Management of Pediatric Tibial Nonunion following Osteotomy: A Case Series and Review of the Literature.

Pediatric tibial nonunion following corrective osteotomy is a rare complication that is not well understood. While adult nonunions have been linked to endocrine and metabolic aberrations, this has not been established in a pediatric population. Pediatric tibial nonunion has been shown to respond to debridement with revision fixation using dynamic compression plating, supplementary bone graft, and fibular osteotomy to allow compression. Necessity of referral for metabolic and endocrinology workup remains unclear in the pediatric population, though inflammatory markers should be obtained in each case to rule out infection. We present three consecutive cases of pediatric tibial nonunion following osteotomy over a five-year period and discuss the management.

Unstable Ankle Fracture Fixation Using Locked Fibular Intramedullary Nail in High-Risk Patients.

Open reduction internal fixation is the gold standard for unstable ankle fracture fixation; however, complications in patients with multiple medical comorbidities are common. Intramedullary nail fixation of the fibula can help to mitigate these difficulties. A retrospective chart review was performed on all patients who underwent fixation for unstable ankle fracture between January 2015 and March 2016 at our level I trauma center. Comorbidities in the patient sample included were one or several of diabetes, renal disease, hypertension, advanced age with osteoporosis, hemorrhagic blisters, and alcoholism. The primary outcomes studied were wound complications, infections, and hardware failure or failure of fixation. Eighteen patients with a mean age of 61 years underwent fibular intramedullary nail fixation, all of whom were considered at high risk for postoperative complications. Patients presented with Weber B or C fracture patterns. All patients had syndesmotic fixation through the nail by one or two 3.5-mm tricortical screws. A medial malleolus was added if needed for stability. The average follow-up time was 291.1 (range 9 to 14 months) days. The prescribed range of time to weightbearing was 2 to 6 weeks. All patients maintained reduction of the fracture and had no wound complications. No syndesmotic screws broke postoperatively, although most patients to failed comply with the postoperative non-weightbearing restrictions. Intramedullary nailing of the fibula with syndesmotic intranail fixation is minimally invasive, quick, and provides adequate fixation strength. It offers a viable treatment option for patients at high risk for complications or who are suspected to have difficulty with follow-up or compliance.

Management of displaced midshaft clavicle fractures in adolescent patients using intramedullary flexible nails: A case series.

INTRODUCTION: Clavicle fractures are common injuries in adolescent patients. In this study we present our technique and results for treating non-comminuted displaced midshaft clavicle fractures using flexible intra medullary nails. METHODS: A retrospective review of prospectively collected data using the electronic medical record was performed. Adolescent patients presenting to a level one pediatric trauma center with acute displaced non comminuted clavicular shaft fractures who were treated with intra medullary flexible nails were included in this study. RESULTS: Seven adolescent patients with non-comminuted displaced mid shaft clavicle fractures were treated with flexible nails over a period of five and half years with an average follow up time of 10 months. The average age was 14.6 years (range 14-16), and a 2 mm nail was used in all cases. Closed reduction was obtained in five cases with only two cases needing open reduction to pass the nail. One patient had skin breakdown over the nail entry and had the nail removed in clinic two months after surgery, all other patients healed with no complication. Sports and full shoulder activity were allowed when radiographic healing was seen at an average 8 weeks. Implant removal was performed four of the seven patients. CONCLUSION: Flexible intramedullary nailing is an effective minimally invasive method for the treatment of displaced midshaft clavicle fractures in the adolescent population. The surgeon should be aware that a 2 mm nail is likely the optimal diameter, and the nail is difficult to pass beyond the lateral 2-3 cm of the distal segment due to canal narrowing, but passage further than this is not necessary to achieve stability and union. Following these pearls will allow the surgeon to successfully perform the procedure.

Operative Management of Unstable Radial Head Fractures in a Young Active Population.

