives of this study were to determine the baseline patient characteristics associated with preoperative opioid use and to establish whether preoperative opioid use is associated with baseline patient-reported outcome measures in patients undergoing common hand surgeries. METHODS: Patients undergoing common hand surgeries from 2015 to 2018 were retrospectively reviewed from a prospective orthopedic registry at a single academic institution. Medical records were reviewed to determine whether patients were opioid users versus nonusers. On enrollment in the registry, patients completed 6 Patient-Reported Outcomes Measurement Information System (PROMIS) domains (Physical Function, Pain Interference, Fatigue, Social Satisfaction, Anxiety, and Depression), the Brief Michigan Hand Questionnaire (BMHQ), a surgical expectations questionnaire, and Numeric Pain Scale (NPS). Statistical analysis included multivariable regression to determine whether preoperative opioid use was associated with patient characteristics and preoperative scores on patient-reported outcome measures. RESULTS: After controlling for covariates, an analysis of 353 patients (opioid users, n = 122; nonusers, n = 231) showed that preoperative opioid use was associated with higher American Society of Anesthesiologists class (odds ratio [OR], 2.88), current smoking (OR, 1.91), and lower body mass index (OR, 0.95). Preoperative opioid use was also associated with significantly worse baseline PROMIS scores across 6 domains, lower BMHQ scores, and NPS hand scores. CONCLUSIONS: Preoperative opioid use is common in hand surgery patients with a rate of 35%. Preoperative opioid use is associated with multiple baseline patient characteristics and is predictive of worse baseline scores on patient-reported outcome measures. Future studies should determine whether such associations persist in the postoperative setting between opioid users and nonusers.
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Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/uso terapêutico , Depressão , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Dor , Estudos Prospectivos , Estudos RetrospectivosRESUMO
OBJECTIVES: Access to fractures of the distal humeral capitellum, trochlea, and lateral condyle is difficult through traditional approaches due to limited anterior articular exposure for direct reduction and fixation. The purpose of this study is to evaluate the relative articular exposure of a surgical dislocation (SD) approach to the distal humerus compared with olecranon osteotomy (OO). METHODS: Eight paired elbows from 4 cadavers underwent either SD or OO approach. Methylene blue staining demarcated visualized articular surface before disarticulation of the elbows. The main outcome measures were average visualized total distal humeral articular surface and anterior and posterior surface, and capitellar surface relative to the total surfaces was compared for each surgical approach using unpaired parametric t-tests. RESULTS: Intraclass correlation between raters was 0.995. The median exposed articular surface for SD and OO approaches was 90.0% and 62.8%, respectively. The overall exposure was significantly greater for the dislocation technique (P = 0.0003). With respect to specific regions of the distal humeral articular surface, SD allowed significantly greater visualization of the anterior surface (95.9% vs. 48.9%, P < 0.0001) and capitellum (100% vs. 40.4%, P < 0.0001). CONCLUSION: The surgical elbow dislocation approach to the distal humerus permits near total exposure of the anterior articular surface and the entire capitellum. Our data support this approach for anterior articular fractures of the distal humerus, to include those fractures that extend to the medial surface of the trochlea.
