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.

A novel technique for ligamentous reconstruction of the sternoclavicular joint.

SUMMARY: The technique presented is a departure from previous attempts to standardize the treatment of sternoclavicular dislocations. It offers stability without requiring extra dissection around vital intrathoracic structures and greatly decreases the risk of migration of the implant used for fixation.

Comparison of insertional trauma between suprapatellar and infrapatellar portals for tibial nailing.

The purpose of this study was to determine differences in insertional articular trauma in infrapatellar tibial portal and suprapatellar portal intramedullary tibial nail insertion techniques. A cadaveric study was performed on 10 matched pairs of fresh-frozen adult cadaver lower extremities with intact extensor mechanisms. Two study groups with 10 limbs each were created: left lower limbs were treated with a standard medial parapatellar nailing portal and right lower limbs were treated with a suprapatellar tibial nailing portal. Start points were created under fluoroscopic guidance in anteroposterior and mediolateral planes. A start wire was placed and opening reaming was performed on the specimens using instrumentation specific to the nailing portal. Specimens were then dissected by medial parapatellar arthrotomy, revealing the intra-articular condition of the knee structures. The border of the tibial entry reamer hole was measured to the anterior horns of the menisci, anterior cruciate ligament root, and intermeniscal ligament using a digital caliper accurate to 0.02 mm. The structure was considered damaged if the structure was obviously damaged on visual inspection or if a measurement was less than 1 mm. Impact to intra-articular structures was numerically lower in the suprapatellar group (2/10) compared with the infrapatellar group (4/10), but the difference was not statistically significant between the 2 groups (P=.629). The suprapatellar portal approach to the tibial start point demonstrated a lower overall incidence of damage to intra-articular structures, but no significant statistical difference existed between the 2 treatment groups.

Treatment of atrophic diaphyseal humeral nonunions with compressive locked plating and augmented with an intramedullary strut allograft.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of thorough debridement and locked compression plating augmented with an intramedullary fibular allograft for the treatment of atrophic diaphyseal humeral nonunions. DESIGN: The study involved a level 4 retrospective case series. SETTING: This study was conducted at a level 1 university trauma center. PATIENTS: Twenty patients with painful atrophic nonunions of the humeral diaphysis were examined. INTERVENTION: This involved a thorough debridement and locked compression plating augmented with an intramedullary fibular allograft. MAIN OUTCOME MEASURES: These were union rate, shoulder range of motion, visual analog scale (VAS) pain, VAS function, patient satisfaction, and American Shoulder and Elbow Surgeons score at latest follow-up. METHODS: Clinical and radiographic examinations were performed preoperatively and postoperatively. VAS pain and function scores were collected preoperatively and postoperatively. Patient satisfaction and ASES scores were recorded at the time of the most recent follow-up. RESULTS: : Bony union was achieved in 19 of 20 patients (95%). The patients demonstrated an average improvement in forward elevation from 65 to 144° (P = 0.001), abduction from 48 to 133° (P < 0.001), external rotation from 34 to 70° (P = 0.05), and internal rotation from S1 to T12 (P = 0.025). VAS pain scores improved from 6.05 to 1.88 (P = 0.032). VAS function scores improved from 2.06 to 7.75 (P = 0.003). The average postoperative ASES score was 76, and the average patient satisfaction was rated 9.3/10. CONCLUSIONS: Atrophic nonunions of the humerus can be successfully treated with debridement of the nonunion, coupled with the use of a fibular allograft and locked compression plating. This technique leads to predictable healing without the morbidity associated with autograft. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evolution of orthopaedic reconstructive care.

The patterns and severity of injury sustained by service members have continuously evolved over the past 10 years of combat in Iraq and Afghanistan. The 2010 surge of combat troops into Afghanistan, combined with a transition to counterinsurgency tactics with an emphasis on dismounted operations, resulted in increased exposure of US service members to improvised explosive devices and a new pattern of injury termed dismounted complex blast injury. This constellation of injuries typically includes multiple extremity injuries, high bilateral transfemoral amputations, amputated or mangled upper extremities, open pelvis fractures, and injury to the perineal and/or genital regions. These polytraumatized patients frequently present with head, abdominal, and genitourinary injuries, as well. Traditional methods of reconstruction must be optimized because tissue availability may be limited.

Reprioritization of research for combat casualty care.

Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.

Parallel plating for a sternomanubrial dislocation.

