Use of light activated intramedullary device for revision of a proximal humerus fracture: a case study.

BACKGROUND: Post-operative non-compliance is a risk factor for fracture fixation failure and presents a challenge for revision surgery planning. We present a patient who underwent revision surgery for a proximal humerus fracture with lateral locked plating augmented with a UV light activated intramedullary implant. CASE: A 45-year-old woman with a history of alcoholism presented with a proximal humerus fracture. After undergoing open reduction internal fixation with a lateral locking plate, the patient suffered a fall secondary to delirium tremens. New radiographs demonstrated displacement of the fracture with failure of screws. Revision surgery consisting of removal of the initial construct as well as open reduction internal fixation via lateral locking plate, augmented with a UV-activated intramedullary cement implant, was performed. CONCLUSION: This is the first case report describing the use of a UV-activated intramedullary cement implant to augment the use of lateral locked plating for proximal humerus fractures. This case illustrates the successful management using UV-activated intramedullary cement to augment fixation, specifically in a patient with risk factors and post-operative non-compliance that predispose to fixation failure.

Reconstruction of the Medial Malleolus With Iliac Crest Autograft After Traumatic Loss: A Case Report.

CASE: A 19-year-old woman sustained an open ankle fracture with complete destruction of the left medial malleolus and significant soft-tissue loss. After temporizing external fixation and coverage with a rotational posterior tibial artery perforator flap, the medial malleolus was reconstructed with an autologous iliac crest bone graft and direct repair of the deltoid ligament. The patient achieved excellent improvement in functional outcomes at 21 months with adequate restoration of ankle motion. CONCLUSION: This case shows reconstruction of the medial malleolus with autologous iliac crest bone graft after traumatic loss can be a viable treatment option for young patients.

Heterotopic ossification in the knee following retrograde nailing of a femur fracture.

BACKGROUND: Heterotopic ossification (HO) is a pathologic bone formation in extra skeletal tissue and articular space. This was an objection to nailing of femur fractures across the knee; however, this has not been the case in many thousands of cases. Nonetheless, we present a patient in who placement of a retrograde nail resulted in calcification in the knee requiring excision. CASE PRESENTATION: A 42-year-old male presented to the clinic complaining of pain, popping, clicking, and mocking in the right knee, especially in the patellar region. Nine months prior he suffered an ipsilateral femur fracture that was treated with a retrograde intramedullary nail. X-ray and CT scan were used to confirm the presentation of a heterotopic bone mass in the Hoffa area of the right knee. The patient underwent an arthrotomy for excision of the bone mass. The bone mass was excised, but bone in the ACL was not removed. The patient experienced pain relief and improved range of motion following excision. CONCLUSION: Intraarticular heterotopic ossification is an infrequent event. We present a case of heterotopic ossification in the knee following retrograde nailing. The patient experienced improved symptoms and range of motion after excision of the intraarticular heterotopic bone mass.

Intramedullary nailing of concurrent ipsilateral fractures of the tibia and femur: primary synchronous nailing versus staged osteosynthesis with temporizing external fixation.

INTRODUCTION: The optimal timing to definitive osteosynthesis in the polytraumatized patient remains an unanswered question. Early total care, damage control orthopaedics, and early appropriate care have been described to manage the fractures in these patients, but there is a paucity of literature specific to ipsilateral tibial and femoral fractures. We sought the perioperative outcomes of primary simultaneous intramedullary nailing (IMN) versus temporizing external fixation (EF) of both fractures. METHODS: A chart review of all patients who sustained fractures of the ipsilateral femur and tibia that were definitively treated with (IMN) from January 2010 to December 2020 was performed. Patients who underwent initial EF and those that were primarily treated with IMNs were examined. RESULTS: IMNs and EF were the initial treatment in 23 and 16 patients, respectively. The mean (range) injury severity score (ISS) was 23.3 (33) in the EF group vs. 18.5 (34) in the IMN group, (p = 0.0686). The EF group had a higher total transfused units of packed red blood cells 7.4 vs. 2.8, the mean initial operative time was 236 vs. 282.6 (min), (p = 0.7399), a longer mean total operative time 601.78 vs. 236 (min), and longer mean length of stay 15.6 vs. 11 (days), (p < 0.5). Rates of complications were not significantly different between groups. CONCLUSION: Primary IMN is as safe as provisional EF in the adequately resuscitated patient with ipsilateral femoral and tibial fractures. This implies the fixation of both fractures into a single surgery without increasing perioperative complications, and decreasing total hospital stay in patients with sufficient preoperative resuscitation.

