Lateral Malleolus Fixation with Fibular Rod.

Surgical treatment of fibula fractures associated with unstable ankle injuries traditionally involves an extensile exposure, direct reduction of the fracture, and fixation with a plate and screw construct. Some patient populations may benefit from less invasive approaches and indirect reduction associated with fibular rods. The aim of this report is to demonstrate successful treatment of an unstable ankle injury in a geriatric patient with insulin dependent diabetes using a fibular rod.

Patella fractures treated with cannulated lag screws and fiberwire® have a high union rate and low rate of implant removal.

OBJECTIVES: The purpose of this study is to report the results of open reduction internal fixation of patella fractures (OTA 34 A-C) using cannulated lag screws and FiberWire® (Arthrex, Naples, FL, USA) with regard to union and symptomatic implant removal. DESIGN: Retrospective review of prospectively collected database. SETTING: Urban Level 1 trauma center and Level 2 trauma center METHODS: All displaced intra-articular patella fractures (OTA 34 A-C) treated with ORIF by cannulated lag screws and FiberWire® tension band/cerclage between January 1, 2009 and August 1, 2018. Three hundred and eighty seven consecutive patients were identified. Fifty fractures were included in the final analysis. MAIN OUTCOME MEASUREMENT: All patients were followed to clinical and radiographic union. Nonunion was defined as lack of clinical and radiographic union, fracture displacement, and/or return to OR for revision surgery. Rate of symptomatic implant removal was recorded. RESULTS: Average age was 57.7 years (range 21-86). Average follow up was 20.6 months (range 6-98 months). Average time to clinical and radiographic union was 3.1 months (range 3-7 months). Four fractures were open. There was a 96% (48/50) rate of primary union, with one patients requiring revision surgery to achieve union, and one developing an asymptomatic radiographic nonunion. The rate of symptomatic implant removal was 8% (4/50). Only 1 of the 4 was operated for a prominent suture knot, and the remaining 3 were for prominent screw removal. Knee range of motion averaged 0.37° extension to 119° flexion (range, 0-150°). CONCLUSION: Patella fractures can be treated with cannulated lag screws and FiberWire® with a high rate of primary union (96%) and a low rate of symptomatic implant removal (8%). The implant removal rate compares favorably with alternative constructs, with an equivalent rate of fracture union.

Symptomatic Iliosacral Screw Removal After Pelvic Trauma-Incidence and Clinical Impact.

OBJECTIVE: To calculate the incidence of symptomatic iliosacral (SI) screw removal following pelvic trauma and to determine the clinical impact of the secondary intervention. DESIGN: Retrospective chart review. SETTING: Level 1 and Level 2 trauma centers. PATIENTS: Four hundred seventy-one consecutive patients undergoing percutaneous posterior pelvic fixation over 10 years, with 7 excluded for spinopelvic fixation,and 7 excluded due to age <16 year old. INTERVENTION: Implant removal. MAIN OUTCOME MEASUREMENT: Secondary intervention. RESULTS: A total of 25/457 patients underwent screw removal (5.4%). Two patients were lost to follow-up, leaving 23 for analysis. There were 13 male patients and 10 female patients. There were 13 SI and 10 trans-sacral screws removed. Four screws were loose before removal (17%). Average time to screw removal was 10.7 months (4-26 minutes). Fifteen (83.3%) patients had subjective improvement, and 3 (16.7%) had no notable improvement. CONCLUSION: The incidence of symptomatic SI screws necessitating removal is low (5.4%). When removed, there is a high likelihood (83%) that the secondary intervention will result in subjective symptomatic improvement. Routine screw removal is unnecessary because most patients tolerate the implants without symptoms necessitating subsequent surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Extreme Nailing: Is It Safe to Allow Immediate Weightbearing After Intramedullary Nail Fixation of Extra-articular Distal Tibial Fractures (OTA/AO 43-A)?

