How Feasible Are Digital Intraoperative Plain Radiographs in Orthopaedic Trauma Surgery?

The purpose of this study is to evaluate the feasibility and outcomes of obtaining routine intraoperative plain radiographs during orthopaedic trauma surgery. Seventy consecutive orthopaedic trauma patients in which intraoperative plain films were obtained in addition to fluoroscopy were reviewed. For each patient the time it took to obtain intraoperative plain radiographs was prospectively measured, in addition to the number of images taken, and quality of image. Then relative imaging times based on fracture locations were compared and the need for revision surgery based on mal-reduction or implant mal-positioning assessed. The average time required for intraoperative plain films to be obtained and reviewed by the surgeon was 3 minutes and 45 seconds. On average, 2.8 images were taken during each surgery. Proximal images took on average 44 seconds longer than distal images to obtain (p = 0.047). There was no significant difference in imaging times for upper versus lower extremities (p = 0.448). High quality images were obtained on all patients. There were no re-operations required in this series for mal-reduction of fracture, mal-positioning of implants or infection. In this study, there were no re-operations or perioperative complications when intraoperative plain films were obtained. Intraoperative plain films are a valuable tool for complex periarticular surgery or other cases where fracture reduction or implant location may be in question. (Journal of Surgical Orthopaedic Advances 32(3):160-163, 2023).

Dual Versus Single-Plate Fixation of Midshaft Clavicular Fractures: A Retrospective Comparative Study.

BACKGROUND: Implant-related symptoms are the most common reason for reoperation after open reduction and internal fixation (ORIF) of midshaft clavicular fractures. Dual mini-fragment plate fixation is a relatively new solution that may decrease implant prominence while maintaining fixation strength and function. There are minimal published data comparing reoperation rates and clinical outcomes between single, superior-plate constructs and dual mini-fragment plate constructs in the fixation of midshaft clavicular fractures. We hypothesized that reducing plate size with the use of dual mini-fragment plating compared with standard, 3.5-mm, superior plating would minimize implant symptoms and the corresponding need for reoperation while still providing sufficient fixation to allow fracture-healing and return to function. METHODS: We retrospectively reviewed the cases of 44 consecutive patients who underwent ORIF of displaced midshaft clavicular fractures utilizing either a single, 3.5-mm, superior plate construct (21 patients) or a dual, 2.7-mm and 2.4-mm, plate construct (23 patients). Outcomes at a minimum of 2 years were assessed. Primary outcome measures included reoperation for any reason and the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, patient self-report section. RESULTS: There was a 100% union rate in both groups. None (0%) of the 23 patients who received the dual (2.7-mm and 2.4-mm) plate construct and 6 (29%) of the 21 patients who received the single (3.5-mm) plate construct underwent reoperation for implant-related symptoms. Using a Fisher exact test, the rate of reoperation was compared between the groups, and the difference was found to be significant (p = 0.008). Using an unpaired t test, the difference in mean ASES scores was not significant (p = 0.138) between the dual-plate group (98 of 100) and the single superior plate group (96 of 100) with retained implants. CONCLUSIONS: In our comparative retrospective series, dual fixation utilizing a 2.7-mm superior plate and a 2.4-mm anterior plate for the treatment of displaced midshaft clavicular fractures was associated with a significantly lower rate of reoperation when compared with single, 3.5-mm, superior plate fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The use of clopidogrel (Plavix) in patients undergoing nonelective orthopaedic surgery.

OBJECTIVE: To assess the effects of Plavix on patients requiring nonelective orthopaedic surgery. DESIGN: Retrospective cohort study. SETTING: University-affiliated teaching institutions. PATIENTS AND PARTICIPANTS: The orthopaedic trauma registry was used to retrospectively identify all patients taking clopidogrel (Plavix; Bristol-Myers Squibb/Sanofi Pharmaceuticals, Bridgewater, NJ) who required nonelective orthopaedic surgery from 2004 to 2008. Twenty-nine patients were identified on Plavix (PG) and 32 matched patients in the control group not taking Plavix (NPG). The Plavix group was separated into those with a surgical delay less than 5 days of the last dose (PG < 5) (n = 28) and a delay greater than 5 days (PG > 5) (n = 1). A randomized age- and injury-matched control group not on Plavix was separated with surgical delay less than 5 days (NPG < 5) (n = 29) and delay greater than 5 days (NPG > 5) (n = 3). INTERVENTION: A retrospective review was performed comparing pre- and postoperative hemoglobin, blood transfusion requirements, surgical delay, 30-day mortality, and postoperative complications. MAIN OUTCOME MEASUREMENTS: Statistical analyses were performed using the Student t test and chi square test to identify differences between the groups. RESULTS: : The mean preoperative hemoglobin of the PG and the NPG was 11.2 g/dL and 12.3 g/dL (P = 0.03). Transfusion rates were similar with 18 of 28 in the PG compared with 13 of 29 in the NPG (P = 0.22). The mean surgical delay between the PG and NPG was 1.88 and 1.68 days (P = 0.64). Overall complications between the PG and NPG was nine of 28 and nine of 29 (P = 0.92). In both groups, two patients had postoperative wound drainage, which resolved without intervention. One patient in each group required revision surgery for nonunion. The 30-day mortality in the Plavix group was zero of 28 (0%) compared with one of 29 (3%) in the control group (cardiac arrest) (P = 0.32). CONCLUSIONS: In this study, there were no serious complications or increased transfusion requirements in the Plavix group. Avoiding surgical delay for patients on Plavix requiring nonelective orthopaedic surgery appears to be safe. The goal should be early operative intervention to decrease the morbidity and mortality of surgical delay. This is especially true for patients with hip fractures, which was the most common nonelective orthopaedic surgery required of patients on Plavix in this study.

