The Prevalence of Metabolic and Endocrine Disturbances on Fracture Nonunion.

OBJECTIVE: This study aims to determine the prevalence of metabolic disturbance in all fracture nonunion cases and identify the most common endocrine abnormalities seen using a simple screening algorithm. METHODS: A retrospective review study was performed evaluating patients who underwent operative intervention for nonunion from January 2010 to December 2018 at 2 level-1 trauma centers. Preoperative laboratory values were recorded for a 9-test "nonunion panel." A metabolic or endocrine abnormality, specifically an abnormality in the thyroid or parathyroid axis, was evaluated. RESULTS: 42% of patients had an undiagnosed metabolic laboratory abnormality. When multiple tests were used, the rate of metabolic dysfunction was between 60% and 75%, depending on the definition of vitamin D insufficiency vs deficiency used. CONCLUSION: Results indicate a relatively high prevalence of metabolic disturbance in patients with nonunion and suggest metabolic screening for all nonunion patients not only those without a mechanical or infectious cause. LEVEL OF EVIDENCE: IV, retrospective case series.

Tibial Shaft and Pilon Fractures With Associated Syndesmotic Injury: A Matched Cohort Assessment.

OBJECTIVE: To determine the outcomes of pilon and tibial shaft fractures with syndesmotic injuries compared with similar fractures without syndesmotic injury. DESIGN: Retrospective case-control study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: All patients over a 5-year period (2012-2017) with tibial shaft or pilon fractures with a concomitant syndesmotic injury and a control group without a syndesmotic injury matched for age, OTA/AO fracture classification, and Gustilo-Anderson open fracture classification. INTERVENTION: Preoperative or intraoperative diagnosis of syndesmotic injury with reduction and fixation of both fracture and syndesmosis. MAIN OUTCOME MEASUREMENT: Rates of deep infection, nonunion, unplanned reoperation, and amputation in patients with a combined syndesmotic injury and tibial shaft or pilon fracture versus those without a syndesmotic injury. RESULTS: A total of 30 patients, including 15 tibial shaft and 15 pilon fractures, were found to have associated syndesmotic injuries. The matched control group comprised 60 patients. The incidence of syndesmotic injury in all tibial shaft fractures was 2.3% and in all pilon fractures was 3.4%. The syndesmotic injury group had more neurologic injuries (23.3% vs. 8.3% P = 0.02), more vascular injuries not requiring repair (30% vs. 15%, P = 0.13), and a higher rate compartment syndrome (6.7% vs. 0%, P = 0.063). Segmental fibula fracture was significantly more common in patients with a syndesmotic injury (36.7% vs. 13.3%, P = 0.04). Fifty percent of the syndesmotic injury group underwent an unplanned reoperation with significantly more unplanned reoperations (50% vs. 27.5%, P = 0.04). The syndesmotic group had a significantly higher deep infection rate (26.7% vs. 8.3% P = 0.047) and higher rate of amputation (26.7% vs. 3.3% P = 0.002) while the nonunion rate was similar (17.4% vs. 16.7% P = 0.85). CONCLUSIONS: Although syndesmotic injuries with tibial shaft or pilon fractures are rare, they are a marker of a potentially limb-threatening injury. Limbs with this combined injury are at increased risk of deep infection, unplanned reoperation, and amputation. The presence of a segmental fibula fracture should raise clinical suspicion to evaluate for syndesmotic injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Indications for cement augmentation in fixation of geriatric intertrochanteric femur fractures: a systematic review of evidence.

