Bridge Plate Fixation of Distal Femur Fractures: Defining Deficient Radiographic Callus Formation and Its Associations.

OBJECTIVE: To determine whether deficient early callus formation can be defined objectively based on the association with an eventual nonunion and specific patient, injury, and treatment factors. METHODS: Final healing outcomes were documented for 160 distal femur fractures treated with locked bridge plate fixation. Radiographic callus was measured on postoperative radiographs until union or nonunion had been declared by the treating surgeon. Deficient callus was defined at 6 and 12 weeks based on associations with eventual nonunion through receiver-operator characteristic analysis. A previously described computational model estimated fracture site motion based on the construct used. Univariable and multivariable analyses then examined the association of patient, injury, and treatment factors with deficient callus formation. RESULTS: There were 26 nonunions. The medial callus area at 6 weeks <24.8 mm 2 was associated with nonunion (12 of 39, 30.8%) versus (12 of 109, 11.0%), P = 0.010. This association strengthened at 12 weeks with medial callus area <44.2 mm 2 more closely associated with nonunion (13 of 28, 46.4%) versus (11 of 120, 9.2%), P <0.001. Multivariable logistic regression analysis found limited initial longitudinal motion (OR 2.713 (1.12-6.60), P = 0.028)) and Charlson Comorbidity Index (1.362 (1.11-1.67), P = 0.003) were independently associated with deficient callus at 12 weeks. Open fracture, mechanism of injury, smoking, diabetes, plate material, bridge span, and shear were not significantly associated with deficient callus. CONCLUSION: Deficient callus at 6 and 12 weeks is associated with eventual nonunion, and such assessments may aid future research into distal femur fracture healing. Deficient callus formation was independently associated with limited initial longitudinal fracture site motion derived through computational modeling of the surgical construct but not more routinely discussed parameters such as plate material and bridge span. Given this, improved methods of in vivo assessment of fracture site motion are necessary to further our ability to optimize the mechanical environment for healing. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Triceps Surae Lengthening in Foot and Ankle Trauma: A Survey of OTA and AOFAS Members.

Background: The prevalence, indications, and preferred methods for gastrocnemius recession and tendo-Achilles lengthening-grouped as triceps surae lengthening (TSL) procedures-in foot and ankle trauma are supported by a scarcity of clinical evidence. We hypothesize that injury, practice environment, and training heritage are significantly associated with probability of performing adjunctive TSL in the operative management of foot and ankle trauma. Methods: A survey was distributed to members of the American Orthopaedic Foot & Ankle Society and the Orthopaedic Trauma Association. Participants rated how likely they would be to perform TSL at initial management, definitive fixation, and after weightbearing in the presence and absence of a positive Silfverskiöld test in 10 clinical scenarios of closed foot and ankle trauma. Results: A total of 258 surgeons with median 14 years' experience responded. Eighty-five percent reported foot and ankle fellowship training, 24% reported traumatology fellowship training, 13% both, and 4% no fellowship. Ninety-nine percent reported performing TSL with a median 25 TSL procedures per year, 72% open gastrocnemius recession, and 17% percutaneous tendo-Achilles lengthening). Across all scenarios, we observed low overall 8% probability with fair agreement (κ = 0.246) of performing TSL (range, 1% at initial management of an unstable Weber B bimalleolar ankle fracture with negative contralateral Silfverskiöld test to 29% at definitive fixation of tongue-type calcaneus fracture with positive contralateral Silfverskiöld test). Silfverskiöld testing significantly influenced TSL probability at all time points. University of Washington training (ß = 1.5, P = .007) but not trauma vs foot fellowship training, years in practice, academic practice, urban setting, or facility trauma designation were significantly associated with likelihood of performing TSL. Conclusion: Orthopaedic traumatology and foot and ankle surgeons report similar indications, methods, and low perceived propensity to use TSL in the management of foot and ankle trauma. We found that graduates of 1 fellowship training site were more likely to perform TSL in the setting of acute trauma potentially indicating the need for better scientific data to support this practice. Level of Evidence: Level V, therapeutic.