The upper sacral nerve root tunnel: an anatomic and clinical study.

OBJECTIVES: To radiographically demonstrate the upper sacral nerve root tunnel (USNRT) in both cadaveric specimens and a clinical cohort and to quantify its clinical relevance. SETTING: Level 1 trauma center and anatomy laboratory. PATIENTS AND PARTICIPANTS: Eleven cadaveric pelves and 23 consecutive patients who underwent fluoroscopically assisted iliosacral screw insertions. INTERVENTIONS: Cadaveric pelves were fluoroscopically imaged using standard pelvic inlet, outlet, and true lateral sacral views. The course of the USNRT pathway was identified. Then, these tunnels were filled completely with a semisolid radio-opaque agent. The specimens were reimaged after the contrast injection. Clinically, 23 consecutive patients with unstable posterior pelvic ring disruptions were treated using fluoroscopically assisted percutaneous iliosacral screws based on these predictable radiographic landmarks. A total of 44 iliosacral screws were inserted. MAIN OUTCOME MEASUREMENTS: For the cadaveric portion, the images with contrast were used to identify the USNRTs. For the clinical study, tunnel visualization was determined on all views intraoperatively. Screw placement was documented by postoperative pelvic plain radiographs and computed tomography scan. RESULTS: In the cadaveric specimens, the contrast agent consistently demonstrated the USNRTs on all 3 pelvic radiographic views. In the clinical series, the USNRTs were well visualized on the pelvic outlet image in all 23 patients (100%). Using the inlet image, the USNRTs were visualized in only 5 of 23 patients (21%). On the true lateral sacral views, the USNRTs were seen in 21 of 23 patients (91%). Using these USNRT radiographic landmarks, no iliosacral screw was extraosseous. CONCLUSIONS: The USNRTs have a consistent radiographic appearance that is best seen on the pelvic outlet and true lateral sacral views, but their course is best understood when seen on all 3 views. Awareness and understanding of the USNRT, its course, and its radiographic landmarks allow the surgeon to avoid tunnel intrusion by an iliosacral screw.

Retrograde intramedullary nailing of femoral diaphyseal fractures caused by low-velocity gunshots.

The purpose of this study was to evaluate the results of retrograde intramedullary nailing of femoral diaphyseal fractures caused by low-velocity gunshots. Seventy-three patients (68 men and 5 women) with 74 femoral diaphyseal fractures caused by gunshots were treated with reamed, retrograde, statically locked intramedullary nailing. The main outcome measures were fracture union, the need for additional operations, shortening, angular deformity, postoperative knee range of motion, and complication rate. Twenty-nine patients sustained additional injuries. During initial treatment, 18 patients underwent further orthopedic and nonorthopedic elective procedures. Three patients had fasciotomies for compartment syndrome. At follow-up, 3 patients had shortening >10 mm (range, 12-18 mm) and 1 had angulation >10 degrees (13 degrees recurvatum). Four patients underwent surgeries after discharge. Complications included 1 case of heterotopic bone formation, 1 hypertrophic nonunion that went on to union after dynamization, 2 postoperative positive blood cultures, and 1 wound dehiscence. There were no cases of septic arthritis. Our data indicate that there is a low incidence of shortening, angular deformity, complication, and infection rates following treatment of femoral gunshot diaphyseal fractures with a retrograde nail. This study demonstrates that this is an acceptable alternative for the treatment of these injuries.

Medial plantar artery pseudoaneurysm following percutaneous pinning for Lisfranc fracture-dislocation.

We report a pseudoaneurysm of the medial plantar artery that developed after percutaneous pinning for a Lisfranc fracture-dislocation in a 68-year-old male. Postembolization ultrasound and arteriography demonstrated successful ablation of the pseudoaneurysm following intra-arterial thrombin injection. Postoperative pulse volume recording and photoplethysmograph of the digits revealed excellent perfusion following ablation.

Percutaneous placement of iliosacral screws without electrodiagnostic monitoring.

BACKGROUND: Iliosacral screws are commonly used for fixation of pelvic ring injuries. Previous reports using different screw insertion techniques have reported high neurologic complication rates, leading to recommendations for intraoperative neurodiagnostic monitoring. The purpose of this study was to evaluate the neurologic complications after percutaneous iliosacral screw placement without neurodiagnostic monitoring. METHODS: During a 21-month period, 326 patients with pelvic ring disruptions were treated at a level 1 trauma center. One hundred seventy-four patients underwent percutaneous stabilization of their pelvic ring injuries without neurodiagnostic monitoring. Patients who were not intubated preoperatively, were neurologically normal, and who underwent a closed reduction were included. Sixty-eight patients who had 106 screws placed met the inclusion criteria and formed the study group. A careful and detailed neurologic examination was performed preoperatively and postoperatively. Plain pelvic radiographs and computed tomography scans were evaluated postoperatively in all patients to assess screw position. RESULTS: No planned screw placement was abandoned because of inadequate fluoroscopic visualization. There were no neurologic injuries as a result of either the closed reduction or the screw placement. Computed tomography scans confirmed the screw position and demonstrated placement as intraosseous in 75 (70.8%) and juxtaforaminal in 31 (29.2%). No screws perforated a nerve root tunnel, spinal canal, or sacral cortex. CONCLUSIONS: Using a standardized technique, appropriate and reliable fluoroscopic landmarks are available in the vast majority of percutaneous iliosacral screw fixation procedures. Iliosacral screw placement without neurodiagnostic monitoring has a low rate of neurologic complications.