INTRODUCTION: Achieving durable mechanical stability in geriatric intertrochanteric proximal femur fractures remains a challenge. Concomitant poor bone quality, unstable fracture patterns, and suboptimal reduction are additional risk factors for early mechanical failure. Cement augmentation of the proximal locking screw or blade is one proposed method to augment implant anchorage. The purpose of this review is to describe the biomechanical and clinical evidence for cement augmentation of geriatric intertrochanteric fractures, and to elaborate indications for cement augmentation. METHODS: The PubMed database was searched for English language studies up to January 2021. Studies that assessed effect of calcium phosphate or methylmethacrylate cement augmentation during open reduction and internal fixation of intertrochanteric fractures were included. Studies with sample size < 5, nontraumatic or periprosthetic fractures, and nonunion or revision surgery were excluded. Study selection adhered to PRISMA criteria. RESULTS: 801 studies were identified, of which 40 met study criteria. 9 studies assessed effect of cement augmentation on fracture displacement. All but one found that cement decreased fracture displacement. 10 studies assessed effect of cement augmentation on total load or cycles to failure. All but one demonstrated that augmented implants increased this variable. Complication rates of cement augmentation during ORIF of intertrochanteric fractures ranged from 0 to 47%, while non-augmented implants ranged from 0 to 51%. Reoperation rates ranged from 0 to 11% in the cement-augmented group and 0 to 11% in the non-augmented group. Fixation failure ranged from 0 to 11% in the cement-augmented group and 0 to 20% in the non-augmented group. Nonunion ranged from 0 to 3.6% in the cement-augmented group and 0 to 34% in the non-augmented group. CONCLUSIONS: Calcium phosphate or PMMA-augmented CMN fixation of IT fractures increased construct stability and improved outcomes in biomechanical and early clinical studies. The findings of these studies suggest an important role for cement augmentation in patient populations at high risk of mechanical failure.

Biomechanics of Osteoporotic Fracture Care: Advances in Locking Plate and Intramedullary Nail Technology.

SUMMARY: Osteoporotic fractures are extremely common and will continue to increase. Methods of internal fixation must address challenges presented by architectural changes of weakened bone. The goals of surgery are to provide mechanically stable internal fixation with minimal biologic insult that provides rapid rehabilitation and early mobilization. Novel techniques and technology that reinforce preservation of periosteal blood supply and utilization of biomechanically stable constructs diminish failure rates. Advents in locking plate technology, intramedullary nail designs, bone augmentation, and multiple implant constructs maximize strength while mitigating axial, torsional, and bending failure modes to provide optimal patient outcomes.

Treating the Orthopaedic Trauma Knowledge Gap: Quantification of Orthopaedic Resident Knowledge Gaps and Validation of a Multimodal Course to Address the Deficiencies.

OBJECTIVES: To determine whether knowledge-based deficiencies are adequately addressed at the AO North America Basic Principles of Fracture Management course. DESIGN: Pretest, posttest. SETTING: Eighteen national trauma courses. PARTICIPANTS: Two thousand one hundred forty-nine learners. INTERVENTION: Pre- and postcourse 20-item tests of basic fracture knowledge, including 14 trauma topics. MAIN OUTCOME MEASURES: Deficiencies were defined as <60% correct answers on the precourse test. Postcourse knowledge gaps were defined as <75% correct responses. RESULTS: Deficiencies were noted in 7 of the 14 topics on the precourse test. All topics with deficiencies on the precourse test were shown to have statistically significant improvement in postcourse test scores. All topics without deficiencies were shown to have statistically significant improvement in postcourse test scores. The average overall precourse test score was 63% (95% confidence interval, 61%-65%), and the average overall postcourse test score was 81% (95% confidence interval, 79%-83%). The pretest to posttest difference was statistically significant (P < 0.05). The control questions, covering material that was not discussed in the course, did not have statistically significant improvement in scores. CONCLUSIONS: Residents are entering residency programs with limited knowledge of fracture care, and significant gaps remain at the junior level at the time of course participation, suggesting that supplemental fracture courses play an important role in resident education. Validation of short-term learning is possible through a pretest and posttest technique, and it can guide design changes, as opposed to relying on satisfaction surveys alone.

The value of preoperative planning.

"Better to throw your disasters into the waste paper basket than to consign your patients to the scrap heap" has been a proverb of Jeff Mast, one of the greatest fracture and deformity surgeons in the history of our specialty. Stated slightly more scientifically, one of the major values of simulation is that it allows one to make mistakes in a consequence-free environment. Preoperative planning is the focus of this article. The primary goal is not to provide you with a recipe of how to steps. Rather, the primary goal of this article is to explain why preoperative planning should be standard, to clarify what should be included, and to provide examples of what can happen when planning is ignored. At the end of this, we should all feel the need to approach fracture care more intellectually with forethought, both in our own practices and in our educational system.

Iliosacral screw placement: are uniplanar changes realistic based on standard fluoroscopic imaging?