OBJECTIVES: To determine whether immediate weightbearing after intramedullary (IM) fixation of extra-articular distal tibial fractures (OTA/AO 43-A) results in a change in alignment before healing. DESIGN: Retrospective review. SETTING: Level 1 trauma center. INTERVENTION: IM nailing of distal tibial fractures. PATIENTS/PARTICIPANTS: Fifty-three patients with 54 fractures, all of whom could bear weight as tolerated postoperatively. Eighteen fractures were OTA/AO 43-A1, 20 OTA/AO 43-A2, and 16 OTA/AO 43-A3; 20 fractures were open. MAIN OUTCOME MEASUREMENTS: Change in fracture alignment or loss of position. RESULTS: Average change from initial angulation at final follow-up was 0.52 ± 1.49 degrees of valgus and 0.48 ± 3.14 degrees of extension. Final alignment was excellent in 14, acceptable in 28, and poor in 12; 2 fractures went from acceptable initial alignment to poor final alignment; and 2 fractures went from excellent to acceptable alignment. Seven fractures had an improvement in alignment over time. Two fractures required free-flap coverage and 4 required staged grafting because of bone loss. Ten fractures had an unplanned return to the operating room (5 for infected nonunion requiring implant exchange, 3 for infection requiring debridement without implant revision, and 2 for aseptic nonunion). No patient had revision for implant failure. CONCLUSIONS: Immediate weightbearing after IM fixation of extra-articular distal tibial fractures (OTA/AO 43-A) led to minimal change in alignment and seems to be safe for most patients. Complications were consistent with those reported in previous non-weightbearing cohorts. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Autograft, Allograft, and Bone Graft Substitutes: Clinical Evidence and Indications for Use in the Setting of Orthopaedic Trauma Surgery.

Bone grafts are the second most common tissue transplanted in the United States, and they are an essential treatment tool in the field of acute and reconstructive traumatic orthopaedic surgery. Available in cancellous, cortical, or bone marrow aspirate form, autogenous bone graft is regarded as the gold standard in the treatment of posttraumatic conditions such as fracture, delayed union, and nonunion. However, drawbacks including donor-site morbidity and limited quantity of graft available for harvest make autograft a less-than-ideal option for certain patient populations. Advancements in allograft and bone graft substitutes in the past decade have created viable alternatives that circumvent some of the weak points of autografts. Allograft is a favorable alternative for its convenience, abundance, and lack of procurement-related patient morbidity. Options include structural, particulate, and demineralized bone matrix form. Commonly used bone graft substitutes include calcium phosphate and calcium sulfate synthetics-these grafts provide their own benefits in structural support and availability. In addition, different growth factors including bone morphogenic proteins can augment the healing process of bony defects treated with grafts. Autograft, allograft, and bone graft substitutes all possess their own varying degrees of osteogenic, osteoconductive, and osteoinductive properties that make them better suited for different procedures. It is the purpose of this review to characterize these properties and present clinical evidence supporting their indications for use in the hopes of better elucidating treatment options for patients requiring bone grafting in an orthopaedic trauma setting.

Assessment of Inter- and Intraobserver Reliability and Accuracy to Evaluate Apical Vertebral Rotation Using Four Methods: An Experimental Study Using a Saw Bone Model.