BACKGROUND: Radial head and neck fractures are the most common elbow fracture in the general adult population; however, the optimal treatment for radial head fractures remains a topic of ongoing clinical controversy. The purpose of this study was to determine the rate of return to function, complications, and reoperation following operative management of unstable radial head fractures in a young, active patient population with intense upper extremity demands. METHODS: A military health care database was queried for all US military servicemembers undergoing open reduction with internal fixation (ORIF; Current Procedural Terminology [CPT] code: 24665) and radial head arthroplasty (RHA; CPT code: 24666) between 2010 and 2015. All patients with minimum 2-year follow-up were included. Univariate and chi-square analyses were performed to evaluate the association between potential risk factors and the primary outcome measures. RESULTS: A total of 67 ORIF (n = 69 elbows) and 10 RHA patients were included. The average age was 31 ± 8.0 years. At mean follow-up of 3.5 ± 1.1 years, 90% of patients overall were able to return to active military service, 96% of which with unrestricted upper extremity function. Nearly one-third (31.2%) of patients developed at least 1 postoperative complication. RHA has higher overall complication rates (70% vs 48%) when compared with ORIF, but this finding did not reach statistical significance ( P = .073). However, RHA had significantly higher rates of implant failure (20% vs 2.9%, P = .0498). Seventeen (21%) individuals required reoperation, 5 of which (6.3%) were revision procedures. Dislocation, coronoid fracture, and concomitant ligamentous repair portended a significantly increased risk of sustaining 1 or more complications ( P < .05), while dislocation and requirement for ligamentous repair independently predicted revision surgery ( P < .05). CONCLUSIONS: Arthroplasty and ORIF are both viable options for treating unstable radial head fractures in a young, athletic population, offering comparable return to function despite increased complications with RHA.

Open reduction and internal fixation (ORIF) versus ORIF and primary subtalar arthrodesis for complex displaced intraarticular calcaneus fractures: An expected value decision analysis.

OBJECTIVES: To determine the optimal patient-oriented treatment between open reduction and internal fixation (ORIF) with or without primary subtalar arthrodesis (PSTA) for patients with displaced intraarticular calcaneus fractures (DIACFs, OTA 82-C3 and C4). DESIGN: Expected value decision analysis. SETTING: Academic military treatment facility. PARTICIPANTS: One hundred randomly selected volunteers. INTERVENTION: Hypothetical clinical scenario involving ORIF versus ORIF with PSTA. MAIN OUTCOME MEASUREMENTS: Decision analysis was used to elucidate the superior treatment option based on expected patient values, composed of: the product of the average outcome probabilities established by previously published studies and the average ascribed patient utility values for each outcome probability. One-way sensitivity analysis was performed to quantify the amount of change required for the inferior treatment to equal or surpass the superior option. RESULTS: Expected values for ORIF and ORIF with PSTA were 8.96 and 18.06, respectively, favoring ORIF with PSTA. One-way sensitivity analysis was performed by artificially decreasing the rate of secondary fusion following isolated ORIF thus increasing its overall expected value. Adjusting the rate of secondary fusion to 0%, the expected value of ORIF with PSTA nearly doubled that of ORIF (18.06 vs 9.45). Similarly, when adjusting the moderate and severe complication rates following ORIF with PSTA to 100%, the expected value of ORIF with PSTA still exceeded that of ORIF (15.45 vs 8.96, and 13.52 vs 8.96, respectively). CONCLUSION: Expected value decision analysis favors ORIF with PSTA as the optimal treatment for complex DIACF.

Open reduction-internal fixation versus intramedullary nailing for humeral shaft fractures: an expected value decision analysis.

BACKGROUND: Previous randomized controlled studies and meta-analyses have failed to collectively favor either open reduction-internal fixation (ORIF) or intramedullary nailing (IMN) fixation. The purpose of our investigation was to elucidate the optimal decision between ORIF and IMN for acute traumatic operative humeral shaft fractures through an expected value decision analysis. METHODS: We performed an expected value decision analysis and sensitivity analysis to elucidate the difference between ORIF and IMN fixation for patients with acute traumatic humeral shaft fractures. We surveyed 100 consecutive, randomly selected volunteers for their outcome preferences. Outcomes included union, delayed union, major complications, minor complications, and infection. A literature review was used to establish probabilities for each of these respective outcomes. A decision tree was constructed and a fold-back analysis was performed to find an expected patient value for each treatment option. RESULTS: The overall patient expected values for ORIF and IMN were 12.7 and 11.2, respectively. Despite artificially decreasing the rates of major complications, infection, delayed union, and nonunion each to 0% for IMN fixation (sensitivity analysis), ORIF continued to maintain a greater overall patient expected value (12.7 vs. 11.4, 11.2, 11.2, and 12.1, respectively). Only if the rate of nonunion after ORIF was increased from 6.1% to 16.8% did the overall expected outcome after ORIF equal that of IMN (11.2). CONCLUSION: Our expected value decision analysis demonstrates that patients favor ORIF over IMN as the optimal treatment decision for an acute traumatic humeral shaft fracture.