What happens at the L5/S1 facet joint when implants are placed across the sacroiliac joint?

BACKGROUND: Injuries to the posterior pelvic ring are often stabilized with fixation across the sacroiliac joint (SIJ). However, the compensatory changes at the neighboring L5/S1 facet joint are unknown. The objective of this study was to determine the compensatory change in pelvic kinematics and contact forces at the L5/S1 facet joint after fixation across the sacroiliac joint (SIJ) using a cadaveric model. METHODS: Five fresh-frozen cadaveric pelvis specimens were dissected to remove non-structural soft tissue. Retroreflective markers were fixed to the L5 body, S1 body and bilateral anterior superior iliac spines to represent the motion of L5, S1 and the ileum, respectively. Pressure sensors were inserted in both L5/S1 facet joints. Testing was performed using a robotic system that applied load to mimic ambulation. Testing was performed prior to SIJ fixation, after unilateral SIJ fixation and bilateral fixation. RESULTS: Contact force at the L5/S1 facet joint significantly increased by 55% from 48.4 N to 75.2 N following unilateral fixation (p = 0.0161) and increased by 100% to 96.9 N after bilateral fixation (p = 0.0038). Unilateral SIJ fixation increased flexion of the ilium relative to L5 from 1.2° to 2.0° (p = 0.01) and increased axial rotation of L5 relative to S1 from 0.7° to 1.6° (p = 0.001). Bilateral fixation increased flexion of the ilium relative to L5 to 2.0° from 1.2° prior to fixation (p = 0.001), increased axial rotation of L5 relative to S1 to 1.2° from 0.7° prior to fixation (p = 0.002) and increased flexion of L5 relative to S1 to 2.4° from 1.5° prior to fixation (p = 0.04). CONCLUSION: The L5/S1 facet joint experiences compensatory increased motion under increased contact force after unilateral and bilateral SIJ fixation, possibly predisposing it to adjacent segment arthritis. LEVEL OF EVIDENCE: V, cadaveric study.

Reduction and fixation of high-energy proximal tibiofibular joint dislocations: a technical trick.

We present our technique for screw stabilization and our clinical experience treating a series of patients presenting with proximal tibiofibular joint fracture-dislocations.

The effect of proximal tibiofibular joint dislocation on knee mechanics: reduction and fixation matters.

PURPOSE: Proximal tibiofibular joint (PTFJ) dislocations are under-investigated injuries. There is scant basic science or clinical evidence to direct management. The purpose of this study was twofold; first to investigate the pathomechanics of PTFJ dislocation on knee mechanics. The second purpose was to evaluate knee mechanics following reduction and fixation. METHODS: Six cadaveric legs were tested on a mechanical platform. A 5 Nm external rotation force was applied to each knee and the external rotation and fibular translation was measured for several study conditions at 0°, 30°, and 90° of flexion. Conditions included: the native state, transection of the posterior PTFJ ligament, transection of the anterior and posterior ligaments, screw fixation, and suspensory fixation. Screw fixation was performed using a single quadricortical 3.5 mm screw. Suspensory fixation was performed using an Arthrex TightRope device RESULTS: Transection of the anterior and posterior ligaments increased external rotation by 4.3°, 5.9°, and 5.6°, at 0°, 30°, and 90° (p ≤ 0.001), respectively. Screw and suspensory fixation returned external rotation to a near native state with mild overconstraint. Complete transection of anterior and posterior ligaments resulted in pathologic anterior fibular translation of 1.51 mm (p = 0.001), 1 mm, (p = 0.02) and 0.44 mm (p = 0.69) for 0°, 30°, 90° of knee flexion. Screw and suspensory fixation restored native translation at all points with a small degree of overconstraint. CONCLUSION: Disruption of the PTFJ causes pathologic external rotation and anterior fibular translation. Fixation restores near native motion with minor overconstraint. Surgeons should consider reduction and fixation of PTFJ injuries to restore native knee mechanics.