STUDY DESIGN: After placing a thoracic three-vertebra segment saw bones model on a standardized turntable, a series of anteroposterior (AP) radiographs were obtained and then set in increments to 90° rotation. Then the specimen was instrumented with 35-mm pedicle screws bilaterally and the rotation process and image acquisition were repeated. OBJECTIVE: Assess reliability and accuracy of spine surgeons evaluating apical vertebral rotation (AVR) through surgeon's visual x-ray estimation, Nash-Moe system, Upasani trigonometric method, and Upasani grading system. BACKGROUND CONTEXT: Accurate assessment of AVR is one measure surgeons can evaluate the success of intervention and potential loss of correction in scoliotic deformities. METHODS: Eighty-four representative images of uninstrumented and instrumented vertebral segments were blinded. AVR was estimated by five experienced spinal deformity surgeons using the four techniques. The surgeons' grading, estimates, and errors compared to actual rotation were calculated. Inter- and intraobserver reliability were calculated using interclass correlation (ICC). RESULTS: Each surgeon's error for simple visual estimation for uninstrumented segments was 8.7° to 17.4° (average error = 12.4°), and for instrumented segments it was 7.7° to 11.3° (average error = 9.5°). Error for the Upasani trigonometric method was -6.7° to 11.6° (average error = 0.9°). There was relatively poor accuracy for Nash-Moe system (38.2%-53.9%) compared with the Upasani grading system (76.74%-80.23%). Interobserver reliability using the Nash-Moe method was good (0.844), with intraobserver reliability from fair to excellent (0.684-0.949). Interobserver reliability for the Upasani grading method was good (0.829), with intraobserver reliability from fair to good (0.751-0.869). We found excellent interobserver reliability for Upasani trigonometric classification (0.935) with fair to excellent intraobserver reliability (0.775-0.991). The interobserver reliability of surgeons' visual estimates was good (0.898) and the intraobserver reliability from good to excellent (0.866-0.99) without pedicle screws, and interobserver reliability was excellent (0.948) and intraobserver reliability also excellent (0.959-0.986) with pedicle screws. CONCLUSIONS: We confirm that both techniques described by Upasani have good reliability and accuracy, appearing more accurate than surgeon's visual estimates or Nash-Moe system. LEVEL OF EVIDENCE: Level III.

Long Segment Blocking Screws Increase the Stability of Retrograde Nail Fixation in Geriatric Supracondylar Femur Fractures: Eliminating the "Bell-Clapper Effect".

OBJECTIVES: To determine the change in stiffness and horizontal translations of a geriatric supracondylar femur fracture model with the addition of distal segment blocking screws versus proximal (long) segment blocking screws to the standard retrograde intramedullary nail construct. METHODS: Unstable supracondylar femur fractures (OTA/AO 33-A3) were created; all specimens were instrumented with a retrograde intramedullary nail. Specimens were divided into 2 groups (6 matched pairs per group). Group 1 compared the standard construct (1 proximal screw and 3 distal screws) to a distally augmented construct, with blocking screws placed in the distal metaphyseal segment. Group 2 compared the distally augmented construct to one in which blocking screws were placed just proximal to the fracture (long segment blocking screws). Specimens were then axially loaded and cycled to failure or run-out. RESULTS: There was no significant difference in baseline stiffness, survival through cyclic loading, stiffness after cyclic loading, or cycles to failure between femurs treated with distal blocking screws and femurs treated without blocking screws (group 1). Femurs with blocking screws in the long proximal segment had significantly greater baseline stiffness, stiffness after cyclic loading, and less horizontal translation at the fracture site (group 2). There was no difference in survival through cyclic loading or cycles to failure. CONCLUSION: Long segment blocking screws are biomechanically superior to blocking screws in the distal segment or no blocking screws initially and after cyclic loading in an unstable geriatric supracondylar femur fracture model treated with intramedullary nail. CLINICAL RELEVANCE: Surgeons may use blocking screws to aid in fracture alignment during retrograde nail fixation. In addition, the placement of long segment blocking screws can help resist failure of fixation in geriatric patients by eliminating the "Bell-clapper effect."

Articular Incongruity in the Lower Extremity: How Much Is Too Much?

Intraarticular fractures carry a significant risk for posttraumatic osteoarthritis, and this risk varies across different joint surfaces of the lower extremity. These differences are likely due to the anatomic and biomechanical specifics of each joint surface. High-quality human studies are lacking to delineate the threshold articular incongruity that significantly increases risk for posttraumatic osteoarthritis and diminished clinical outcomes for many joint surfaces. Even with anatomic reduction of the articular surface, close attention must be paid to mechanical axis and joint stability to optimize outcomes.

OTA/AO Classification Is Highly Predictive of Acute Compartment Syndrome After Tibia Fracture: A Cohort of 2885 Fractures.