Sternomanubrial dislocations are rare injuries. Although few cases of this injury have been reported in the literature, the etiology has varied widely: trampoline injury, seizures, falls from height, sporting injuries, gradual deformities from spine fractures, and motor vehicle collisions. This injury has been classified into 2 types: in type I, the sternal body is displaced posteriorly to the manubrium, and in the more common type II, the sternal body is displaced anteriorly. The sternomanubrial joint is an amphiarthroidal joint that bears hyaline cartilage on both surfaces connected by a fibrocartilage meniscus. It serves a protective role to vital thoracic structures and is an anterior stabilizing strut to the thorax, assisting the thoracic spine in upright stability. It is important to not ignore type I dislocations because posterior sternum displacement is a harbinger of injury to the pulmonary tree, heart, and esophagus. Chronic instability at this joint can lead to dyspnea and dysphasia due to sternum displacement. In the right scenario, type II injuries are occasionally treated conservatively with palliative treatment until the sternum heals with malformation. This article describes the case of a 20-year-old man who was treated surgically for symptomatic type II sternomanubrial dislocation with dual anterior locked plating. Locked plating gives the benefit of unicortical fixation, with the screws and plate acting as a unit to resist motion. Screw pullout and failure is less common, and the construct is more resistant for this application. The patient returned to full participation in activities of daily living and military duty 4 months postoperatively.

Management of contaminated open fractures: a comparison of two types of irrigation in a porcine model.

BACKGROUND: Treatment of open fractures demands rapid intervention consisting of intravenous antibiotics, aggressive debridement, fracture immobilization, and soft tissue management including additional debridements and soft tissue coverage. Despite this approach, infection, particularly osteomyelitis, after open fracture continues to be a source of significant morbidity. Recent literature has provided several studies that performed clinical trials in superficial wounds. These investigations compared sterile solutions with tap water for wound decontamination. The results suggest that tap water washouts are cost-effective for these specific wounds. MATERIAL: An established protocol using sterile porcine hind limb tibias, as reported by Bhandari et al., was applied with modification. There were then 15 specimens and 5 controls (no irrigation) for each condition. The conditions were potable water and sterile water. A representative bacterium of gram-positive, Staphylococcus aureus, or gram-negative, Escherichia coli, acted as the contaminant. Sectioned, sterile porcine hind limb tibias were inoculated with 1 mL of a known concentration (1 × 10(10)) of bacterium and incubated. Each specimen was then irrigated, with bulb irrigation at a standardized distance of 15 cm, with 500 mL of irrigation. The specimen, along with 0.5 mL of wash (irrigant collected after it was placed over the specimen), was placed in 5 mL of Brain Heart Infusion broth. All specimens were incubated in this broth at 37°C for 2 hours. At 2 hours, a 100-µL supernatant was plated on blood agar plates and incubated for 24 hours. Colony counts for each specimen and controls were then performed. RESULTS: The number of colony forming units (CFUs) for each type of bacterium was different. The average CFUs from bone samples contaminated with E. coli was 5.18 × 10(8) after irrigation with sterile water and 6.24 × 10(8) after irrigation with tap water. The average CFUs from bone samples contaminated with S. aureus was 18 × 10(6) after irrigation with sterile water and 12 × 10(6) after irrigation with tap water. The average CFUs from the irrigation samples from E. coli contamination treated with sterile water was 1.3 × 10(6) and the CFUs from E. coli contamination treated with tap water was 2.2 × 10(6). The average CFUs from the irrigation samples from S. aureus contamination treated with sterile water was 1.57 × 10(6) and the CFUs from S. aureus contamination treated with tap water was 1.56 × 10(6). CONCLUSION: There was no significant difference between the CFUs for the sterile and potable water (p = 0.201) for each bacterium (p = 0.871).

Use of an "antibiotic plate" for infected periprosthetic fracture in total hip arthroplasty.

Periprosthetic fracture and infection are dreaded complications after total hip arthroplasty. We present the case of a 50-year-old man who suffered an early postoperative Vancouver B1 periprosthetic fracture, which was further complicated by concurrent infection after open reduction and internal fixation. We report the novel use of an antibiotic-impregnated cement coated locking plate during the staged treatment of concomitant periprosthetic fracture and chronic total hip arthroplasty infection. At 1-year follow-up, the patient is pain free and ambulating independently with full range of motion.

Acute compartment syndrome of the foot following fixation of a pilon variant ankle fracture.

