Postoperative wound complications in extensile lateral approach versus sinus tarsi approach for calcaneal fractures: Are we improving? Updated meta-analysis of recent literature.

INTRODUCTION: To analyze recent literature comparing clinical outcomes of displaced intra-articular calcaneal fractures (DIACF) treated with open reduction and internal fixation using the extensile lateral approach (ELA) vs the minimally invasive sinus tarsi approach (STA), with a focus on wound complications. MATERIALS AND METHODS: A comprehensive literature search was conducted utilizing PubMed, EMBASE, and Cochrane Library databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 2013 and 2022, level of evidence (LOE) I-III, head-to-head comparative studies reporting on clinical outcomes after DIACFs treated with ORIF using ELA versus STA, and literature with full-text written in English were included. Data collection included: publication year, study design, number of surgeons, number of participants, demographic data (mean age at time of surgery, percent male, body mass index, medical co-morbidities), preoperative data (mechanism of injury, Sanders classification, time from injury to surgical fixation), intraoperative data, and postoperative clinical and radiographic outcomes (Böhler angle, angle of Gissane, calcaneal height/length/width). RESULTS: A total of 21 articles (4 randomized control trials, 17 cohort studies) comprising of 2086 patients with calcaneal fractures, treated with either ELA (n = 1129) or STA (n = 957) met inclusion criteria. The risk of postoperative wound-related complications (RR 2.82, 95 % CI: 2.00-3.98, I2=27 %) and the risk of reoperation (RR 1.85, 95 % CI: 0.69-5.00, I2=67 %) was higher in ELA patients comparted to STA patients. However, the increased risk of postoperative wound-related complications with an ELA vs. STA was shown to be trending downward in recent publications. The ELA group also experienced longer time to surgery, extended operative times, and prolonged hospital stays when compared to the STA group. Radiographic measurements at final follow-up, including Böhler angle, angle of Gissane, as well as calcaneal height, length, and width, showed no statistically significant differences between the two groups. CONCLUSION: Surgical treatment of calcaneal fractures utilizing the ELA continues to have an increased rate of complications and reoperation when compared to the less invasive STA, yet recent trends in the literature show that this rate is decreasing. Operative treatment of calcaneal fractures via either an ELA or STA can both achieve comparable postoperative radiographic outcomes. LEVEL OF EVIDENCE: Therapeutic Level III.

Distal Tibia Apex Posterior Angulation: A Normal Anatomic Variant Related to Hindfoot Alignment With Side-to-Side Symmetry.

OBJECTIVES: The sagittal plane of the distal tibia has not been well-described. This study sought to characterize sagittal plane morphology, determine symmetry from side to side, and identify differences based on hindfoot alignment. METHODS: One hundred twelve bilateral lateral weight-bearing ankle radiographs were retrospectively evaluated (224 ankles). Hindfoot alignment was classified as neutral, planus, or cavus using the Meary angle. The angle between the diaphyseal and distal tibia axes was measured, and the apex location relative to the plafond was recorded. RESULTS: A mean distal tibia apex posterior angulation (DTAPA) of 2.0° (range -2° to 7°, SD = 2.06°) was located 8.0 cm proximal to the plafond. No difference was observed from side to side in DTAPA magnitude (P = 0.36) or location (P = 0.90). Planus alignment was associated with a significantly greater DTAPA (3.05°) as compared with neutral (1.89°) (P = 0.002) and cavus (1.25°) (P < 0.001) alignment. CONCLUSION: The distal tibia has an apex posterior angulation, suggesting that the true anatomic axis of the tibia terminates just posterior to the plafond center. Hindfoot alignment is related to distal tibia morphology. DTAPA symmetry indicates that contralateral imaging can be used to guide reconstruction of patient-specific anatomy and alignment. Knowledge of the DTAPA may help mitigate sagittal malalignment during distal tibia fracture surgery.

Krackow Suture Technique Effect on Patella Tendon Vascularity: Quantitative MRI Analysis.

OBJECTIVES: To assess the effects of Krackow suture technique on the vascularity of the patellar tendon. METHODS: Six fresh-frozen matched pair cadaveric knee specimens were used. The superficial femoral arteries were cannulated in all knees. The experimental knee underwent an anterior approach, patellar tendon transection from the inferior pole of the patella, 4-strand Krackow stitch placement, patellar tendon repair via 3-bone tunnels, and standard skin closure. The control knee underwent the identical procedure without Krackow stitching. All specimens then underwent precontrast and postcontrast enhanced quantitative magnetic resonance imaging assessment (with gadolinium-based contrast agent). Region of interest analysis was performed to assess for variation in signal enhancement between the experimental and control limbs in various patellar tendon regions and subregions. Latex infusion and anatomical dissection were performed to further evaluate vessel integrity and assess extrinsic vascularity. RESULTS: Quantitative magnetic resonance imaging analysis demonstrated no statistically significant difference in overall arterial contributions. A small but nonsignificant decrease of 7.5% (SD ± 7.1%) in arterial contributions to the entire tendon was observed. Small nonstatistically significant regional decreases throughout the tendon were also detected. In the regional analysis, the largest to smallest decreases in arterial contributions after suture placement were found in the inferomedial, superolateral, lateral, and inferior tendon subregions. In the anatomical dissection, nutrient branches were seen dorsally and posteroinferiorly. CONCLUSION: The vascularity of the patellar tendon was not significantly affected by Krackow suture placement. Analysis demonstrated small and not statistically significant decreases in arterial contributions, suggesting this technique does not significantly compromise arterial perfusion.