BACKGROUND: With the aim of improving the understanding of iliosacral screw placement, two hypotheses were tested: (1) standard intraoperative inlet and outlet images are not based on orthogonal coordinates, and (2) therefore making starting point and aim changes by moving perpendicular to the c-arm beam will displace the guide wire on the other intraoperative radiographic view. METHODS: This is a prospective case series with review of intraoperative data from consecutive patients treated at a University Level I trauma center. The study group included ten consecutive patients with nondysmorphic upper sacral segments and unstable posterior pelvic ring injuries that required surgical treatment. Posterior surgical stabilization included iliosacral screw placement using a standardized three- view technique in the supine position. The main outcome measurement included the angles from the perpendicular required to achieve what have been considered the ideal inlet and outlet views intraoperatively. The angle arc for each patient created by the recorded angles was then determined. RESULTS: The average sagittal plane tilt required to achieve the ideal inlet view was 25 degrees (range, 21-33 degrees). The average sagittal plane tilt required to achieve the ideal outlet view was 42 degrees (range, 30-50 degrees). The average arc between the ideal inlet and outlet views was 67 degrees (range, 62-76 degrees). These views never created an orthogonal system. CONCLUSION: We commonly work in orthogonal systems. Within these systems, it is possible to make a uniplanar correction by moving perpendicular to one plane or radiographic view. The ideal views to image the safe zone for iliosacral screw placement do not create an orthogonal system. When this average angle arc is placed on a graphic model of the pelvis, it becomes clear that the plane of the radiographic beam of the ideal inlet view is collinear with the anterior aspect of the upper two sacral bodies. The outlet view is oblique to the upper sacral bodies. Surgeons must keep this in mind when using fluoroscopic views to insert iliosacral screws.

Acetabular fracture reductions in the obese patient.

OBJECTIVES: To evaluate the radiographic and computed tomographic reduction qualities after acetabular fracture repair in obese and nonobese patients. DESIGN: Retrospective review. SETTING: University medical center. PATIENTS/PARTICIPANTS: Two hundred forty-two patients were treated with open reduction internal fixation for displaced acetabular fractures. The nonobese group (Group 1) consisted of 149 patients and the obese group (Group 2) had 93 patients. A nonmorbidly obese group (Group 3 = 221 patients) and a morbidly obese group (Group 4 = 21 patients) were also created from the same patient population. INTERVENTION: Operative repair of acetabular fractures. MAIN OUTCOME MEASUREMENTS: Reductions on postoperative radiographs were classified as anatomic with less than 1 mm, imperfect with 2 to 3 mm, and poor with greater than 3 mm of residual displacement. On postoperative computed tomographic scans, reductions were considered nonanatomic with persistent gap or step displacements greater than or equal to 2 mm. RESULTS: Anatomic radiographic reductions were achieved in 72% of the nonobese patients, 70% of the obese patients, 72% of the nonmorbidly obese patients, and 61% of the morbidly obese patients. (P = 0.379) On postoperative computed tomographic scans, an acceptable reduction was obtained in 47% of the nonobese patients, 44% of the obese patients, 47% of the nonmorbidly obese patients, and 31% of the morbidly obese patients. (P = 0.232). CONCLUSIONS: Anatomic or satisfactory reductions can be similarly achieved in all classes of nonmorbidly obese patients who have sustained displaced acetabular fractures. In the morbidly obese, anatomic reductions may be more difficult to obtain.

Lateral ankle radiographs: do we really understand what we are seeing?