Anterior Cruciate Ligament Graft Removal Versus Retention in the Setting of Septic Arthritis After Reconstruction: A Systematic Review and Expected Value Decision Analysis.

PURPOSE: To provide further guidance on the optimal decision between anterior cruciate ligament (ACL) graft removal versus retention in the setting of septic arthritis following reconstruction using an expected value decision analysis. METHODS: A systematic review and expected value decision analysis and sensitivity analyses were performed to quantify the clinical decision. A decision tree was created with 5 outcomes of interest: nonoperative complications, revision surgery, early reoperation, late reoperation, and "well." Pooled probabilities of each outcome were generated through a systematic literature review. We included only peer-reviewed studies, published in English, with at least 6 months of follow-up. One hundred randomly selected volunteers were given descriptions of the clinical scenario, the 2 treatment options, and outcomes of interest. Patients younger than 18 and older than 50 years and those previously treated for either ACL injury or septic arthritis, or both, were excluded from the analysis to minimize bias. These hypothetical patients indicated preferences for each outcome on a visual analog scale and responses were averaged to generate overall "utility values." Fold-back analysis summed products of pooled outcomes probabilities with respective averaged utility values. The resulting overall expected values for graft removal and debridement were compared, with the highest expected value considered to be superior. We then performed 1-way sensitivity analyses to mitigate sample bias. RESULTS: Fold-back analysis revealed graft removal to be strongly favored over retention, with overall expected values of 17.2 and 8.64, respectively. The most important contributor to the difference in overall expected values was late reoperation (8.59 vs 2.50 for removal and retention, respectively). Despite adjustments made to the rates of revision and early reoperation during the 1-way sensitivity analyses, graft removal remained the optimal strategy. CONCLUSIONS: This expected value decision analysis revealed that ACL graft removal was strongly favored by patients over graft retention in the setting of postoperative septic arthritis when consideration was given to the probabilities of wellness, nonoperative complications, revision surgery, early reoperation, and late reoperation. Sensitivity analysis revealed that although variation in rates of other outcomes did not impact this preference, the rate of late reoperation had a substantial impact. Only a sizable increase in the probability of late reoperation (from 0% to 60%) after graft removal would cause potential patients to favor graft retention. LEVEL OF EVIDENCE: Level IV, systematic review and decision analysis.

Radial Head Arthroplasty in the Active Duty Military Service Member With Minimum 2-Year Follow-Up.

PURPOSE: Radial head arthroplasty (RHA) is a viable treatment for complex radial head fracture. Whereas elbow stability and function is typically restored at short- to mid-term follow-up, the outcome in higher-demand populations is not well defined. We sought to characterize the functional and occupational outcomes following RHA in an active duty military population with intense upper extremity demands. METHODS: We retrospectively reviewed the records of all U.S. military service members undergoing primary RHA from 2010 and 2013 with a minimum of 2-year follow-up. Patient-based, injury-related, and surgical variables were extracted from the military-wide electronic medical record. Functional and occupational outcomes including pain, and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire were recorded. The primary outcomes of interest were the rate and level of return to upper extremity activity. Secondary outcome measures included return to duty, complications, and revision surgery. RESULTS: Nineteen patients were included with average age 31 years and median 37 months' follow-up. Ten were Mason III, 6 were part of a terrible triad injury, and the remainder were fracture-dislocations. At an average follow-up of 3.7 years, 15 patients returned to active military duty, and 9 resumed their regular upper extremity military function. At the time of final follow-up, the average DASH score was 13. Seven patients returned to their usual level of sport and exercise, 6 at a reduced level, and 6 did not resume physical exercises secondary to pain or stiffness. Sixteen adverse outcomes among 14 patients included symptomatic heterotopic ossification (5 of 19) and neurological sequelae (4 of 19). Three elected to have a revision procedure at an average of 13 months for heterotopic ossification or loosening. CONCLUSIONS: Among active patients with radial head fractures treated with RHA, three-quarters will return to active duty military service, push-ups, and sport; however, half may report an adverse outcome unrelated to the prosthesis and only about half of patients will return to their preinjury level of function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Functional Outcomes Following Surgical Management of Femoral Neck Stress Fractures.