Apex posterior angulation of the humerus: A characterization of normal sagittal plane anatomy with implications for surgical fixation.

INTRODUCTION: An understanding of the sagittal plane morphology of the humerus is relevant during surgical fixation of humeral fractures but is not well described in the literature. The purpose of this study was to better characterize the native sagittal plane morphology of the humerus. MATERIALS AND METHODS: 170 patients with uninjured full length lateral humerus radiographs were retrospectively evaluated. The angle between the proximal humeral diaphyseal axis and the distal humeral diaphyseal axis was identified and measured. The proximal axis was defined by two points equidistant from the anterior and posterior cortex 10 mm and 100 mm distal to the metaphyseal flare, and the distal axis by two points at 10 mm and 50 mm proximal to the capitellum/trochlea. The relative location of the center of rotation of angulation (CORA) was calculated as a percentage of humeral length. RESULTS: 114 radiographs were included in the analysis (66 right humeri, 48 left humeri). The average apex posterior angulation was 6.5 +/- 2.9°. The CORA occurred at an average of 80% (SD+/-13%) of the length of the humerus (proximal to distal). Total humeral length and absolute distance to CORA were greater in males compared to females (364 ± 50 mm versus 326 ± 30 mm; p<0.001; 290 ± 68 mm versus 260 ± 48 mm; p=0.003), but there were no significant sex differences with respect to magnitude of the apex posterior angulation (p=0.077) or location of CORA as a percentage of total humeral length (p=0.916). There were no statistically significant associations between age and total humeral length (p=0.056), distance to CORA (p=0.130), location of CORA as percentage of total humeral length (p=0.753), or magnitude of angulation (p=0.075). CONCLUSION: An apex posterior bow consistently exists in the distal one-quarter of the humerus that is consistent across ages and between sexes. This normal anatomic bow is important to recognize to avoid an extension malreduction and has implications for implant fit and contouring.

Relative Sagittal Alignment of the Medial and Lateral Articular Surfaces of the Tibial Plateau Using Radiographic Parameters: A Radiographic Cadaveric Study.

OBJECTIVES: To characterize anatomic slope (sagittal alignment) of medial and lateral articular surfaces of the tibial plateau using x-ray and computed tomography (CT). METHODS: Fluoroscopy was used to acquire "perfect" anteroposterior (AP) images of 8 cadaveric knees by tilting a C-arm through a 30-degree cranial/caudal arc in 0.5-degree increments. Five surgeons independently selected perfect AP images that most accurately profiled medial and lateral articular surfaces. Corresponding angles were used to define tangent subchondral structures on sagittal CT that were considered as dominant bony landmarks in a protocol to determine tibial slope on sagittal CT in 46 additional cadaveric knees. RESULTS: Mean perfect C-arm AP angles were 4.2 degrees ± 2.6 degrees posterior for the medial plateau and 5.0 degrees ± 3.8 degrees posterior for the lateral plateau. It was noted that images acquired within a range of angles (medial range, 1.8 degrees ± 0.7 degrees; lateral range, 3.9 degrees ± 3.8 degrees) rather than a single angle adequately profiled each compartment. Using the CT protocol, mean medial slope (5.2 degrees ± 2.3 degrees posterior; range, 0.9-11.5 degrees) was less than lateral slope (7.5 degrees ± 3.0 degrees posterior; range 0.6-12.5 degrees; P < 0.001) in 54 knees. The difference between medial and lateral slopes in any individual specimen ranged from 3.1 degree more medially to 6.8 degrees more laterally. No differences were noted between right and left knees in paired specimens. CONCLUSIONS: On average, tibial slope in the lateral plateau is slightly greater than that in the medial plateau, and variation exists between compartments across patients. Because tibial slope is similar between contralateral limbs, evaluating slope on the uninjured side can provide a template for sagittal plane reduction of tibial plateau fractures.

The Effect of Nonsteroidal Anti-inflammatory Drugs and Selective COX-2 Inhibitors on Bone Healing.

A recently published study, "Risk of Nonunion With Nonselective NSAIDs, COX-2 Inhibitors, and Opioids" by George et al (J Bone Joint Surg Am. 2020;102:1230-1238), assesses whether the use of nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), selective cyclooxygenase 2 (COX-2) enzyme inhibitors, or opioids was associated with a risk of long bone fracture nonunion in Optum's deidentified private health database. This review analyzes the study, including strengths, weaknesses, and areas for future research. The study found an association between COX-2 inhibitor and opioid use with fracture nonunion but not with nonselective NSAID use. Although the literature on this topic is varied, these results are at least partially aligned with several animal studies that show COX-2 inhibitors to be associated with fracture nonunion. The George et al study design has several important limitations, indicating that further research is needed on this topic.

