Heterotopic Ossification after Trauma.

Heterotopic ossification (HO) refers to benign ectopic bone formation in soft tissue and is common following trauma surgery. HO bone can restrict movement and progress into ankylosis that may necessitate surgical intervention. This article discusses the current literature on the pathophysiology, prophylaxis, treatment, and epidemiology of postoperative HO following orthopedic trauma.

Medial Clavicle Fracture Fixation Including the Sternum: A Case Report.

CASE: A 29-year-old man presented with a displaced medial clavicle fracture. Surgical repair was performed using a precontoured plate designed for the contralateral distal clavicle, and medial fixation was accomplished at the sternum. The patient had no complications and demonstrated full strength and range of motion at the 8-month follow-up. CONCLUSION: Medial clavicle fractures with a small medial fragment can be immobilized using a plate designed for the contralateral distal clavicle that crosses the sternoclavicular joint to obtain medial fixation in the sternum. This technique may provide a viable treatment modality for this unique fracture pattern.

Orthopaedic Trauma-Induced Pyoderma Gangrenosum: A Case Report.

CASE: We present a case of a 60-year-old polytraumatized man who developed postoperative pyoderma gangrenosum (PG) after his initial stabilization procedures, mimicking a postoperative infection. This caused a delay in diagnosis, leading to progression of his wounds and a delay in initiation of the appropriate treatment. Once his PG was appropriately treated, his clinical status and wounds improved. He underwent successful wound coverage by plastic surgery and has been recovering from his injuries. CONCLUSION: Prompt identification and initiation of treatment for postoperative PG is critical to avoid exacerbation of wounds and subsequent morbidity to the patient.

The Role of Implant Removal in Orthopedic Trauma.

Although implant removal is common after orthopedic trauma, indications for removal remain controversial. There are few data in the literature to allow evidence-based decision-making. The risk of complications from implant removal must be weighed against the possible benefits and the likelihood of improving the patient's symptoms.

Proper Distal Placement of Tibial Nail Improves Rate of Malalignment for Distal Tibia Fractures.

OBJECTIVES: We hypothesize that the anatomic center of the distal tibia is just lateral and anterior to the center of the distal tibia articular surface in the coronal and sagittal planes, respectively, and that placement of the nail along this axis results in improved rates of malalignment when treating distal tibia fractures. DESIGN: Retrospective study. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. SETTING: One Level I and one Level II trauma center. PATIENTS/PARTICIPANTS: Two hundred three distal tibia fractures treated with intramedullary nailing (IMN) (primary cohort) whose main fracture line extended within 5 cm of the plafond to evaluate the rate of malalignment with distal nail placement. Additionally, we retrospectively reviewed a secondary cohort of 15 patients with proximal tibia fractures treated with intramedullary nailing for evaluation of passive anatomic distal nail position. MAIN OUTCOME MEASURES: Primary malalignment ≤5 degrees on the anteroposterior (AP), mortise, and lateral planes were evaluated in distal tibia fractures on perioperative radiographs. RESULTS: Primary Cohort: 85 patients met inclusion criteria for evaluation in the coronal plane. Overall malalignment in the coronal plane was 17.6%. There was a 2.9% (1/34) fracture malalignment rate when the nail was placed lateral to the center of the joint versus 27.5% (14/51) when placed medial to the center of the joint, with all occurring in valgus. This achieved statistical significance (P = 0.04). Correlation was highest when measuring the trajectory on mortise view using the talus as reference point. When evaluating the sagittal plane, there were 64 patients that met inclusion criteria with a 48% malalignment rate. Malalignment was greatest when the nail was placed in the anterior quadrant 100% (4/4), versus 50% (22/44) in the anterior middle, and 31.3% (5/16) in the posterior middle quadrant. This achieved statistical significance (P = 0.05). No nails were placed in the most posterior quadrant. Secondary Cohort: 15 patients met inclusion criteria for distal nail placement. The position of the nail in the coronal plane was measured on both the anteroposterior and mortise ankle radiographs using both the plafond and talus as a reference, whereas sagittal nail placement was measured on the lateral ankle radiographs. In the coronal plane, the mean passive distal position of the nail when referenced from the lateral cortex was 45.2% of the tibia plafond and 45.5% the width of the talus, or just lateral to the center of each. In the sagittal plane, passive nail placement was 40% the sagittal width of the joint measured from the anterior cortex, or just anterior to the center of the joint. CONCLUSIONS: This is the first patient series that defines optimal tibial nail placement in the treatment of distal tibia fractures. Distal placement of the nail just lateral to the center of the talus and plafond, or along mechanical axis of the tibia, results in significantly reduced rates of malalignment on the coronal plane when compared to nail placement medial to the center of the talus or plafond. Fluoroscopic judgment of distal nail trajectory was improved on the mortise view using the talus as a reference when compared to using the anteroposterior view. On the sagittal plane, anatomic passive nail placement is just anterior to the center of the plafond. However, nonanatomic nail placement just posterior to the center of the plafond had a lower incidence of malalignment compared with nails placed anterior to the center of the plafond. Further study of appropriate nail positioning on the sagittal plane is needed.

Bone Morphogenetic Protein: Is There Still a Role in Orthopedic Trauma in 2017?

