Early Complications of a Novel Retrograde Intramedullary Femoral Nail in the Treatment of Femur Fractures.

OBJECTIVES: To determine the early implant failure rate of a novel retrograde intramedullary femoral nail. DESIGN: Retrospective cohort study. SETTING: Academic level 1 trauma center. PATIENTS SELECTION CRITERIA: Patients aged 18 years and older with an acute OTA/AO 32-A, 32-B, 32-C, and 33-A fractures or periprosthetic distal femur fracture from April 2018 to April 2022 were included in the study. The 2 interventions compared were the Synthes Expert retrograde/antegrade femoral nail (or control implant) versus the next-generation retrograde femoral nail (RFN)-advanced retrograde femoral nail (RFNA or experimental implant) (Synthes, West Chester, PA). OUTCOME MEASURES AND COMPARISONS: Early implant-related complications between the experimental and control implants were assessed including locking screw back out, screw breakage, intramedullary nail failure, need for secondary surgery, and loss of fracture reduction. RESULTS: Three hundred fourteen patients were identified with a mean age of 31.0 years, and 62.4% of the patients being male. Open fractures occurred in 32.5% of patients with 3.8% of injuries being distal femur periprosthetic fractures. Fifty-six patients were in the experimental group and 258 patients in the control group. Mean follow-up was 46.8 weeks for the control cohort and 21.0 weeks for the experimental cohort. Distal interlocking screw back out occurred in 23.2% (13 of 56) of the experimental group patients and 1.9% (5 of 258) of the control group patients ( P < 0.0001). Initial diagnosis of interlocking screw back out occurred at an average of 3.2 weeks postoperatively (range, 2-12 weeks). Fifty-four percent of patients who sustained screw back out underwent a secondary operation to remove the symptomatic screws (12.5% of all patients treated with the experimental implant required an unplanned secondary operation due to screw back out). A logistic regression model was used to predict screw back out and found the experimental implant group was 4.3 times as likely to experience distal locking screw back out compared with the control group ( P = 0.01). CONCLUSIONS: The retrograde femoral nail-advanced implant was associated with a significantly higher rate of screw back out with a substantial number of unplanned secondary surgeries compared with the previous generation of this implant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

No Difference in Short-Term Complications following Treatment of Closed Tibial Shaft Fractures with Intramedullary Nailing versus Plate Fixation.

Objectives: Tibial shaft fractures are treated with both intramedullary nailing (IMN) and plate fixation (ORIF). Using a large national database, we aimed to explore the differences in thirty-day complication rates between IMN and ORIF. Methods: Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had undergone either tibial IMN or ORIF for closed fractures from 2010 to 2018 were identified using current procedural terminology (CPT) codes. After excluding all patients with open fractures, the propensity score was matching. Univariate and multivariate logistic regressions were used to identify risk factors associated with the thirty-day incidence of complications in the two cohorts. Results: A total of 5,400 patients were identified with 3,902 (72.3%) undergoing IMN and 1,498 (27.7%) ORIF. After excluding any ICD-10 diagnosis codes not pertaining to closed, traumatic tibial shaft fractures, 2,136 IMN and 621 ORIF cases remained. After matching, the baseline demographics were not significantly different between the cohorts. Following matching, the rate of any adverse event (aae) did not differ significantly between the IMN (7.08% (n = 44)) and ORIF (8.86% (n = 55)) cohorts (p=0.13). There was also no significant difference in operative time (IMN = 98.5 min, ORIF = 100 min; p=0.3) or length of stay (IMN = 3.7 days, ORIF = 3.3 days; p=0.08) between the cohorts. Conclusion: There were no significant differences in short-term complications between cohorts. These are important data for the surgeon when considering surgical management of closed tibial shaft fractures.

Gracilis Free Flap in a Patient with Sickle Cell Disease.