OBJECTIVES: To evaluate the validity of using lateral intraoperative fluoroscopic imaging to assess the reduction of the tibial plafond articular surface, two hypotheses were tested: 1) the distal tibial subchondral shadow on the lateral ankle radiograph is created equally by the medial, central, and lateral portions of the distal tibia; and (2) displacement of a 5-mm width osteochondral fragment is consistently recognizable on lateral fluoroscopic imaging. METHODS: Six human fresh-frozen tibial plafond cadaveric specimens were sagitally sectioned in 5-mm increments after removal of the anterior soft tissue and stabilization of the position of the ankle through external fixation. To test the first hypothesis, a perfect lateral radiograph was taken after sectioning the specimens. The sagittal sections were then removed sequentially from medial to lateral. A perfect lateral radiograph was taken after each change. The sagittal sections were then removed beginning laterally and moving medially. A perfect lateral radiograph was taken after each change. The images were then compared with specific evaluation of the change in the subchondral shadow density. To test the second hypothesis, three malreductions were created by displacing a 5-mm osteochondral segment. After each malreduction, a perfect lateral radiograph was saved. These saved fluoroscopic images were placed in random order with lateral images of normal specimens. Four experienced ankle surgeons were then asked to determine whether the radiographs revealed displacement. Inter- and intraobserver reliability was then evaluated. RESULTS: First, the subchondral shadow of the distal tibia appears to be created by an equal confluence of the subchondral bone of the medial, central, and lateral aspects of the tibial plafond. Second, fellowship-trained observers experienced in pilon fracture treatment correctly identified malreduction only 45% of the time. Intraclass correlation coefficient revealed very poor interobserver reliability with an alpha reliability statistic of 0.183. Intraobserver reliability across all four observers yielded an alpha statistic of 0.474, indicating inconsistencies in observers' evaluation of identical images at separate viewings. CONCLUSIONS: It is difficult to discern rotational or translational displacement of a 5-mm osteochondral fragment on a perfect lateral fluoroscopic view of the ankle. Even with what appears to be a perfect lateral fluoroscopic view intraoperatively, displacement may still be present. When small osteochondral fragments are present, direct visualization of the articular surface is necessary to confidently establish that an anatomic reduction has been achieved.

Periarticular tibial fracture treatment in the obese population.

Lambotte's 7 steps of fracture treatment have stood the test of time. Incision, preparation of the bone ends, reduction, temporary fixation, permanent fixation, closure, and dressing are modified to suit the needs of each fracture and each patient. One specific patient characteristic, obesity, has provided complex challenges in fracture care. This article reviews the challenges of obesity as they relate to the 7 steps of lower extremity periarticular fracture care. Specifically, helpful modifications to these 7 steps are provided for the treatment of tibial plateau fractures and tibial plafond fractures. As there is little published evidence with respect to the treatment of these injuries in the obese population, the suggestions that are provided are based on the extrapolation from published evidence of fracture care in other areas in patients with obesity, logic, and personal experience with fracture care in patients with obesity.

Radiographic quantification and analysis of dysmorphic upper sacral osseous anatomy and associated iliosacral screw insertions.

OBJECTIVE: To quantify upper sacral dysmorphic osseous anatomy and assess its impact on second sacral segment iliosacral screw insertion. DESIGN: Retrospective evaluation of a prospective trauma database. SETTING: Regional Level I trauma center. PATIENTS: Twenty-four patients with unstable posterior pelvic ring disruptions and sacral dysmorphism were evaluated radiographically and second segment (S2) screws were placed using a standard technique. MAIN OUTCOME MEASUREMENTS: The sacral osseous pathway limits were measured using preoperative pelvic computed tomography at the upper and second sacral segments. The S2 screw location relative to the sacral nerve root tunnels and the maximum possible screw lengths for both S1 and S2 screws were evaluated with postoperative pelvic computed tomography. The S2 screw positions were graded as intraosseous, juxtaforaminal, or extruded. Preoperative and postoperative peripheral neurologic examinations were documented. RESULTS: The dysmorphic S1 width available for screw insertion averaged 13.2 mm. The S2 pathway width averaged 15.2 mm. The maximum potential screw length for the dysmorphic S1 averaged 100.8 mm and for S2 measured 151.9 mm. Twenty of 24 patients with S2 screws were intraosseous and in four patients were juxtaforaminal. There were no extruded screws. There were no neurologic injuries. CONCLUSIONS: Dysmorphic S1 segments are anatomically competent for routine screw fixation. The S2 segment provides a larger osseous site for screw insertion than S1 in dysmorphic sacrums. Significantly longer screws are possible in S2 compared with the dysmorphic S1 segment. S2 iliosacral screws can be safely and accurately accomplished using a standard technique in patients with unstable posterior pelvic ring disruptions and sacral dysmorphism. Safe screw insertions avoid iatrogenic nerve root injuries.

The clamshell osteotomy: a new technique to correct complex diaphyseal malunions: surgical technique.