Laterally Based External Fixation for Pott's Fractures.

In this article, we describe the construction and appropriate use of a lateral-based fixator for ankle fractures. This lateral-based frame is useful for treating Pott's fractures. With lateral ankle dislocations, the lateral frame places the hindfoot in alignment with the leg. Soft tissue trauma has been recognized as an early limiting factor in patients with ankle fractures, in addition to the need for obtaining and maintaining anatomic position. A kickstand is added for heel and medial soft tissue offloading. The lateral frame is a quick and reproducible technique with satisfactory results.Level of Evidence: Level V: Surgical Technique.

Does an antibiotic nail made in a lubricated tube release antibiotic?

INTRODUCTION: The treatment of long-bone osteomyelitis has long been a difficult problem. Recently, antibiotic-impregnated intramedullary rods for the treatment of infected long-bone fractures have been gaining popularity but they are quite difficult to fabricate. Recently, a new technique that utilizes mineral oil to coat the inside of a chest tube mold prior to introduction of cement has been proven to ease fabrication. We hypothesized that the use of mineral oil would alter the elution characteristics of tobramycin from the intramedullary device. METHODS: Two groups of antibiotic nails were fabricated under sterile conditions. The control group utilized a chest tube mold. The study group utilized a chest tube that was coated with mineral oil prior to cement injection. Each intramedullary nail was placed in pooled human serum and incubated under physiologic conditions. The level of tobramycin in each sample was measured at timepoints 0, 1, 6, and 24 h. RESULTS: There was no significant difference when comparing control with the experimental group at any timepoint. Antibiotic nails eluted tobramycin at a rapid rate in the first 6 h of exposure to serum, regardless of their preparation with oil or without oil. The rate of elution fell precipitously between 6 and 24 h. CONCLUSION: We believe that although this study, as with any study, cannot perfectly recreate in vivo conditions, we have clearly shown that mineral oil has no significant effect on elution of tobramycin from antibiotic nails.

Rifampin and tobramycin combination with PMMA antibiotic cement.

Rifampin is a powerful antibiotic used in the treatment of biofilm-forming bacteria with studies supporting its use in PMMA cement. However, it has not been widely accepted for its use in PMMA cement due to a perception that it is unable to solidify in a timely manner. The technique described consists of ratio of aminoglycoside and rifampin that reduces time to solidification to approximately 15-20 min.

Results of 167 consecutive cases of acetabular fractures using the Kocher-Langenbeck approach: a case series.

BACKGROUND: Acetabular fractures are quite challenging injuries for the orthopedic surgeon because of their low incidence and their deep and complex anatomy. The objective of this study was to evaluate surgeon-independent parameters that might influence radiographic outcome and early complication rates of high-energy acetabular fractures treated by open reduction and internal fixation via the Kocher-Langenbeck approach, the golden standard for posterior access. METHODS: One hundred sixty-seven consecutive patients (111 males and 56 females) with a mean age of 41.8 years and a mean follow-up period of 10 months were surgically treated by one experienced surgeon at a level I trauma center within 10 years. To quantify the radiographic outcome, the Matta, Brooker, and Epstein grades were used. Posttraumatic arthritis and avascular necrosis of the femoral head (defined as Helfet grades 3 or 4 and Ficat/Arlet stages 3 or 4, respectively) were evaluated. Furthermore, subgroup analyses according to fracture type, age, and gender were performed for each outcome measure and complication (infection, hemorrhagic shock, revision surgery, nerve damage, and need of a total hip arthroplasty). RESULTS: 65 A1, 34 A2, 51 B1, and 17 B2 fractures were identified according to the AO/ASIF classification. Of all patients, reduction was rated anatomic in 63.5%, imperfect in 22.2%, and poor in 14.4%. Degenerative changes were observed in 49.7%; 37.9% were affected by heterotopic ossification, 21.6% by posttraumatic arthritis, and 5.4% by avascular necrosis of the femoral head. Fifteen percent were diagnosed with a nerve damage, and 4.8% sustained an infection. Total hip arthroplasty was performed in 10.2%. Revision surgery due to secondary loss of reduction, seroma/hematoma, and wound infection was indicated in 6.0%. CONCLUSIONS: Fracture type, age, and gender are prognostic factors for the surgical outcome after ORIF of high-energy acetabular fractures.

Surgical Wound Classification and Surgical Site Infections in the Orthopaedic Patient.