Does a Medial Malleolar Osteotomy or Posteromedial Approach Provide Greater Surgical Visualization for the Treatment of Talar Body Fractures?

BACKGROUND: Surgical management of talar body fractures is influenced by soft-tissue condition and fracture pattern. Two common surgical approaches for the treatment of talar body fractures are the medial malleolar osteotomy (MMO) and the posteromedial approach (PMA). The purpose of this study was to compare the observable talar body surface area with the MMO and the PMA. We hypothesized that visualization following a PMA improves with distraction and distraction with a gastrocnemius recession. METHODS: Five pairs of cadaver limbs were used. Each pair of specimens underwent both approaches to act as an internal control. The laterality of the PMA was determined by randomization, and the MMO was performed on the contralateral ankle. The PMA was performed to visualize the talus, and the talar surface area was recorded using a handheld 3D surface scanner. A distractor was then placed across the joint, and the surface area was remeasured. Finally, a gastrocnemius recession was performed, and the measured surface area under the distraction was recorded. The MMO was performed in standard fashion using fluoroscopy, and the observable talar surface area was recorded. Scans were performed twice for each approach, and the surface areas were averaged. The talus was excised and scanned after each approach in order to compare the visualized surface area with the total surface area of the native talus. RESULTS: The MMO and the PMA exposed a mean of 11.2 and 6.7 cm2, respectively, of the talar surface. Visualization with the PMA was improved with distraction, revealing 8.3 cm2 of the talus (p = 0.01 when compared with an isolated PMA). A PMA with distraction and gastrocnemius recession exposed 9.9 cm2 of the talar dome and body. There was no significant difference in exposure between the MMO and the PMA with distraction and gastrocnemius recession (p = 0.32). CONCLUSIONS: The MMO and the PMA both afford excellent visualization for reduction and fixation of talar body fractures. Visualization using the PMA is improved with distraction and distraction with a gastrocnemius recession. The results of this study may assist surgeons in selecting the optimal approach for surgical repair of talar body fractures.

Open Reduction of Closed Pediatric Tibial Shaft Fractures Treated With Intramedullary Stabilization Does Not Increase Risk of Postoperative Complications.

OBJECTIVE: To compare union and complication rates in pediatric patients presenting with tibial shaft fractures treated with closed or open reduction before intramedullary stabilization. DESIGN: Retrospective review. SETTING: Multiple pediatric trauma centers. PATIENTS: Pediatric patients presenting with tibial shaft fractures treated with intramedullary stabilization. INTERVENTION: Intramedullary stabilization after closed or open reduction (percutaneous and open approach). MAIN OUTCOME MEASURES: Union rates, infection rate (superficial and deep), and unplanned return to the operating room (OR). RESULTS: One hundred sixty-six patients were included in this study. One hundred thirty-six patients presented with closed fractures, and 30 patients presented with open tibial shaft fractures. Thirty-seven of the 136 patients (27%) with closed fractures had their fracture specifically opened during surgical fixation. There was no statistical difference in radiographic union at 6 months between fractures electively opened and those treated with closed reduction alone 97% versus 98% (P = 0.9). No patient who underwent an open reduction developed infections or wound-healing concerns, whereas 2 of the 99 (2%) patients treated closed had superficial surgical site infections requiring additional treatment (P = 0.999). There was no difference in unplanned return to OR between those who underwent open reduction at the time of intramedullary stabilization (P = 0.568). CONCLUSION: Performing an open reduction in a closed pediatric tibial shaft fracture before intramedullary fixation does not increase the risk of surgical site infections or wound issues, delayed union, or unplanned return to the OR. An open reduction of a closed tibial shaft fracture for purposes of improving a reduction before intramedullary stabilization may be a safe and effective clinical practice. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

How to reject Benatar's asymmetry argument.