BACKGROUND: The treatment of complex diaphyseal malunions is challenging, requiring extensive preoperative planning and precise operative technique. We have developed a simpler method to treat some of these deformities. METHODS: Ten patients with complex diaphyseal malunions (including four femoral and six tibial malunions) underwent a clamshell osteotomy. The indications for surgery included pain at adjacent joints and deformity. After surgical exposure, the malunited segment was transected perpendicular to the normal diaphysis proximally and distally. The transected segment was again osteotomized along its long axis and was wedged open, similar to opening a clamshell. The proximal and distal segments of the diaphysis were then aligned with use of an intramedullary rod as an anatomic axis template and with use of the contralateral extremity as a length and rotation template. The patients were assessed clinically and radiographically at a mean of thirty-one months (range, six to fifty-two months) after the osteotomy. RESULTS: Complete angular correction was achieved in each case; the amount of correction ranged from 2° to 20° in the coronal plane, from 0° to 32° in the sagittal plane, and from 0° to 25° in the axial plane (rotation). Correction of length ranged from 0 to 5 cm, and limb length was restored to within 2 cm in all patients. All osteotomy sites were healed clinically by six months. While no deep infections occurred, superficial wound dehiscence occurred in two patients along the approach for the longitudinal portion of the osteotomy, emphasizing the importance of careful soft-tissue handling and patient selection. CONCLUSIONS: The clamshell osteotomy provides a useful way to correct many forms of diaphyseal malunion by realigning the anatomic axis of the long bone with use of a reamed intramedullary rod as a template. This technique provides an alternative that could decrease preoperative planning time and complexity as well as decrease the need for intraoperative osteotomy precision in a correctly chosen subset of patients with diaphyseal deformities.

The clamshell osteotomy: a new technique to correct complex diaphyseal malunions.

BACKGROUND: The treatment of complex diaphyseal malunions is challenging, requiring extensive preoperative planning and precise operative technique. We have developed a simpler method to treat some of these deformities. METHODS: Ten patients with complex diaphyseal malunions (including four femoral and six tibial malunions) underwent a clamshell osteotomy. The indications for surgery included pain at adjacent joints and deformity. After surgical exposure, the malunited segment was transected perpendicular to the normal diaphysis proximally and distally. The transected segment was again osteotomized along its long axis and was wedged open, similar to opening a clamshell. The proximal and distal segments of the diaphysis were then aligned with use of an intramedullary rod as an anatomic axis template and with use of the contralateral extremity as a length and rotation template. The patients were assessed clinically and radiographically at a mean of thirty-one months (range, six to fifty-two months) after the osteotomy. RESULTS: Complete angular correction was achieved in each case; the amount of correction ranged from 2 degrees to 20 degrees in the coronal plane, from 0 degrees to 32 degrees in the sagittal plane, and from 0 degrees to 25 degrees in the axial plane (rotation). Correction of length ranged from 0 to 5 cm, and limb length was restored to within 2 cm in all patients. All osteotomy sites were healed clinically by six months. While no deep infections occurred, superficial wound dehiscence occurred in two patients along the approach for the longitudinal portion of the osteotomy, emphasizing the importance of careful soft-tissue handling and patient selection. CONCLUSIONS: The clamshell osteotomy provides a useful way to correct many forms of diaphyseal malunion by realigning the anatomic axis of the long bone with use of a reamed intramedullary rod as a template. This technique provides an alternative that could decrease preoperative planning time and complexity as well as decrease the need for intraoperative osteotomy precision in a correctly chosen subset of patients with diaphyseal deformities.

Femoroacetabular impingement: do outcomes reliably improve with surgical dislocations?

Femoroacetabular impingement is a motion-based concept of conflict that occurs secondary to morphologic abnormalities of the proximal femur and/or acetabulum. Creating impingement-free motion through restoration of normal morphology serves as the goal of joint-preserving procedures. We retrospectively reviewed the short-term functional and radiographic outcomes of 46 patients (48 hips) with femoroacetabular impingement treated with a surgical dislocation and restoration of offset. The average Merle D'Aubigné-Postel score improved from a preoperative of 13 (range, 7-16 +/- 1.7) to a postoperative score of 16.8 (range, 12-18 +/- 1.3). Creating impingement-free motion via a surgical dislocation improves symptoms in patients with limited radiographic signs of arthritis who are experiencing impingement-related hip pain.