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Articulação do Cotovelo , Fraturas do Úmero , Fraturas Intra-Articulares , Adulto , Cotovelo , Articulação do Cotovelo/diagnóstico por imagem , Articulação do Cotovelo/cirurgia , Fixação Interna de Fraturas , Humanos , Fraturas do Úmero/diagnóstico por imagem , Fraturas do Úmero/cirurgia , Úmero , Fraturas Intra-Articulares/diagnóstico por imagem , Fraturas Intra-Articulares/cirurgia , Amplitude de Movimento Articular , Resultado do TratamentoRESUMO
OBJECTIVES: To determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol. DESIGN: Prospective cohort study. SETTING: Academic trauma center. PATIENTS: Eight pilon fracture patients and 19 tibial plateau fracture patients who underwent open reduction internal fixation. MAIN OUTCOME MEASURES: Skin perfusion (fluorescence units) as measured by LA-ICGA. RESULTS: Six patients were classified as Tscherne grade 0, 9 as grade 1, 10 as grade 2, and 2 as grade 3. Perfusion decreased by 14 fluorescence units (95% confidence interval, -21 to -6; P < 0.01) with each increase in Tscherne grade. Sixteen patients underwent staged fixation with an external fixator (mean time to definitive fixation 14.1 days). The mean perfusion increased significantly at the time of definitive fixation by a mean of 13.9 fluorescence units (95% confidence interval 4.8-22.9; P = 0.01). CONCLUSIONS: LA-ICGA perfusion measures are associated with severity of soft tissue injury surrounding orthopaedic trauma fractures and appear to improve over time when fractures are stabilized in an external fixator. Further research is warranted to investigate whether objective perfusion measures are predictive of postoperative wound healing complications and whether this tool can be used to effectively guide timing of safe surgical fixation. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Fixação Interna de Fraturas , Fraturas da Tíbia , Angiografia , Fixadores Externos , Humanos , Lasers , Perfusão , Projetos Piloto , Estudos Prospectivos , Estudos Retrospectivos , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Resultado do TratamentoRESUMO
PURPOSE: To evaluate the safety and efficacy of a hybrid flexor carpi radialis (FCR) approach for volar plate osteosynthesis of displaced distal radius fractures with concurrent prophylactic carpal tunnel release (CTR) in patients without preoperative signs or symptoms of acute carpal tunnel syndrome secondary to the fracture. METHODS: A total of 68 displaced distal radius fractures in 65 eligible adult patients (35 men, 30 women; mean age, 48.6 +/- 15.4 y) who had volar plate osteosynthesis and concomitant prophylactic CTR through a hybrid FCR approach by a single surgeon were included in this study. A systematic chart review and subsequent telephone questionnaire were performed to identify any postoperative median nerve dysfunction, recurrent motor or palmar cutaneous branch injury, tendon injury, or other complications directly related to the approach. RESULTS: Reported symptoms consistent with late median nerve dysfunction were identified in 2 cases; however, no patients in this series required additional surgery for early or late median neuropathy. Furthermore, no cases of median nerve sensory or motor branch injury or tendon injury were identified. No other unforeseen complications specifically related to the approach were observed. CONCLUSIONS: Volar plate osteosynthesis of distal radius fractures with a concurrent prophylactic CTR can be safely performed through the described hybrid FCR approach in patients without signs or symptoms of acute CTS. Routine release of the transverse carpal ligament with the hybrid FCR approach at the time of fracture fixation might reduce the incidence of postoperative median nerve dysfunction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
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Síndrome do Túnel Carpal/prevenção & controle , Descompressão Cirúrgica/métodos , Fixação Interna de Fraturas/instrumentação , Luxações Articulares/cirurgia , Fraturas do Rádio/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Placas Ósseas , Feminino , Seguimentos , Fixação Interna de Fraturas/métodos , Consolidação da Fratura/fisiologia , Humanos , Escala de Gravidade do Ferimento , Luxações Articulares/diagnóstico por imagem , Masculino , Nervo Mediano/lesões , Pessoa de Meia-Idade , Placa Palmar/cirurgia , Radiografia , Fraturas do Rádio/diagnóstico por imagem , Amplitude de Movimento Articular/fisiologia , Estudos Retrospectivos , Medição de Risco , Inquéritos e Questionários , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: To determine whether a