OBJECTIVE: To determine the correlation between the OTA/AO classification of tibia fractures and the development of acute compartment syndrome (ACS). DESIGN: Retrospective review of prospectively collected database. SETTING: Single Level 1 academic trauma center. PATIENTS: All patients with a tibia fracture from 2006 to 2016 were reviewed for this study. Three thousand six hundred six fractures were initially identified. Skeletally mature patients with plate or intramedullary fixation managed from initial injury through definitive fixation at our institution were included, leaving 2885 fractures in 2778 patients. METHODS: After database and chart review, univariate analyses were conducted using independent t tests for continuous data and χ tests of independence for categorical data. A simultaneous multivariate binary logistic regression was developed to identify variables significantly associated with ACS. RESULTS: ACS occurred in 136 limbs (4.7%). The average age was 36.2 years versus 43.3 years in those without (P < 0.001). Men were 1.7 times more likely to progress to ACS than women (P = 0.012). Patients who underwent external fixation were 1.9 times more likely to develop ACS (P = 0.003). OTA/AO 43 injuries were at least 4.0 times less likely to foster ACS versus OTA/AO 41 or 42 injuries (P < 0.007). OTA/AO 41-C injuries were 5.5 times more likely to advance to ACS compared with OTA/AO 41-A (P = 0.03). There was a significantly higher rate of ACS in OTA/AO 42-B (P = 0.005) and OTA/AO 42-C (P = 0.002) fractures when compared with OTA/AO 42-A fractures. In the distal segment, fracture type did not predict the risk of ACS (P > 0.15). Group 1 fractures had a lower rate of ACS compared with group 2 (P = 0.03) and group 3 (P = 0.003) fractures in the middle segment only. Bilateral tibia fractures had a 2.7 times lower rate of ACS (P = 0.04). Open injury, multiple segment injury, fixation type, and concurrent pelvic or femoral fractures did not predict ACS. CONCLUSIONS: In this large cohort of tibia fractures, we found that the age, sex, and OTA/AO classification were highly predictive for the development of ACS. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous or Open Reduction of Closed Tibial Shaft Fractures During Intramedullary Nailing Does Not Increase Wound Complications, Infection or Nonunion Rates.

OBJECTIVE: To compare the incidence of complications (wound, infection, and nonunion) among those patients treated with closed, percutaneous, and open intramedullary nailing for closed tibial shaft fractures. DESIGN: Retrospective review. SETTING: Multiple trauma centers. PATIENTS: Skeletally mature patients with closed tibia fractures amenable to treatment with an intramedullary device. INTERVENTION: Intramedullary fixation with closed, percutaneous, or open reduction. MAIN OUTCOME MEASUREMENTS: Superficial wound complication, deep infection, nonunion. RESULTS: A total of 317 tibial shaft fractures in 315 patients were included in the study. Two-hundred fractures in 198 patients were treated with closed reduction, 61 fractures in 61 patients were treated with percutaneous reduction, and 56 fractures in 56 patients were treated with formal open reduction. The superficial wound complication rate was 1% (2/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 3.6% (2/56) for the open group with no statistical difference between the groups (P = 0.179). The deep infection rate was 2% (4/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 7.1% (4/56) for the open group with no significant difference between the groups (P = 0.133). Nonunion rate was 5.0% (10/200) for the closed group, 4.9% (3/61) for the percutaneous group, and 7.1% (4/56) for the open group, with no statistical difference between the groups (P = 0.492). CONCLUSIONS: This is the largest reported series of closed tibial shaft fractures nailed with percutaneous and open reduction. Percutaneous or open reduction did not result in increased wound complications, infection, or nonunion rates. Carefully performed percutaneous or open approaches can be safely used in obtaining reduction of difficult tibial shaft fractures treated with intramedullary devices. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Negative Stress Examination Under Anesthesia Reliably Predicts Pelvic Ring Union Without Displacement.