Introduction: Free tissue transfer in the sickle cell population presents many challenges to the reconstructive surgeon. There are few reported cases of successful free tissue transfers within the sickle cell population. The majority of successful cases involve fasciocutaneous free flaps with few successful muscle flaps. This case report describes the successful utilization of a gracillis free flap to reconstruct a multifocal soft tissue defect following a closed distal tibia fracture in a patient with sickle cell disease (SCD). Case Report: This is a 20-year-old female with past medical history significant for sickle cell anemia, cardiomyopathy secondary to a ventricular septal defect and multiple occurrences of osteomyelitis who underwent gracilis free flap transfer to reconstruct soft tissue loss around the ankle after surgical fixation of a left pathological tibia fracture. Conclusion: The use of free flaps in sickle cell patients has shown to be extremely challenging due to the high risks of sickling and subsequent pedicle thrombosis associated with this population. However, there have been an increasing number of successful cases of free tissue transfers with most of these flaps arising from muscular origins. Therefore, more cases regarding free flaps in the sickle cell population are needed to fully understand the best protocols to follow. The techniques utilized among successful cases, regarding protocols prior to the surgery along with successful graft location selection, can help advance future cases and shows promise for future sickle cell patients.

Safety of Prepping the External Fixator In Situ During Staged Internal Fixation of Pilon Fractures: A Retrospective Comparative Cohort Study.

OBJECTIVE: (1) To assess the rate of fracture-related infection (FRI) and unplanned reoperation of disinfecting and prepping in the external fixator (Ex-Fix) instrument during definitive open reduction and internal fixation (ORIF) of pilon fractures treated by a staged protocol and (2) to determine whether the amount of time from external fixation to ORIF influences the risk of FRI. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS: One hundred thirty-three patients who underwent operative treatment for pilon fracture between 2010 and 2020. INTERVENTION: External fixation and ORIF with or without the Ex-Fix prepped in situ during definitive fixation. MAIN OUTCOME MEASUREMENTS: FRI and unplanned reoperation rates. RESULTS: 133 patients were enrolled, of which 47 (35.3%) had Ex-Fix elements prepped in situ. There was an overall infection rate of 23.3% and unplanned reoperation rate of 11.3%, and there was no significant difference in rates between the 2 cohorts. Patients with Ex-Fix elements prepped in situ who developed an FRI had a higher rate of MRSA and MSSA . Diabetes ( P = 0.0019), open fracture ( P = 0.0014), and longer (≥30 days) interval to ORIF ( P = 0.0001) were associated with postoperative FRI. CONCLUSIONS: Prepping elements of the Ex-Fix in situ did not lead to an increase in rates of FRI or unplanned reoperation. Although diabetes and open fracture were associated with FRI risk, a stronger association was a longer interval of Ex-Fix utilization before definitive internal fixation, specifically 30 days or greater. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Arteriovenous Vascular Loops in Latissimus Free Flap Reconstruction of Cervical and Cervicothoracic Spine Wounds.

Introduction Wound dehiscence is the most common complication after spinal fusion procedures, resulting in an increase in mortality rate and hospital length of stay. Reconstruction of these wounds presents a challenge, as the spine is dependent on these implants for stability and must be maintained throughout the wound dehiscence treatment protocol. We describe a method for extending the thoracodorsal pedicle with an arteriovenous loop to permit an increased excursion of the latissimus dorsi muscle in patients with exposed implants and present the results of this procedure. Materials and Methods A retrospective review of patients treated with a latissimus free flap with saphenous vein pedicle extension for posterior spinal wounds from 2010 to 2020 were reviewed. Patient charts were reviewed for demographic information including comorbidities, previous spine operations, wound size and location, and postoperative complications including total flap loss, flap dehiscence, and need for secondary surgery. Results Six patients were identified who underwent a total of eight extended pedicle free flaps. Mean age was 64.8 years with a mean follow-up of 12.3 months (range, 6-20 months). Four wounds were in the cervicothoracic region with two wounds in the cervical region. Mean number of previous spine surgeries was 3.5 (range, 2-4). Mean wound size was 189 cm 2 with a mean vein graft length of 28 cm. Wound coverage was successful in five of six patients. Major complications occurred in five of six patients. Total flap loss occurred in two patients (33%) and both underwent a second extended latissimus flap from the contralateral side. Three patients developed postoperative flap dehiscence which resolved with regular dressing changes. Conclusion Extended pedicle latissimus flaps are an effective treatment for posterior spine wounds but are associated with a high complication rate, secondary to medically complex patients with multiple prior surgeries. Careful patient selection is critical for success.