INTRODUCTION: The Centers for Disease Control and Prevention created a surgical wound classification system (SWC: I, clean; II, clean/contaminated; III, contaminated; and IV, dirty) to preemptively identify patients at risk of surgical site infection (SSI). The validity of this system is yet to be demonstrated in orthopaedic surgery. We hypothesize a poor association between the SWC and the rate of subsequent SSI in orthopaedic trauma cases. METHODS: Nine hundred fifty-six orthopaedic cases were reviewed. Wounds were risk stratified intraoperatively using the SWC grades (I-IV). SSI was diagnosed clinically or with objective markers. The SWC was compared with SSI rates using a Fisher exact test. Significance was set at P < 0.05. RESULTS: Four hundred patients met the selection criteria. The rate of infection was not significantly different across the SWC grades (P = 0.270). There was a significantly higher risk of SSI among patients with diabetes (P = 0.028). CONCLUSIONS: The Centers for Disease Control and Prevention SWC showed poor utility in predicting and risk stratifying postoperative SSIs in orthopaedic surgical cases.

Comparison between suprapatellar and parapatellar approaches for intramedullary nailing of the tibia. Cadaveric study.

Intramedullary nailing is one viable option for treating fractures of the tibia with a short, proximal segment. For a procedure being carried out with the knee in a semi-extended position, either a suprapatellar or parapatellar approach may be used. The objective of this study is to demonstrate whether the entry point for tibia nails is obtainable through suprapatellar or parapatellar approaches and to evaluate the most frequent injuries of the knee with these two approaches. MATERIALS AND METHODS: Paired legs from 10 fresh frozen cadavers were used. An arthroscopy was performed in each knee, documenting the status of the knee prior to the insertion of the tibia nail. In a random manner, the left or right leg underwent nailing with a suprapatellar or parapatellar approach in a semi-extended position. Fluoroscopy was utilized in each case to localize the entry point, and a tibia nail was inserted in all cases. A knee arthrotomy was then performed and the status of the following structures was assessed: patella and trochlea cartilage, tibia plateau cartilage, inter-meniscal ligament, lateral and medial meniscus, and the ACL. RESULTS: The correct fluoroscopy entry point was achieved in all of the specimens (20). Three legs (3/10) with parapatellar approach had intra-articular disruption. In legs with a suprapatellar approach, patellar cartilage and trochlea cartilage damage was found in two of the specimens, respectively. There was one specimen with cartilage damage in the parapatellar approach. There were no meniscal injuries. Partial laceration of the intermeniscal ligament was found in three of the knees for each approach. One ACL injury was found in the suprapatellar group. Mean distance from the entry point to major structures is not significantly different with either approach. (p=0.45). CONCLUSIONS: A good fluoroscopic entry point can be achieved using either the parapatellar or suprapatellar approach. The parapatellar approach for tibia nailing has similar rate of soft tissue damage compared to the suprapatellar approach. The suprapatellar approach damaged the cartilage in one-third of the cases and if cartilage injury occurs with the parapatellar approach, this is located in a low risk area.

Evolution of the Hoffmann Fixators.

Dr. Raoul Hoffmann of Geneva, Switzerland with the collaboration of Henri Jaquet developed the original Hoffmann external fixateur as a system for treating broken bones without necessarily opening a fracture site to reposition the bone ends. This system has evolved to a more flexible, modular concept with input from surgeons and engineers. In this chapter the modifications of the Hoffmann family of fixators are traced and the important steps in the development of the concept and the instrumentation emphasized.

Complication Risk After Treatment of Intertrochanteric Hip Fractures in the Medicare Population.

The study evaluated the incidence of and complications associated with the use of an intramedullary nail vs open reduction and internal fixation (ORIF) with a sliding compression hip screw and plate in treating intertrochanteric fractures. The authors hypothesized that the biomechanically stronger and less invasive intramedullary nail would have superior results and fewer complications compared with ORIF. Patients followed for up to 1 year postoperatively were identified from the 5% nationwide sample of Medicare administrative claims data (1998-2007) using the corresponding International Classification of Diseases, 9th revision, Clinical Modification, codes 820.21 and 820.31. There were 9157 patients treated with intramedullary nails and 27,687 treated with compression screw and plate fixation. Intertrochanteric hip fractures treated with an intramedullary nail during this period increased from 3.3% to 63.1% compared with ORIF. Patients treated with an intramedullary nail had a higher adjusted risk of pulmonary embolism at 90 days (P=.003) and a higher risk of mortality at 1 year (P<.001) compared with those treated with ORIF. Patients who underwent intramedullary nailing during 2006 to 2007 had a lower adjusted risk of conversion to total hip replacement at 1 year (P=.037) compared with those who had ORIF. Over the decade of the study, intramedullary nail usage increased 59.8% compared with ORIF. Increased use of intramedullary nails compared with ORIF has not shown improved outcomes or decreased complications in patients with intertrochanteric hip fractures. The increased use of intramedullary nails for intertrochanteric hip fractures appears to be multifactorial, including the less invasive nature of the surgery and increased experience with the closed surgical technique.