Approximately 10 years ago bone morphogenic protein (BMP) was seen as a miraculous adjuvant to assist with bone growth. However, in the face of an increasing number of complications and a lack of understanding its long-term effects, it is unclear what role BMP has in the current treatment of orthopedic trauma patients. This article reviews the current recommendations, trends, and associated complications of BMP use in fracture care.

Proximity and Risks of the Anterior Neurovascular and Tendinous Anatomy of the Distal Leg Relative to Anteriorly Applied Distal Locking Screws for Tibia Nailing: A Plea for Open Insertion.

PURPOSE: To determine the proximity and potential risks to distal leg anatomy from anterior to posterior (A-P) applied distal tibia locking screws for tibial nailing. DESIGN: Retrospective. SETTING: ACS level I trauma center. PATIENTS/PARTICIPANTS: Twenty consecutive adult patients undergoing computed tomograms with intravenous contrast (computed tomography angiograms) on uninjured legs. MAIN OUTCOME MEASUREMENTS: Simulated 5-mm distal interlocking screws placed in the A-P axis of an ideally placed tibial nail at 10-mm increments from the tibial plafond (10-40 mm) were studied in relation to the distal leg's anterior anatomy. RESULTS: All A-P screws (80/80, 100%) impacted the tibialis anterior tendon, extensor hallucis longus tendon, and/or anterior tibial neurovascular (NV) bundle between 10 and 40 mm cranial to the plafond. The NV bundle was impacted in 53% of cases. The medial extent of the tibialis anterior tendon was greatest 10 mm cranial to the plafond and averaged 27 degrees (95% confidence interval, 22-33 degrees) medial to the A-P line. The maximum lateral border of the foot's common extensors, found 40 mm cranial to the plafond, averaged 71 degrees (95% confidence interval, 62-80 degrees) lateral to the A-P line. DISCUSSION: The anterior tibial NV bundle and foot and ankle extensor tendons are at high risk from A-P-directed distal locking screws. The tendinous anatomy of the distal leg is at risk between 33 degrees medial and 80 degrees lateral to the A-P axis of a tibial nail. Distal locking screws placed from the A-P direction should be thoughtfully applied and an open approach should be strongly considered.

Metaphyseal Distal Tibia Fractures: A Cohort, Single-Surgeon Study Comparing Outcomes of Patients Treated With Minimally Invasive Plating Versus Intramedullary Nailing.

OBJECTIVES: The purpose of this study was to compare clinical and functional outcomes of patients with distal tibia fractures treated with minimally invasive plating (MIPO) or intramedullary nailing (IMN). DESIGN: Cohort study. SETTING: Level II regional trauma center. PATIENTS: Overall, 86 patients with metaphyseal distal fractures (within 5 cm of joint) with simple or no articular involvement treated by a single, fellowship trained, orthopedic trauma surgeon from 2002 to 2013. INTERVENTION: Intramedullary nailing or minimally invasive plate osteosynthesis. MAIN OUTCOME MEASURES: Clinical and radiographic results were evaluated at a minimum of 1-year follow-up. Limb-specific outcomes (American Orthopedic Foot and Ankle Surgeons' ankle-hindfoot instrument) and whole-person measures [Short Form 36 (SF-36) instrument] were assessed at the final follow-up. RESULTS: We studied 86 patients with distal tibia fractures treated with MIPO (43 patients) and IMN (43 patients). Thirty-seven patients in the MIPO group and 27 in the IMN group met inclusion criteria. All patients ultimately healed, with the average time to union of 23 weeks in both the groups. Complications were similar between the 2 groups (MIPO vs. IMN, respectively), including nonunion (8% vs. 7%), malalignment (3.6% vs. 3%), wound complications (3.6% vs. 3%), and infection (0% vs. 3.6%). The need for secondary procedures for the removal of implants was 25.9% in the IMN group (distal locking screws only in 6/7) versus 8.3% in the MIPO group (P = 0.05). Additionally, the American Orthopedic Foot and Ankle Surgeons and all SF-36 version 2 domain scores were quantitatively higher for the IMN group, although only Role Emotional reached a level of statistical superiority between the groups. CONCLUSIONS: Similar clinical results and marginally enhanced functional outcomes were seen when treating nonarticular or minimally articular metaphyseal distal tibia fractures with IMN compared with MIPO. However, patients treated with IMN required more frequent secondary surgeries for the removal of painful distal locking screws. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Simultaneous proximal femoral rotational and distal femoral varus osteotomies for femoral retroversion and genu valgum.

Whereas excess femoral anteversion and its related symptoms have been described many times, excess femoral retroversion is less well documented. We report the case of a 30-year-old woman who had a history of chronic bilateral hip and knee pain and evidence of excess femoral retroversion, genu valgum, early-onset lateral and patellofemoral compartment osteoarthritis of both knees, and hip arthritis. She experienced symptomatic relief after undergoing staged bilateral simultaneous proximal femoral rotational and distal femoral lateral opening wedge osteotomies. Although this combination of alignment problems is not an infrequent clinical occurrence, we have found no literature on this condition or treatment. The patient provided written informed consent for print and electronic publication of this case report.