Risk Factors for Infection and Subsequent Adverse Clinical Results in the Setting of Operatively Treated Pilon Fractures.

OBJECTIVE: To determine patient-specific and injury-specific factors that may predict infection and other adverse clinical results in the setting of tibial pilon fractures. DESIGN: Retrospective chart review. SETTING: Level 1 academic trauma center. PATIENTS: Two hundred forty-eight patients who underwent operative treatment for tibial pilon fractures between 2010 and 2020. INTERVENTION: External fixation and/or open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Fracture-related infection rates and specific bacteriology, risk factors associated with development of a fracture-related infection, and predictors of adverse clinical results. RESULTS: Two hundred forty-eight patients were enrolled. There was an infection rate of 21%. The 3 most common pathogens cultured were methicillin-resistant Staphylococcus aureus (20.3%), Enterobacter cloacae (16.7%), and methicillin-resistant Staphylococcus aureus (15.5%). There was no significant difference in age, sex, race, body mass index, or smoking status between those who developed an infection and those who did not. Patients with diabetes mellitus ( P = 0.0001), open fractures ( P = 0.0043), and comminuted fractures (OTA/AO 43C2 and 43C3) ( P = 0.0065) were more likely to develop a fracture-related infection. The presence of a polymicrobial infection was positively associated with adverse clinical results ( P = 0.006). History of diabetes was also positively associated with adverse results ( P = 0.019). CONCLUSIONS: History of diabetes and severe fractures, such as those that were open or comminuted fractures, were positively associated with developing a fracture-related infection after the operative fixation of tibial pilon fractures. History of diabetes and presence of a polymicrobial infection were independently associated with adverse clinical results. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute Hindfoot Nailing for Ankle Fractures: A Systematic Review of Indications and Outcomes.

OBJECTIVES: To assess the complication rate of hindfoot nailing of acute fractures involving the tibiotalar joint, and mortality, patient-reported outcome measures, and return to preinjury activities. DATA SOURCES: MEDLINE; EMBASE. STUDY SELECTION: A systematic literature search for articles in English was completed using MEDLINE and EMBASE databases on April 23, 2020. Original research articles that assessed patients with acute intra-articular fractures of the ankle joint (malleolar ankle fractures and/or pilon fractures) that were treated with a locked hindfoot intramedullary nail, inserted retrograde through the plantar surface of the foot, were selected for inclusion. Case reports (≤4 patients), studies with nonlocked implants, and non-English studies were excluded. DATA EXTRACTION AND SYNTHESIS: A validated data extraction form was used, which included study demographics (authors, journal, date of publication, and study design), patient characteristics, implant type, and reported outcomes. Risk of bias for each included study was evaluated using the Institute of Health Economics Quality Appraisal Checklist for case series and the Risk of Bias in randomized trials tool, where appropriate. The best evidence was summarized and weighted mean values were provided when appropriate. RESULTS: Ten case series and one randomized controlled trial were included. The overall quality of studies was poor with considerable bias. The majority of studies included elderly patients (weighted mean age 75.5 years) with diabetes (42% of patients). Overall complication rate was 16% with an 8% major complication rate (deep infection, malunion, nonunion, implant failure) and an overall infection rate of 6.2%. Pooled mortality rate was 27% with fracture union rates from 88% to 100%. Mean proportion of patients able to return to preinjury level of activity was 85%. CONCLUSIONS: Hindfoot nailing of acute ankle and pilon fractures in elderly patients and patients with diabetes is associated with complication rates comparable with other methods of fixation. Issues with elimination of subtalar joint motion and implant complications secondary to poor implant fixation persist. The literature to date has composed of primarily Level IV studies with considerable bias. Further research is necessary to clarify the role of hindfoot nailing of acute ankle and pilon fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comminuted Fibular Head Fractures With Posterolateral Knee Instability: A Novel Repair Technique Using a Tension-Slide Device.