The Military Health System Management Analysis and Reporting Tool was queried to identify all active duty US military service members who underwent operative fixation of femoral neck stress fractures from 2011 to 2012. A total of 13 patients with 17 femoral neck stress fractures met the inclusion criteria. Average patient age was 23.8±5.1 years, and 62% were women. At a mean 26-month follow-up, approximately one-half (46%) of the young military recruits were able to return to their preoperative activity level. Two (11%) required reoperation. Increased time to diagnosis and to subsequent fixation was associated with a greater risk of poor outcomes resulting in medical separation. [Orthopedics. 2017; 40(3):e395-e399.].

Medial Malleolar Fractures and Associated Deltoid Ligament Disruptions: Current Management Controversies.

Operative fixation of medial malleolar fractures, whether isolated or in the setting of bi- or trimalleolar fractures, remains controversial. Increasingly, anatomic reduction and internal fixation is used to treat medial malleolar fractures to avoid long-term sequelae of symptomatic nonunion and posttraumatic osteoarthritis. However, outcomes have not been significantly different between operative and nonoperative cohorts. Repair of associated deltoid ligament disruption is not common because of reportedly poor outcomes. This review provides an overview of the literature on medial malleolar fracture fixation and current treatment options. [Orthopedics. 2017; 40(2):e216-e222.].

A New Technique for Obtaining Bone Graft in Cases of Distal Femur Nonunion: Passing a Reamer/Irrigator/Aspirator Retrograde Through the Nonunion Site.

Bone grafting is one of the most common orthopedic procedures. We conducted a study to assess the possibility of passing a Reamer/Irrigator/Aspirator (RIA; DePuy Synthes) retrograde through the nonunion site in distal femur cases. This technique would avoid the complications and discomfort associated with a separate entry site for RIA. All patients with a distal femur nonunion treated with RIA bone grafting between 2009 and 2013 were included in the study. Nonunions were mobilized with excision of fibrous tissues. The distal part was angulated into varus, and then the guide wire was passed from the nonunion site laterally. Five patients had a RIA passed retrograde through the nonunion site. Mean age of these patients was 40.4 years (range, 22-66 years). Mean reamer size was 13.4 mm (mode, 14 mm), producing an average bone graft volume of 33 mL. There were no intraoperative or postoperative fractures. In 1 case, the reamer shaft broke. Passing a RIA retrograde through the nonunion site in distal femur cases is reproducible, and the technique avoids the discomfort and pain associated with a separate entry point as well as the complication of eccentric reaming of the proximal and distal part of the femoral canal.

Variables Affecting Return to Play After Anterior Cruciate Ligament Injury in the National Football League.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common in the National Football League (NFL). Limited literature exists regarding return to play (RTP) and the factors affecting RTP after ACL reconstruction in NFL players. PURPOSE/HYPOTHESIS: To determine RTP rates after ACL reconstruction in NFL players and to ascertain which variables affect RTP in these players. We hypothesized that RTP in this population will be less than in the general population and similar to the limited studies published previously. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 92 NFL athletes who sustained ACL injuries requiring ACL reconstruction from 2013 to 2015 were retrospectively studied to determine rate of RTP and the variables affecting RTP. RESULTS: Sixty-two percent (57/92) of NFL athletes returned to NFL game play prior to the end of the 2015-2016 postseason. ACL injuries were noted in 10 different player positions, with 81.5% of all injuries as isolated ACL injuries (75/92) and 18.5% with concomitant knee injuries. A significant difference in ability to RTP was found for players who sustained in-season injuries compared with those who sustained off-season/preseason injuries (P = .02). No significant differences in RTP were found for players who played less than 4 years in the NFL compared with those who played longer. The mean draft round of players who returned was 3.96, with the odds ratio favoring RTP at 4.44 (P = .003) for players drafted in the first 3 rounds of the NFL draft compared with those drafted in the fourth round or later. No significant differences were found with regard to playing surface, laterality, concomitant injury, previous ipsilateral or contralateral ACL reconstruction, final outcome of the game, or contact compared with noncontact injuries. CONCLUSION: The RTP rates we reported after ACL reconstruction in NFL players are similar to prior studies; however, running backs and wide receivers had lower rates of RTP than previously reported. As previously published, quarterbacks were found to have high RTP rates. Most ACL injuries take place during the preseason or early regular season. Early selection in the NFL draft was a strong predictor of ability to RTP.