Considerations with failed intertrochanteric and subtrochanteric femur fractures: how to treat, revise, and replace.

With the increasing number of intertrochanteric and subtrochanteric femur fractures, there will be an increasing need for surgical intervention. As a result, there will be an increasing number of failures and the need for revision surgery. The following outlines some of the pitfalls related to these complex fractures and options for revision surgery.

A comprehensive update on current fixation options for two-part proximal humerus fractures: a biomechanical investigation.

BACKGROUND: Recent advancements in implant technology offer updated options for surgical management that have been rapidly adopted into clinical practice. The objective of this study is to biomechanically test and compare the current fixation options available for surgical fixation of two-part proximal humerus fractures and establish load to failure and stiffness values. METHODS: Sixteen match-paired (32 total) fresh-frozen, cadaveric specimens were randomized to receive 1 of 4 fixation constructs following creation of an AO/OTA Type 11A3 (two-part) proximal humerus fractures. Fixation constructs tested consisted of 3.5 mm fixed angle plate (3.5-FAP), 4.5 mm fixed angle plate (4.5-FAP), humeral intramedullary nail (IMN), and a humeral intramedullary nail with a fixed angle blade (IMN-FAB). Specimen bone density was measured to ensure no adequate, non-osteoporotic bone. Constructs were tested for stiffness and ultimate load to failure and compared via one-way ANOVA analysis with subsequent post hoc Tukey HSD multiple group comparison statistical analysis. RESULTS: The IMN-FAB construct was significantly stiffer than the 3.5-FAP construct (123.8 vs. 23.9, p<0.0001), the 4.5-FAP construct (123.8 vs. 33.3, p<0.0001) and the IMN construct (123.8 vs. 60.1, p=0.005). The IMN-FAB construct reported a significantly higher load to failure than the 3.5-FAB construct (4667.3 N vs. 1756.9 N, p<0.0001), and the 4.5-FAP construct (4667.3 N vs. 2829.4 N, p=0.019, Table 2). The IMN construct had a significantly higher load to failure than the 3.5-FAP construct (3946.8 vs. 1756.9, p=0.001, Table 2). CONCLUSION: Biomechanical testing of modern fixation options for two-part proximal humerus fracture exhibited that the stiffest and highest load to failure construct was the IMN-FAB followed by the IMN, 3.5-FAP and then the 4.5-FAP constructs. However, prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures.

The anterior intra-pelvic (modified rives-stoppa) approach for fixation of acetabular fractures.

OBJECTIVES: Report the technical aspects, radiographic results, and complications after minimum 1-year follow up of the anterior intra-pelvic (AIP or modified Rives-Stoppa) approach as an alternative to the ilioinguinal approach for the treatment of acetabular fractures. DESIGN: Retrospective review. SETTING: Level I trauma center. MATERIALS AND METHODS: All skeletally mature patients requiring an anterior approach for fixation of an acetabular fracture with minimum 1-year clinical and radiographic follow up were included. Charts and radiographs were reviewed for fracture pattern, time to surgery, operative time, blood loss, quality of reduction, and perioperative complications. A consecutive group of 57 patients treated by a single surgeon using the AIP approach was identified as a subset of a larger series 536 acetabular fractures treated by the same surgeon between February 2004 and February 2008. RESULTS: Of the 57 patients, average time to operation was 5 days and a supplemental lateral window was required in 34 patients (60%). Average blood loss was 750 mL, and average operative time was 263 minutes. One patient (1.8%) had a vascular injury requiring embolization. One patient (1.8%) had a wound infection in the lateral window, two patients (3.5%) developed a direct inguinal hernia requiring surgical repair, and one patient (1.8%) had atrophy of the ipsilateral rectus abdominus without hernia. Of the 50 patients with minimum 1-year follow up, there were 22 associated both column, 12 anterior column, seven anterior column posterior hemitransverse, six transverse, and three T-type fractures. Seventy percent of the reductions were graded excellent, 22% were graded good, and 8% poor. Clinical outcomes (Merle D'Aubigne) at 1 year were 36% excellent, 55% good, and 10% poor. Thirteen patients (26%) were noted to have significant weakness of the hip adductors (obturator nerve palsy) postoperatively; all but one resolved and improved within 6 months. CONCLUSION: Use of the AIP (modified Rives-Stoppa) approach for the treatment of acetabular fractures permits good to excellent reduction in the majority of cases while giving excellent visualization and access to the quadrilateral plate and posterior column. The AIP approach has a complication rate that is comparable to the ilioinguinal approach. We recommend the use of this technique as a potential alternative (but not replacement) to the classic ilioinguinal approach when anterior exposure of the acetabulum is required.