SUMMARY: Comminuted proximal fibula fractures or arcuate fractures (OTA/AO 4F1B fractures) can defunction the posterolateral corner (PLC) and result in posterolateral knee instability. Ongoing posterolateral knee instability can limit function, cause significant pain, and lead to early knee arthrosis. The anatomy of the PLC and proximal fibula limits the options for repair of this injury. The ideal method for osteosynthesis of these injuries has not been established. The goals of treatment include reconstitution of posterolateral stability, restoration of the anatomic relationship of PLC structures, and restoration of bone stock that would permit future reconstruction. This article characterizes the injury pattern, outlines the technique, and provides the clinical and radiographic outcomes of osteosynthesis of comminuted fibular head fractures using a novel application of the tension-slide technique.

Olecranon Osteotomy Implant Removal Rates and Associated Complications.

OBJECTIVE: This study reports on olecranon osteotomy implant removal rates, fixation types, and associated complications. DESIGN: Multicentre case series. SETTING: Patients were identified through an electronic medical database at one Level 1 trauma center and three Level 2 trauma centers. PATIENTS: Two hundred thirty-five patients were identified through the database, of which 92 patients met inclusion criteria. INTERVENTION: Patients underwent olecranon osteotomy for fixation of distal humerus fractures and the implant used was at the surgeon's discretion. MAIN OUTCOME MEASUREMENT: Implant removal rate. RESULTS: Thirty-four of 92 (37.0%) patients underwent removal of implant from their olecranon osteotomy. Implant removal rates were as follows: 28 of the 63 patients for tension band wiring (TBW) (44.4%), 6 of the 18 patients for plates (33.3%), 0 of the 1 patient for cable-pin, and 0 of the 10 patients for osteotomies fixed with a screw fixation. Screw fixation was removed less frequently than TBW (P = 0.01). Screws were less commonly removed than all other fixation types (P = 0.01). TBWs (28/63) were more commonly removed than all other implants (6/29) (P < 0.05). The nonunion rate for olecranon osteotomies was 3.3%. TBWs (18/18) are more likely to be removed for implant irritation than plates. TBWs had an odds ratio of 3.29 for requiring implant removal if they were left >1 mm off of the olecranon tip. CONCLUSION: In this study, 34 of the 92 (37%) patients undergoing an olecranon osteotomy for treatment of a distal humerus fracture required removal of olecranon implant. Screw fixation (0/10) was found to be removed less frequently than TBW fixation 28 of the 63 patients (44.4%). LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evolution of a Novel Tissue Preservation Protocol to Optimize Osteochondral Transplantation Outcomes.

OBJECTIVE: Osteochondral allograft transplantation is a procedure to treat focal osteochondral lesions (OCLs), but is limited by tissue availability, the quality of transplanted tissue, and inconsistent storage protocols. The objective of this study was to assess the clinical outcomes of a novel tissue procurement, storage, and quality control protocol in treating OCLs. DESIGN: Prospective case series. Donor cadaveric tissue was processed, stored, and the tissue quality analyzed using the unique tissue preservation protocol developed at our institution. Advanced cross-sectional imaging was used to size match donor tissue with recipient patients. Osteochondral allografts were transplanted using the Arthrex Allograft OATS. Patients were evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS), and 36-Item Short Form Survey (SF-36) preoperatively and at 1 year and 2 years postoperatively. RESULTS: Twenty patients (17 knees, 3 shoulders) were included in the study. There was a significant improvement in the following scores: overall WOMAC score, WOMAC function and pain subcategories; KOOS pain, knee-related symptoms, activities of daily living, sports and recreation, and quality of life; SF-36 physical functioning, physical role, pain, and social functioning subcategories; and VAS at all time points postoperatively. There was a significant improvement in WOMAC stiffness at 2 years postoperatively. There were 2 failures, defined by graft subsidence and persistent pain requiring reoperation. CONCLUSION: The protocol developed at our institution for OAT resulted in significant clinical improvement in patients with OCLs and is an improvement on existing tissue storage techniques.