Medial malleolus screws: out in one view and out.

Cartilage damage or mechanical blocking from screw penetration into intra-articular cartilage can reduce the chances of successful outcomes during medial malleolus fixation. There have been diverging opinions among surgeons concerning the reliability of radiographic assessment of fracture fixation and malleolus screw positioning. Therefore, this radiographic study examines the location of medial malleolus lag screws relative to the ankle mortise articular surface. In three Sawbones models, Kirschner wires were overdrilled with a 4.0-mm cannulated cortical screw simulating screws that would be intra- and extra-articular when performing open reduction and internal fixation of a medial malleolar fracture. Under fluoroscopy, images were evaluated to determine whether known intra-articular screws appeared extra-articular in any radiographic view. No image from models with known intra-articular penetration appeared extra-articular in any view or under "live" fluoroscopy. At 20° internal rotation, a screw with a known extra-articular position appeared to be within the cartilage. Intra-operative fluoroscopy is necessary to ensure proper extra-articular placement of screws. If a screw is pictured extra-articular in any radiograph, then it can be assumed that the screw is indeed out of the joint.

Antibiotic-laden PMMA bead chains for the prevention of infection in compound fractures: current state of the art.

Antibiotic-laden PMMA bead chains are a valuable method of local antibiotic treatment in the prevention of infection in open fractures. When used in this setting, they provide high concentrations of broad-spectrum antibiotics to the area of the highest risk which may not be well perfused or reached by systemic antibiotics, while also eliminating dead space. In this article, the historical and current state of antibiotic-laden bead chains is discussed. The literature provides evidence that antibiotic-laden bead chains are a useful adjuvant with systemic antibiotics in the prevention of infection in open fractures. These bead chains can be sterilely prepared in the operating room or manufactured, and they maintain their elution and antimicrobial properties for a considerable time period. The bead chains also allow a high local concentration of antibiotics without risk of systemic toxicity or fear of clinically significant growth or persistence of bacteria on the beads. Bead chains are a practical method of local antibiotic therapy when the wounds can be closed.

Use of carbon-fiber-reinforced composite implants in orthopedic surgery.

Carbon-fiber-reinforced polyetheretherketone implants offer several benefits over traditional metal implants. Their radiolucent property permits improved, artifact-free radiographic imaging. Their lower modulus of elasticity better matches that of bone. Their fatigue strength is greater than most metal implants. This article reviews the use of these implants in orthopedic surgery, including treatment of conditions involving the spine, trauma, tumor, and infection.

Clavicular caution: an anatomic study of neurovascular structures.

Open reduction and internal fixation of the clavicle is used to treat displaced fractures of the midshaft of the clavicle. Complications of operative intervention include injuries to major neurovascular structures including the subclavian artery and vein. Unlike other surgical approaches, palpation or visualization of the deep neurovascular structures at risk is rarely performed and is not part of the routine approach. This study aims to further elucidate the relationship of major neurovascular structures in the shoulder to the clavicle using sectioned fresh frozen cadaveric specimens. Using five cadaveric specimens, sagittal sections were performed using a band saw. Sections were taken every 15mm. Using these sections, structures were identified and photos were taken using a standardized approach to allow for precise and accurate measurements. Measurements taken included the distance from the nearest clavicular cortex to the centre of the subclavian artery, vein, and brachial plexus. These measurements were taken from five limbs on five different cadavers. Our results were consistent with previous studies. Medially, the subclavian vein was intimately related medially (4.8mm) to the clavicle, whereas the artery and brachial plexus were both >2cm from the clavicle. At about the junction of the middle and second-thirds of the clavicle, all three structures were within 2cm of the clavicle. Moving laterally, these structures moved further away and at the acromioclavicular (AC) joint were at least 4.5cm away from the clavicle on average. This study reiterates that the medial third of the clavicle is closely associated with neurovascular structures and that care should be taken here when using drills, depth gauges, and clamps.

Custom-made antibiotic cement nails: a comparative study of different fabrication techniques.