In this article I reconsider David Benatar's primary argument for anti-natalism-the asymmetry argument-and outline a three-step process for rejecting it. I begin in Part 2 by reconstructing the asymmetry argument into three main premises. I then turn in Parts 3-5 to explain how each of these premises is in fact false. Finally, I conclude in Part 6 by considering the relationship between the asymmetry argument and the quality of life argument in Benatar's overall case for anti-natalism and argue that it is the latter argument that is actually doing the work. In this sense, the asymmetry argument is not only unsuccessful in generating Benatar's anti-natalist conclusion, it is also unnecessary as well.

The impact of stenosis and translation on spinal cord injuries in traumatic cervical facet dislocations.

BACKGROUND CONTEXT: Although facet dislocations account for only 6% of cervical trauma, the consequences are often devastating. Cervical facet dislocations are associated with a disproportionate amount of spinal cord injuries; however, neurologic examination of patients is often difficult, as patients commonly present with reduced levels of consciousness. There are limited studies that have investigated the impact of spinal canal diameter and translation on neurologic injury following facet dislocations. PURPOSE: Review a consecutive series of patients with facet dislocations to assess the impact of sagittal diameter and translation on Spinal Cord Injury (SCI). STUDY DESIGN: Retrospective review at a level I trauma center identified 97 patients with facet dislocations. METHODS: Between 2004 and 2014, a retrospective review at a level I trauma center identified patients with traumatic facet dislocation. Demographic data, neurologic exams, and radiographic findings were reviewed. We assessed sagittal diameter at the injury level, as well as above and below, and translation. This study has no funding source and its authors have no potential conflicts of interest-associated biases. RESULTS: Ninety-seven patients presented with facet dislocations. Fifty-nine (61%) presented with a SCI. Those with ASIA A averaged 8.0 mm of injury level canal diameter, and ASIA E averaged 12.6 mm (p < .001). Additionally, those with ASIA A averaged 8.0 mm of translation, and ASIA E averaged 4.2 mm (p < 0.001). Two groups were created based on their general motor function. Those with ASIA A-C averaged 8.4 mm of injury level canal diameter, and ASIA D-E averaged 12.3 mm (p < .001). Those with ASIA A-C averaged 7.8 mm of translation, and ASIA D-E averaged 4.4 mm (p < .001). Receiver operating characteristic (ROC) curves demonstrated that translation was a good predictor of ASIA A-C and canal diameter was an almost perfect predictor of ASIA D-E. CONCLUSIONS: Our data indicate that patients with greater translation and/or a smaller canal diameter at the injury level have a higher rate of SCI. Adjacent canal diameter did not correlate with neurologic injury.

Radiographic Analysis of Simulated First Dorsal Interosseous and Opponens Pollicis Loading Upon Thumb CMC Joint Subluxation: A Cadaver Study.

BACKGROUND: Therapy programs to treat thumb carpometacarpal (CMC) arthritis may engage selective activation and reeducation of thenar muscles, particularly the first dorsal interosseous (FDI) and opponens pollicis (OP) to reduce subluxation of the joint. We describe the effect of simulated selective activation of the FDI and OP muscles upon radiographic subluxation of the thumb CMC joint. METHODS: In a cadaver model of CMC subluxation, loads were applied to the FDI, the OP, and then concomitantly at 0%, 25%, 50%, 75%, and 100% maximal loads and radial subluxation of the joint and reduction in subluxation was measured. RESULTS: Selective activation of the OP, alone, improved the subluxation ratio (SR) in a dose-dependent manner. Selective activation of FDI, alone, demonstrated minimal effects on SR. Concomitant activation of OP and FDI improved the SR across all loading states, and activation of 75% and greater, when compared with FDI activation alone, resulted in a statistically significant improvement in SR to within 10% of the presubluxed joint. CONCLUSIONS: Concomitant activation of the FDI and OP acts to reduce subluxation of the thumb CMC joint in a dose-dependent fashion. The OP is likely the predominant reducing force. Hand therapy programs that focus on selective strengthening programs likely function in part to encourage patients to activate the easily palpable and easily understood FDI. Concomitant coactivation of the OP may be the major reducing force to elicit clinical and radiographic reduction of subluxation, improved thumb positioning, and reduction of pain and arthritic symptoms.