Acute traumatic compartment syndrome of the foot is a serious potential complication after fractures, crush injuries, or reperfusion injury after vascular repair. Foot compartment syndrome in association with injuries to the ankle is rare. This article presents a case of acute compartment syndrome of the foot following open reduction and internal fixation of an ankle fracture. A 16-year-old girl presented after sustaining a left ankle injury. Radiographs demonstrated a length-stable posterior and lateral malleolar ankle fracture. Initial treatment consisted of a bulky splint and crutches pending the improvement of her swelling. Over the course of a week, the soft tissue environment of the distal lower extremity improved, and the patient underwent open reduction and internal fixation of both her fibula and distal tibia through 2 approaches. Approximately 2 hours from the completion of surgery, the patient reported worsening pain over the medial aspect of her foot and into her calcaneus. Physical examination of the foot demonstrated a swollen and tense abductor hallicus and heel pad. Posterior tibial and dorsalis pedis pulses were palpable and her sensation was intact throughout her foot. Emergently, fasciotomy of both compartments was performed through a medial incision. Postoperatively, the patient reported immediate pain relief. At 18-month follow-up, she reported no pain and had returned to all of her preinjury athletic activities.

Delayed presentation of bladder entrapment secondary to nonoperative treatment of a lateral compression pelvic fracture.

Entrapment of the bladder secondary to pelvic fracture is infrequently described in the literature. Entrapment has most commonly been found to occur through the actions of internal or external fixation. This case report presents bladder entrapment that was not detected until the patient developed genitourinary symptoms and dyspareunia 8 months after nonoperative treatment of a stable lateral compression pelvic fracture.

Injury to the tarsometatarsal joint complex during fixation of Lisfranc fracture dislocations: an anatomic study.

BACKGROUND: The cause of posttraumatic arthritis in Lisfranc injuries is argued in the literature. The purpose of this study was to determine whether the involved joint surface area increased with repositioning of the guidewire before screw placement. MATERIALS: Nine matched pairs of cadaveric feet were disarticulated at the tibiotalar joint. Under fluoroscopic guidance, cannulated screws were placed over guidewires after a single pass across the joint for right feet and two passes across the joint for left feet. Specimens were disarticulated through the midfoot, and the digital images of the joint surface were evaluated for joint surface area and the surface area of cartilaginous damage resulting from screw placement. RESULTS: Mean injury area for the first metatarsal (MT1) was 0.106 cm2 for one pass and 0.168 cm2 for two passes of the guidewire before screw advancement (p = 0.003) The mean injury area for the second metatarsal (MT2) was 0.123 and 0.178 cm2 for one and two passes, respectively (p = 0.018). Four of nine (44%) of the left foot specimens (2 passes of the guidewire) sustained fractures across the MT2 base and three of those specimens also revealed fractures on the middle cuneiform side of the joint (33%). CONCLUSION: Changing the placement of the guidewire across the midfoot significantly increased the joint surface affected by screw placement. Screws placed plantar to the midline of the joint increased the risk of fracture on both sides of the tarsometatarsal complex.

Patellar tendon repair with suture anchors using a combined suture technique of a Krackow-Bunnell weave.

Suture repair of the ruptured patellar tendon is the treatment of choice for patients requiring operative management. This standard technique includes fixation through transosseous tunnels in the patella. The use of suture anchor fixation has several advantages over the standard approach, including less dissection, decreased surgical time, more accurate suture placement, and a low-profile construct. Additionally, the pullout strength of suture anchors warrants consideration of this technique in these repairs. This article describes using suture anchors for repair of the acute ruptured patellar tendon with a combination of Krackow and Bunnell sutures.

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.

Arthroscopic superior labrum anterior-posterior repair in military patients.

The purpose of this retrospective study was to determine the efficacy of arthroscopic superior labrum anterior-posterior (SLAP) repair in a military population. In this study, 27 patients (of 30 consecutive patients) who had suture anchor repair of a type II SLAP lesion were evaluated at a mean of 30.5 months postoperatively. Fifteen patients had isolated tears, whereas twelve also had a concomitant diagnosis. At follow-up, the overall mean American Shoulder and Elbow Surgeons score was 86.9 points and the mean University of California, Los Angeles score was 30.4 points. The results were excellent in 4 patients, good in 20, and fair in 3. Of the patients, 96% returned to full duty (mean, 4.4 months). Patients treated for concomitant diagnoses and a SLAP tear had significantly higher American Shoulder and Elbow Surgeons scores and tended to have higher University of California, Los Angeles scores than those treated for an isolated SLAP tear. The findings indicate that arthroscopic SLAP repair in military patients results in a high rate of return to duty. The results suggest that concomitant shoulder pathology should be treated at the time of SLAP repair.

Lymphocutaneous nocardiosis from commercially treated lumber: a case report.

GOAL: To understand nocardiaI infections to better manage patients with the condition. OBJECTIVES: 1. Identify the organisms causing nocardial infections in humans. 2. Describe the presenting symptoms of nocardial infections. 3. Explain the treatment of nocardial infections.