Operative experience of pelvic fractures in the obese.

BACKGROUND: Disruptions of the pelvic ring may be a significant short- or long-term source of morbidity and mortality. In the obese, temporary stabilization and definitive fixation of the injured pelvis is a much more difficult undertaking, requiring more surgeon expertise and larger surgical approaches. Complications that arise as a result of the operative fixation of pelvic ring injuries may significantly minimize any potential long-term benefits conferred by attempts at fixation. METHODS: During a continuous 46-month period, 288 patients with pelvic ring injuries were prospectively enrolled into a database. A cohort of 186 nonobese patients (group 1) was compared to the cohort of 102 obese patients (group 2). Injury patterns were classified and outcome variables were grouped into perioperative variables, perioperative complications, and late complications. RESULTS: Injury patterns differed significantly between the two groups. There was an increase in the perioperative variables. Overall, there were complications in 19% of nonobese patients and 39% of obese patients (p < 0.001). Wound complications dominated in the obese group. There were 64 additional surgeries in 30 (16%) patients that were the direct result of complications in group 1 and 62 additional surgeries in 31 (31%) patients in group 2. CONCLUSIONS: In the obese, the time commitment, postoperative complication rate, and subsequent surgery rate are significantly greater. In this patient population, special attention should be focused on operative and soft tissue techniques in an effort to lessen the infection risk, the most likely cause of morbidity.

Acetabular fracture patterns and their associated injuries.

OBJECTIVES: Characterize relationships between acetabular fractures patterns and visceral organ injuries. DESIGN: Retrospective review. SETTING: : University medical center. PATIENTS/PARTICIPANTS: Three hundred twenty-three patients with displaced acetabular fractures identified in a prospectively maintained database. INTERVENTION: Acetabular fractures were classified according to force vector at the time of injury. Posterior wall, posterior column, and posterior column/posterior wall injuries were assumed to have been caused by an axial load. The remaining seven acetabular fracture types were assumed to have resulted from a lateral or trochanteric load. Records were reviewed to establish any relationship between acetabular fracture patterns defined by their force vector and injuries to other skeletal and nonskeletal organ systems. MAIN OUTCOME MEASUREMENTS: Comparison of organ injury end points of additional skeletal injury; bowel, bladder, brain, kidney, liver, spleen, and lung injury; retroperitoneal hematoma; and vascular injury of the pelvis. Data were analyzed using chi-square, with statistical significance defined as P < 0.05. RESULTS: Acetabular fractures resulting from lateral loads had a statistically higher association with retroperitoneal hematomas (P < 0.001), spleen (P < 0.008), liver (P < 0.002), vascular (P < 0.001), kidney (P < 0.001), and bladder (P < 0.001) injuries than did posteriorly directed acetabular fractures. Transverse posterior wall fractures exhibited intermediate characteristics between axial load and the remaining lateral load patterns. CONCLUSIONS: Direction of force is important in the etiology of nonskeletal injury patterns. The possibility of additional nonskeletal injury increases from the rates seen in axial load patterns to those in lateral load patterns involving the anterior column.

Supracondylar femur nonunion associated with previous vascular repair: importance of vascular exam in preoperative planning of nonunion repair.

One case of a Gustilo type 3C open OTA 33A-1 supracondylar femur fracture with superficial femoral artery injury that underwent reverse saphenous vein graft repair and open reduction and internal fixation with a retrograde femoral nail is reviewed. The fracture progressed to a hypertrophic nonunion despite 2 bone-grafting procedures and a nail dynamization. Upon referral for revision of the nonunion, a vascular examination revealed a well-perfused extremity with slightly diminished pedal pulses. An arteriogram was ordered that revealed an intraosseous aneurysm associated with the nonunion site and vascular repair. In a joint procedure with vascular and orthopedic surgeons, the previous vessel repair was mobilized, the aneurysmal feeder vessels were ligated, and the nonunion was revised with bridge plating and iliac crest autograft. The nonunion healed uneventfully, and the patient shows no signs of vascular compromise at the 2-year follow-up. The importance of the preoperative vascular assessment is emphasized, and the literature is reviewed.