INTRODUCTION: The management of intramedullary long bone infections remains a challenge. Placement of antibiotic cement nails is a useful adjuvant to the antibiotic treatment of osteomyelitis. However, fabrication of antibiotic cement nails can be arduous. The purpose of this article is to introduce an easy and reproducible technique for the fabrication of antibiotics cement nails. MATERIALS AND METHODS: We compared the time required to peel the chest tube off the 6 antibiotic cement nail using 2 different cement-cooling techniques and the addition of mineral oil in the chest tube. Additionally, we evaluated the optimal time to cut the chest tube (before and after cement hardening), consistency of nail's diameter, and the roughness of its surface. Cooling and peeling times were measured and failure was defined as a working time (from cement mixing to have a usable antibiotic cement nail) that exceeded 1 h. RESULTS: When the antibiotic cement nail was left to cool by convection (i.e. air-cooling), we failed to peel the plastic off the cement nail. When the chest tube was cut after conductive cooling (i.e. cold water-cooled), the cooling time was 10 min and the peeling time was 30 min without the use of mineral oil; the addition of mineral oil reduced peeling time to 7.5 min. Following peeling, residual adherent plastic pieces were found along the entire surface of the nail when no mineral oil was used. This was rarely seen when mineral oil was utilized to coat the inner layer of the chest tube. CONCLUSION: Conductively cooling of the cement nail (in cold water) and pre-lubricating the chest tube with mineral oil are 2 tricks that render fabrication of antibiotic nail more efficient, reliable, and practical.

Poor prognosis and advanced clinicopathological features of clear cell renal cell carcinoma (ccRCC) are associated with cytoplasmic subcellular localisation of Hypoxia inducible factor-2α.

BACKGROUND: Pre-clinical studies have implicated hypoxia inducible factor (HIF)-2α as an important oncogene for clear cell renal cell carcinoma (ccRCC). Generally considered to act as a nuclear transcription factor, a recent study has also implicated HIF-2α as a protein translational initiation complex function within the cytoplasm (Uniacke et al., 2012). We hypothesised that both the absolute expression as well as the sub-cellular localisation of HIF-2α would predict clinicopathological features and cancer specific survival (CSS) in ccRCC. METHODS: A tissue microarray (TMA) study was conducted on three hundred and eight ccRCC patients. Survival differences were investigated with the log rank test and associations with CSS with uni- and multivariate Cox regression analyses. Recursive partition tree analysis was used to identify relevant cutoff values. RESULTS: High HIF-2α nuclear (N) (cutoff >32%) expression was associated with smaller tumour sizes (p=0.002) and lower Fuhrman grades (p=0.044), whereas tumours with high cytoplasmic (C) HIF-2α (>0%) more often had positive lymph nodes (p=0.004), distant metastases (p=0.021) and higher Fuhrman grades (p<0.0001). After adjustment for TNM stage, Eastern Cooperative Oncology Group performance status (ECOG PS), and Fuhrman grade, both continuous (p<0.0001) and dichotomised (p<0.0001) HIF-2α C variables remained significant predictors of CSS, while neither HIF-2α N variable was retained. CONCLUSION: Our investigation supports that HIF-2α may have a unique tumour promoter role in the cytoplasm. This preliminary finding justifies further experimental and mechanistic studies that examine the biological functions of HIF-2α when located in the cytoplasm.

Complications of operative treatment of clavicle fractures in a Level I Trauma Center.

Traditionally, the belief is that the clavicle heals readily and with nonoperative treatment. Since evidence suggests that many clavicles benefit from operative care, the aim of this study was to find the incidence of complications after operative treatment of clavicle fractures. This retrospective study includes 56 patients (41 male and 15 female) who were treated operatively for clavicle fractures between 2010 and 2012. The indications were displacement more than 20 mm, comminution, tenting of the skin, floating shoulder, and open fractures. Seventy-five percent of the fractures occurred in the midshaft and 25 % in the lateral third of the clavicle. There were no fractures of the medial third. The midshaft fractures were either plated with 3.5 mm reconstruction plates or anatomical locking plates. For internal fixation of the lateral fractures, we used acromioclavicular hook plates. The mean follow-up period was 4.6 months (range 1.0-28.0). Three patients did not participate in the follow-up. There were 12 patients with complications (21 %). Five of them required reoperations. Two patients were reoperated due to clavicle nonunions, two patients due to traumatic refracture of the plated clavicle, and one because of pain caused by the plate. Four cases developed superficial infections, and there was one patient with a deep tissue infection. None of the patients showed signs of neurovascular impairment postoperatively. None of the patients complained about decreased range of motion or loss of muscle strength postoperatively. Plating of clavicle fractures is a procedure that results in lower rates of malunion, nonunion, and functional impairment compared with nonoperative treatment. Nonetheless, one case in ten has a complicated course. Attention to technique and careful follow-up may prevent these problems.