Traumatic Cervical Unilateral and Bilateral Facet Dislocations Treated With Anterior Cervical Discectomy and Fusion Has a Low Failure Rate.

STUDY DESIGN: Retrospective radiographic and chart review. OBJECTIVE: To define the rate and associated risk factors of treatment failure of anterior cervical fusion for treatment of cervical facet dislocations. METHODS: Between 2004 and 2014, a retrospective review at a single level 1 trauma center identified 38 patients with unilateral or bilateral dislocated facet(s) treated with anterior cervical discectomy and fusion (ACDF). Two patients were eliminated due to less than 30-day follow-up. Demographic data, initial neurological exams, surgical data, radiographic findings, and follow-up records were reviewed. RESULTS: Of the 36 patients with facet dislocations treated with ACDF using a fixed locking plate, 16 were unilateral and 20 were bilateral. The mean age was 35 years (range 13-58). Mean follow-up was 323 days (range 30-1998). There were 3 treatment failures (8%). Three of 7 (43%) endplate fractures failed (P < .01), and 1/28 (4%) facet fractures failed (P = .13). The mean time to failure was 4 weeks (1-7 weeks). One treatment failure had a facet fracture, and all 3 failures had an associated endplate fracture. CONCLUSION: Treatment failure occurred in 3 out of 36 (8%) patients with facet fracture dislocations treated with anterior cervical discectomy, fusion, and plating. Rates of failure are lower than has been previously reported. Endplate fractures of the inferior level in jumped facets appears to be a major risk factor of biomechanical failure. However, a facet fracture may not be a risk factor for failure. In the absence of an endplate fracture, ACDF is a reasonable treatment option in patients with single-level cervical facet dislocation.

Hematopoietic cell transplantation for mantle cell lymphoma: predictive value of pretransplant positron emission tomography/computed tomography and bone marrow evaluations for outcomes.

BACKGROUND: The prognostic roles of 18F-fludeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging and marrow involvement evaluation on outcomes following autologous and allogeneic hematopoietic cell transplantation (HCT) for mantle cell lymphoma (MCL) are uncertain and require more data. PATIENTS AND METHODS: We categorized 66 patients with MCL who received HCT (38 autologous and 28 allogeneic) on the basis of pre-HCT residual disease (RD) status as assessed by marrow MCL morphology and flow/molecular analysis and PET/CT imaging to RD positive (RD(+)) (either or both measures positive) and RD(-) (both negative). We analyzed the predictive value of these RD detection methods on transplant outcomes. RESULTS: The 2-year relapse rate after autograft was significantly higher in pre-HCT RD(+) patients (46% [95% CI 16-77%]) than in patients who were RD(-) (19% [95% CI 0-42%]; P = .02), leading to worse 5-year disease-free survival (DFS) in RD(+) patients (46% [95% CI 14%-73%] vs. 68% [95% CI 33-87%], P = .04). In multivariate analysis, RD(+) status was associated with a reduction in DFS (hazard ratio, 5.6; P = .02). Most allogeneic HCT recipients had advanced disease and most were RD(+) (12 PET/CT(+); 5 marrow-positive). The 5-year DFS and relapse rates after allogeneic HCT were 34% and 25% for all patients and 40% and 33% for RD(+) recipients, suggesting that active disease at the time of allograft does not preclude long-term remissions in advanced MCL. CONCLUSION: Both autologous and allogeneic HCT lead to promising long-term survival. RD detected prior to autograft was associated with increased relapse and worse 5 year DFS. Allograft recipients had favorable long-term outcomes even in presence of pre-HCT detectable disease.