OBJECTIVES: To identify the negative predictive value of examination under anesthesia (EUA) for determining pelvic ring stability and union without further displacement. DESIGN: Retrospective cohort study. SETTING: Two academic Level 1 trauma centers. PATIENTS/PARTICIPANTS: Thirty-four adult patients with closed pelvic ring injuries treated over a 5-year period. INTERVENTIONS: Pelvic stress EUA. MAIN OUTCOME MEASURES: Pelvic ring union and pelvic ring displacement at final follow-up. RESULTS: Thirty-four patients with closed pelvic ring injuries who underwent pelvic EUA during the study period and had a negative examination (indicating a stable pelvis) were identified. Mean age was 38 years (range 16-76), and 19 patients (55.9%) were male. Twenty-two patients (64.7%) had Young-Burgess lateral compression (LC)-1 injuries with complete sacral fractures, 4 patients (11.8%) had LC-2 injuries, and 8 patients (23.5%) had anteroposterior compression (APC)-1 injuries. Eight patients (23.5%) had associated injuries requiring restricted weight-bearing on one or both lower extremities and were excluded from the analysis. Immediate weight-bearing as tolerated was permitted bilaterally in the remaining 26 patients. Mean pelvic ring displacement at the time of injury was 3.8 mm (range 1-15 mm) for LC injuries and 9.1 mm (range 2-20 mm) for APC injuries. Patients were followed for a mean of 8 months (range 3-34 months). At final follow-up, mean displacement was 3.7 mm (range 0-17 mm) for LC injuries and 7.1 mm (range 2-19 mm) for APC injuries. Mean change in displacement from injury to union was -0.1 mm for LC injuries and -2.0 mm for APC injuries, indicating decreased pelvic ring displacement at union. All patients were able to tolerate full weight-bearing bilaterally with no pain, and there were no instances of delayed operative fixation after negative EUA. CONCLUSIONS: Negative pelvic EUA after closed pelvic ring injury accurately predicts pelvic stability and union without displacement after nonoperative treatment with full weight-bearing bilaterally. Unless otherwise dictated by associated injuries, immediate weight-bearing as tolerated seems safe in patients with pelvic ring injuries who have had a negative EUA. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Open Reduction for AO/OTA 81-B3 (Hawkins 3) Talar Neck Fractures: The Natural Delivery Method.

Fractures of the talar neck with subtalar and tibiotalar joint dislocation (AO/OTA 81-B3) represent a treatment challenge for the orthopedic surgeon. The magnitude of deformity and complexity of the pathoanatomy adds to concerns for soft tissue embarrassment to convey an urgency of surgical intervention. Previous studies have described the several techniques for talar reduction, including medial malleolar osteotomy, posterior Schanz pin manipulation, or posteromedial incision to facilitate relocation at the time of definitive open treatment. We describe a simple technique for stepwise surgical intervention using adjuncts to reduction on the surgical field that facilitate an atraumatic relocation of the displaced body fragment through a standard lateral incision, simplifying fixation of the residual talar neck fracture. A reasonable metaphor for the technique is its similarity to reducing an obstetric shoulder dystocia in the delivery of a newborn infant.

Unexpected radiographic lucency following grafting of bone defects with calcium sulfate/tricalcium phosphate bone substitute.

OBJECTIVE: To report the development of unexpected radiographic lucency (URL) corresponding to the use of a commercially available calcium sulfate/tricalcium phosphate composite used to treat benign osseous lesions. MATERIALS AND METHODS: This is a retrospective comparative study of patients with and without URL after treatment with curettage and grafting with calcium sulfate/tricalcium phosphate. The charts of 87 patients meeting the inclusion criteria were reviewed for demographic, clinical, and radiographic data. The group with URL was compared to those with more typical patterns of graft incorporation. RESULTS: Thirteen of 87 cases (15%) showed URL. There was no difference with respect to the pathologic subtype, anatomic location, or specific bone for the presence of URL. Of patients with URL, one (7.7%) required reoperation and regrafting, whereas among patients without URL, five (6.7%) had clinical complications, with one requiring reoperation and regrafting, and one requiring radiofrequency ablation. CONCLUSIONS: The majority of patients treated with calcium sulfate/tricalcium phosphate cementing after curettage of low-grade bone lesions go on to uneventful healing in our series. In a minority of patients, URL occurs in lieu of the more typical pattern of centripetal incorporation. However, there is no increase in complications associated with URL. Based on these findings, patients should be informed of the possibility of this risk, although there appears to be little risk of clinically relevant adverse consequences. Physicians should be aware of this complication in order to avoid mistaking it for recurrence of the primary lesion.