The Influence of Sagittal Proximal Tibial Anatomy in Tibial Intramedullary Nailing.

OBJECTIVES: To quantify anatomic variation in sagittal proximal tibial anatomy and determine if anatomy or nail insertion method influences the radiographic nail position. DESIGN: Retrospective cohort of prospectively collected data. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Forty-five patients with 46 tibia fractures (OTA/AO 41A, 42, and 43) treated with infrapatellar (IP) or suprapatellar (SP) nailing. The average patient age was 40.6 years (range 19-62 years). INTERVENTION: Patients received IP or SP nailing. Cohorts were analyzed based on the nailing technique and proximal tibial anatomy. MAIN OUTCOME MEASUREMENTS: Proximal tibial radiographic anatomy was quantified using novel measurements [anterior tubercle angle (ATA) and entry point position (EPP)]. Nail entry point, entry point displacement after reaming, nail position, and quality of reduction was measured and compared between groups. RESULTS: ATA was highly variable between patients. ATA was strongly correlated with EPP with a higher ATA associated with EPP more colinear with the intramedullary canal. Patients with low ATA treated with IP nailing had significantly longer operative times (60.0 vs. 45.7 minutes). Low ATA tibias had a higher incidence of entry point displacement due to eccentric reaming compared with high ATA tibias (70% vs. 38%) with the highest incidence of entry point displacement and absolute displacement in low ATA tibias treated with IP nailing (86%, 2.8 mm). SP nailing demonstrated shorter operative times relative to IP nailing (45.5 vs. 55.6 minutes). CONCLUSIONS: There is considerable variability in proximal tibial anatomy and these features influences the nail position within the tibia. These differences in anatomy should be considered to potentially reduce operative times, entry point displacement and anteriorization of tibial nails. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteonecrosis of the distal tibia after pilon fractures.

BACKGROUND: Pilon fractures are devastating injuries with high complication rates. Osteonecrosis has been previously described after Weber C fracture-dislocations but has not been reported following fixation of pilon fractures. METHODS: All AO/OTA 43-C pilon fractures from 2007 to 2018 were reviewed. Injury factors and demographics were recorded. Computed tomography (CT) scans of the fracture pattern were analyzed to determine risk factors for ON. RESULTS: 71 pilon fractures in 69 patients were included. Mean follow-up was 21.6 months. 18 patients demonstrated ON at a mean 7.3 months' post-injury. Regression analysis demonstrated no differences between cohorts with respect to smoking status, open injury, or diabetic status. ON was associated with small anterolateral fragment less than 2.0cm2 (OR=19.47, p=0.012), higher comminution (OR=3.00, p=0.005), use of calcium phosphate bone substitute (OR=20.72, p=0.013). CONCLUSIONS: ON of the distal tibia was not associated with patient factors but was associated with fracture characteristics.

Plate-Assisted Intramedullary Nailing of Proximal Third Tibia Fractures.

OBJECTIVES: To report on the safety of unicortical plate stabilization in conjunction with intramedullary nailing (IMN) of proximal third tibia fractures. DESIGN: Retrospective cohort. SETTING: A Level I trauma center. PATIENTS/PARTICIPANTS: All Orthopaedic Trauma Association 41A and 42A/B/C proximal tibia fractures treated with IMN from January 2011 to May 2018 were reviewed. Fifty-three proximal tibia fractures in 50 patients were included in the study. Twenty-four patients were treated with plate-assisted reduction and IMN, and 29 were treated with IMN alone. The plate-assisted IMN cohort was subdivided into patients with plate retention and those that had the plate removed. INTERVENTION: Plate-assisted IMN and IMN only. MAIN OUTCOME MEASUREMENTS: Patients were followed up for evidence of nonunion, reduction quality, postoperative infection, and rate of implant removal. RESULTS: There were no statistically significant differences between plate-assisted IMN and IMN only for age, fracture type, mechanism of injury, quality of reduction, or implant removal rate. Open fractures were treated more often with plate-assisted IMN (88%) compared with the number of open fractures treated with IMN only (12%). There were no differences in nonunion rate or rate of postoperative infection between the 2 groups. CONCLUSIONS: Plate-assisted IMN of proximal third tibia fractures can safely be performed even in open tibia fractures with similar rates of nonunion, infection, and implant removal rates to patients treated with IMN only. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical outcomes and complications following primary total elbow arthroplasty using the Latitude prosthesis.