New Technique for Tibiotalar Arthrodesis Using a New Intramedullary Nail Device: A Cadaveric Study.

Introduction. Ankle arthrodesis is performed in a variety of methods. We propose a new technique for tibiotalar arthrodesis using a newly designed intramedullary nail. Methods. We proposed development of an intramedullary device for ankle arthrodesis which spared the subtalar joint using a sinus tarsi approach. Standard saw bones models and computer assisted modeling and stress analysis were used to develop different nail design geometries and determine the feasibility of insertion. After the final design was constructed, the device was tested on three cadaveric specimens. Results. Four basic nail geometries were developed. The optimal design was composed of two relatively straight segments, each with a different radius of curvature for their respective tibial and talar component. We successfully implemented this design into three cadaveric specimens. Conclusion. Our newly designed tibiotalar nail provides a new technique for isolated tibiotalar fusion. It utilizes the advantages of a tibiotalar calcaneal nail and spares the subtalar joint. This design serves as the foundation for future research to include compression options across the tibiotalar joint and eventual transition to clinical practice.

Lower Extremity Limb Salvage: Lessons Learned From 14 Years at War.

American survivability during the current conflicts in Iraq and Afghanistan continues to improve, though the rate of extremity injury remains quite high. The decision to proceed with amputation versus limb salvage remains controversial. Exposure to combat wound with severe high-energy lower extremity trauma during the previous 14 years at war has incited important advances in limb salvage technique and rehabilitation.

Medialized Clavicular Bone Tunnel Position Predicts Failure After Anatomic Coracoclavicular Ligament Reconstruction in Young, Active Male Patients.

BACKGROUND: Recent radiographic data have suggested that medialized conoid tunnel placement greater than 25% of absolute clavicular length is correlated with early failure after anatomic coracoclavicular ligament reconstructions. A comparison with a larger active duty military cohort of clinical and radiographic outcomes can serve as a basis for standardizing surgical technique. PURPOSE: To establish the ideal radiographic tunnel position for anatomic coracoclavicular ligament reconstruction and to elucidate variables associated with early loss of reduction and ability to return to active-duty military service. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of the military's electronic medical record between the years 2000 and 2013 was performed. All anatomic coracoclavicular reconstructions at a single institution were included for analysis, and nonanatomic or revision reconstructions were excluded. Radiographic failure was defined as 6 mm of superior clavicle displacement on immediate postoperative films. RESULTS: A cohort of 38 patients underwent 39 anatomic coracoclavicular reconstructions. Average follow-up time was 26 months (range, 1.2-92 months). A total of 20 radiographic failures were identified, with an average conoid tunnel ratio of 0.27. When conoid tunnel ratios were compared with a reference ratio of 0.20 to 0.25, increased risk of failure was statistically significant with lateralization greater than 0.20 (P = .018; odds ratio [OR] = 40 [95% CI, 1.05-999.06]) or with medialization of 0.251 to 0.30 (P = .002; OR = 39 [95% CI, 1.58-944.36]) or greater than 0.30 (P = .029; OR = 21 [95% CI, 0.77-562.15]). Medialization of the trapezoid position greater than 0.16 (vs a range of 0.13-0.16) was also found to be significant for failure (P < .023; OR = 8 [95% CI, 1.33-48.18]). However, these significant findings did not correlate with symptoms or ability to return to duty (P > .05). CONCLUSION: The optimal technique for treating acromioclavicular separations has yet to be determined. Recently, anatomic coracoclavicular reconstruction has demonstrated biomechanical superiority to previously described methods. The findings of optimal tunnel positioning in anatomic reconstructions from this large active-duty military cohort can assist preoperative planning to reduce failure rates when treating these difficult injuries.