Initial Treatment of "Pelvic Injuries" with Commercially Available Pelvic Binders Results in Displacement of Acetabular Fractures: A Report of Three Cases.

CASES: Three hemodynamically stable patients with displaced acetabular fractures were treated with commercially available pelvic binders after blunt trauma. In two of the patients, placement of the binder corresponded with transfer from a community hospital to a tertiary care facility. CONCLUSION: The pelvic binder is an increasingly utilized portable device that can provide lifesaving tamponade in patients with hemodynamically unstable pelvic injuries. However, incorrect application of the device may expose patients to unnecessary morbidity. This report demonstrates the need to establish appropriate guidelines and provide training for first responders and community physicians who are likely to encounter these fractures in the acute setting.

Practical aspects of measuring intracellular calcium signals with fluorescent indicators.

The use of fluorescent indicators for monitoring calcium (Ca(2+)) signals and for measuring Ca(2+) concentration ([Ca(2+)]) in living cells is described. The following topics are covered in detail: (1) ratiometric and nonratiometric fluorescent indicators and the principles underlying their use, (2) techniques for loading Ca(2+) indicators and Ca(2+) buffers into living cells, (3) calibration of indicator fluorescence intensity measurements to yield values of intracellular [Ca(2+)], (4) analysis of nonratiometric fluorescence intensity data and caveats relating to their interpretation, (5) techniques for manipulating intracellular and extracellular [Ca(2+)], and (6) the use of fluorescent indicators to monitor Ca(2+) signals in mitochondria. The chapter aims to present these fundamental topics in a manner that is practically useful and intuitively accessible. The origins of key mathematical equations used in the article are outlined in two appendices.

Caged vanilloid ligands for activation of TRPV1 receptors by 1- and 2-photon excitation.

Nociceptive neurons in the peripheral nervous system detect noxious stimuli and report the information to the central nervous system. Most nociceptive neurons express the vanilloid receptor, TRPV1, a nonselective cation channel gated by vanilloid ligands such as capsaicin, the pungent essence of chili peppers. Here, we report the synthesis and biological application of two caged vanilloids: biologically inert precursors that, when photolyzed, release bioactive vanilloid ligands. The two caged vanilloids, Nb-VNA and Nv-VNA, are photoreleased with quantum efficiency of 0.13 and 0.041, respectively. Under flash photolysis conditions, photorelease of Nb-VNA and Nv-VNA is 95% complete in approximately 40 micros and approximately 125 micros, respectively. Through 1-photon excitation with ultraviolet light (360 nm), or 2-photon excitation with red light (720 nm), the caged vanilloids can be photoreleased in situ to activate TRPV1 receptors on nociceptive neurons. The consequent increase in intracellular free Ca(2+) concentration ([Ca(2+)](i)) can be visualized by laser-scanning confocal imaging of neurons loaded with the fluorescent Ca(2+) indicator, fluo-3. Stimulation results from TRPV1 receptor activation, because the response is blocked by capsazepine, a selective TRPV1 antagonist. In Ca(2+)-free extracellular medium, photoreleased vanilloid can still elevate [Ca(2+)](i), which suggests that TRPV1 receptors also reside on endomembranes in neurons and can mediate Ca(2+) release from intracellular stores. Notably, whole-cell voltage clamp measurements showed that flash photorelease of vanilloid can activate TRPV1 channels in <4 ms at 22 degrees C. In combination with 1- or 2-photon excitation, caged vanilloids are a powerful tool for probing morphologically distinct structures of nociceptive sensory neurons with high spatial and temporal precision.