BACKGROUND: The Latitude total elbow arthroplasty (TEA) is an implant with limited published data on its performance and outcomes. The aim of this study was to report the short-term outcomes of the Latitude TEA as well as to describe the radiographic outcomes and complications. METHODS: The Latitude was implanted in 20 patients (23 elbows) in a linked configuration. Patients were recalled to clinic for the assessment of their range-of-motion and compared to preoperative values. Administration of functional outcome measures was also performed. RESULTS: Mean follow-up was 4.7 years (range, 1 to 7.5 years) with four elbows requiring revision. The flexion-extension arc improved from 86.6 to 101.3 (range, 76 to 126) postoperatively (p = 0.04). The average Disabilities of the Arm, Shoulder, and Hand score was 28.1 (range, 5.8 to 50.4) and the average Mayo Elbow Performance Score was 89.6 (range, 76 to 100), with 83% of elbows scoring in the good or excellent range. Radiolucencies were detected in 60% of patients and 31% of these lucencies progressed in size at the time of follow-up. CONCLUSIONS: The Latitude prosthesis provides patients with favorable clinical outcomes with improvements in their range-of-motion and a complication rate comparable to other elbow arthroplasty implants.

Conservative treatment of cubital tunnel syndrome: A systematic review.

Cubital tunnel syndrome (CuTS) is one of the most common compression neuropathies of the upper extremity. Conservative management of cubital tunnel syndrome is often considered first line therapy for mild or moderate symptoms; however, there is little evidence-based literature to guide physicians in this regard. As such, the objective of this study is to complete a comprehensive literature search of the conservative therapies available for treatment of CuTS. Additionally, we hope to assess the evidence for each therapy so that we can make evidence- based recommendations regarding the type and duration of optimal treatment. The databases MEDLINE, EMBASE, and CINAHL were search using a sensitive search strategy. Eligibility for studies included any studies or conference abstracts in which patients were treated conservatively for primary CuTS. Any form of non-operative treatment was acceptable. A data extraction form was developed to collect all information and outcomes of interest, including study design, level of evidence, number of patients, treatment modalities, follow- up time, patient reported outcomes, and electrophysiological markers. Qualitative and quantitative analysis was then completed based on the data extraction form. Given the heterogeneity of the included studies, results were summarized as best evidence available. Our sensitive literature search produced 6484 studies. Initial screening based on title and abstract resulted in the selection of 40 studies that underwent full text review. From these 19 studies were included for analysis in our systematic review. There were 3 level I studies, 4 level II studies, 3 level III studies, and 9 level IV studies. In total this included 844 patients. The most commonly reported outcomes included subjective patient reported outcomes and nerve conduction studies. The most common treatment modalities, from most to least common, included education and activity modification, splinting, steroid/lidocaine injection, nerve mobilization/gliding, pulsed ultrasound, laser therapy, non-steroidal antiinflammatory drugs, and physiotherapy. The most common duration of therapy was 3 months with a median follow-up time of 3 months. There was moderate strength evidence to recommend the use of education/activity modification or splinting in mild or moderate CuTS. There is a paucity of literature and highquality studies regarding the conservative management of CuTS. Regardless, there appears to be a role for non-operative management in CuTS, although further studies are needed to delineate this role further. In the cases of mild or moderate CuTS it is reasonable to trial education/activity modification or splinting as both appear to be equally effective.