single-incision extensile approach to the distal radius used for open reduction internal fixation and a concomitant radial sided carpal tunnel (CT) release safely and effectively decompresses the carpal tunnel. METHODS: Five pairs of cadaveric forearms were mounted to a tabletop with a cable pulley system attached to the long finger. Each paired specimen was randomized to volar plating via either the flexor carpi radialis approach (control group) or the extensile volar exposure (combined flexor carpi radialis and radial-sided carpal tunnel release). Before and after the respective exposure and plating, increased CT pressures were created with 2.27, 4.54, and 6.81 kg of distraction. We used a paired t-test to compare the change in CT pressure at each level of distraction before and after intervention for the 2 groups, with significance set at p = .05. A dissection of each exposure was performed with attention given to the radial aspect of the transverse carpal ligament (TCL) and any possible iatrogenic injuries. RESULTS: Carpal tunnel pressure increased with increasing distraction. We noted a statistically significant reduction in CT pressure after the extensile exposure and plating with 4.54 (p = .023) and 6.81 (p < .001) kg of distraction, respectively. No significant reduction in mean CT pressure for the control group specimens occurred at any level of distraction force. The average length of the radial TCL was 22 mm (range, 18-31 mm); the average distance between the recurrent motor branch and distal TCL was 11 mm (range, 8-15 mm). No iatrogenic tendon or nerve injury occurred with the extensile volar exposure. CONCLUSIONS: Carpal tunnel pressure is safely reduced and the distal radius is adequately exposed for fixation with the extensile volar approach.
Assuntos
Placas Ósseas , Síndrome do Túnel Carpal/cirurgia , Descompressão Cirúrgica/métodos , Fixação Interna de Fraturas/instrumentação , Fraturas do Rádio/cirurgia , Idoso , Idoso de 80 Anos ou mais , Fenômenos Biomecânicos , Cadáver , Dissecação , Feminino , Antebraço , Fixação Interna de Fraturas/métodos , Humanos , Ligamentos Articulares/fisiopatologia , Masculino , Pessoa de Meia-Idade , Regeneração Nervosa/fisiologia , Pressão , Distribuição AleatóriaRESUMO
PURPOSE: We evaluated a cohort of patients who developed vasopressor-induced limb ischemia and the management options to prevent progression or minimize morbidity of digital necrosis. METHODS: We reviewed all current literature on pressor-induced limb ischemia and report options for the management of patients requiring vasopressors who developed limb ischemia. We then retrospectively reviewed presentation, treatment, and short-term outcomes for patients at our tertiary referral academic medical center that developed this complication. Finally, we recommend guidelines for the tiered management of these complex patients. RESULTS: Thirty-six patients were included. Twenty-six patients (72%) required resuscitation with more than one vasopressor. Vasopressors were initiated for septic-shock (52.7%), cardiogenic-shock (16.7%), hypovolemic-shock (13.9%), acute transplant rejection (13.9%), and neurogenic-shock (2.8%). According to the tiered management recommendations, patients were managed with phase 1 care (19%), phase 2 care (8.3%), phase 3 care (50%) or phase 4 care (5.6%). The patient expired in the acute setting in 13.9% of cases. CONCLUSION: Life-saving vasopressors risk digital ischemia and necrosis. Early recognition, reporting, and treatment of this complication are important in minimizing morbidity. Using a tiered approach helps organize the healthcare team's management of this iatrogenic complication while respecting the treatment paradigm of "life over limb," and may be safely performed with acceptable outcomes.
RESUMO
The purpose of the current study was to examine the functional outcomes of C3.1 and C3.2 distal radius fractures. A trauma registry was used to identify patients with C3.1 and C3.2 distal radius fractures (n = 33). Clinical follow-up consisted of completion of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and assignment of a Gartland and Werley Demerit Point System score. Average follow-up duration was 62 months. Mean DASH score was 14 points; mean Gartland and Werley score was 6 points. Results were 14 excellent, 12 good, 10 fair, and one poor. Patients regained an average of 78% of the flexion-extension arc, 94% of the pronation-supination arc, and 83% of grip strength compared with the uninjured side. Standardized and uniformly applied attempts at reconstruction of the distal radial articular surface led to successful outcomes in the majority of patients.