Topical Antibiotic Powder and Nonunion Risk in Surgically Treated Tibial Plateau and Pilon Fractures.

INTRODUCTION: High-energy periarticular tibia fractures are challenging injuries with a significant risk of complications. Postoperative infection rates, although improved, remain unacceptable. Intrawound topical antibiotic (TA) application has been popularized to reduce postoperative infections. Although TA may minimize infections, it remains unclear whether TAs have any impact on the development of nonunion. Recent investigations of TA use in fracture care have questioned its efficacy in vivo and suggested a potentially deleterious effect on fracture healing. This study investigates the impact of TA on nonunion rates in surgically treated high-energy periarticular tibia fractures. METHODS: Retrospective analysis of surgically treated periarticular tibia fractures at a single Level 1 trauma center was conducted. Intervention in question was the clinical effect of intrawound TA powder application at definitive closure. A total of 222 high-energy periarticular tibia fractures were included, 114 with TA use and 108 without. The primary outcome was the occurrence of nonunion, with secondary outcomes being superficial and deep postoperative surgical site infections. RESULTS: Twenty-seven patients (12.1%) were diagnosed with nonunions (14 pilons and 13 plateaus). There was no statistically significant difference in nonunion rates among patients who received topical antibiotics (15.8%) versus the group of patients who did not (8.3%) ( P = 0.23). Odds of developing nonunion was significant for open injuries (odds ratio 6.16, P < 0.001) and patients with a provisional external fixator (odds ratio 8.72, P = 0.03) before definitive fixation. No notable difference in the number of superficial and deep infections was identified between groups. CONCLUSION: The use of TA in high-energy periarticular tibia fractures showed no statistically significant increase in nonunion rates but did not conclusively rule out nonunion as a possible effect of intrawound TA. Additional large-scale multicenter prospective studies are needed to confirm these findings. The current body of literature regarding high-energy periarticular tibia fractures does suggest that TAs lower the risk of postoperative infections, but the nonunion risk remains unclear. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Effect of Intraoperative Multidimensional Fluoroscopy Versus Conventional Fluoroscopy on Syndesmotic Reduction.

BACKGROUND: Despite multiple techniques to improve syndesmotic reduction accuracy, syndesmotic malreduction in unstable ankle fractures remains prevalent. We performed a prospective, observational study to assess the ability of intraoperative multidimensional fluoroscopy to lead a surgeon to change the syndesmotic reduction obtained by conventional fluoroscopic techniques with the goal of achieving an accurate reduction. METHODS: Thirty patients with unilateral malleolar ankle fractures and syndesmotic instability were enrolled. Following fixation of the malleollar fractures, the syndesmosis was provisionally reduced. Once the surgeon believed acceptable reduction was obtained by comparison with the contralateral, uninjured ankle mortise and lateral fluoroscopic images, provisional fixation was used to maintain reduction. Intraoperative, multidimensional fluoroscopy was used to generate cross-sectional images to assess the reduction. The surgeon then decided if a change in the reduction was needed, and fixation proceeded per surgeon preference. Postoperative bilateral computed tomography (CT) scans of the ankles were used to assess the reduction. RESULTS: The main outcome recorded was syndesmotic reduction change by the attending surgeon following 3-dimensional (3D) fluoroscopic imaging. The secondary outcome was syndesmotic reduction accuracy on postoperative CT scan. Fourteen of 30 patients had intraoperative reduction change following 3D fluoroscopic imaging. Three of 30 patients had residual malreduction compared with the contralateral ankle on bilateral postoperative CT scan. CONCLUSION: Intraoperative 3D fluoroscopy frequently led the surgeon to change the syndesmotic reduction obtained by conventional techniques and provided additional information not available with 2-dimensional fluoroscopy. A 10% syndesmotic malreduction rate was obtained with this technique. LEVEL OF EVIDENCE: Diagnostic level II, prospective comparative study.

High Rate of Union for Aseptic Distal Tibial Nonunions in Adults Treated With Slow Gradual Compression via Circular External Fixation.

OBJECTIVE: To evaluate the healing rate of aseptic nonunions of the distal third of the tibia treated with Ilizarov slow gradual compression and deformity correction. DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS/PARTICIPANTS: Ninety-four consecutive adult patients with 94 distal third tibial aseptic nonunions. INTERVENTION: Ilizarov external fixation and slow gradual compression; most patients also underwent bone grafting, deformity correction, or both before the initiation of compression. MAIN OUTCOME MEASUREMENTS: Rate of bony union. RESULTS: Eighty-seven of 94 cases (92.6%) healed after slow gradual compression across the nonunion site with a circular external fixator. Four of the 7 patients who failed treatment healed after additional operative treatment, and the remaining 3 refused further care. CONCLUSIONS: Circular external fixation with slow gradual compression was successful in treating aseptic nonunions of the distal third of the tibia in 92.6% of cases. Careful selection of patients for this treatment method can lead to a high success rate with a relatively low rate of major complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Modified Iliac Oblique-Outlet View: A Novel Radiographic Technique for Antegrade Anterior Column Screw Placement.

Percutaneous fixation of acetabular fractures can be challenging because of the complex anatomy of the anterior column. We have used a modified iliac oblique-outlet image view in conjunction with more traditional radiographic views to place antegrade anterior column screws. This technique does not replace the pelvic inlet but is a good alternative in the lateral decubitus position because it helps to mitigate the difficulties of obtaining the pelvic inlet radiograph in this position. The purpose of this study is to describe the radiographic technique, demonstrate proper and aberrant screw placement using Sawbones, and present a review of patients in which this technique was used in clinical practice.

{Omega}-oxidation of {alpha}-chlorinated fatty acids: identification of {alpha}-chlorinated dicarboxylic acids.

Myeloperoxidase-derived HOCl targets tissue- and lipoprotein-associated plasmalogens to generate α-chlorinated fatty aldehydes, including 2-chlorohexadecanal. Under physiological conditions, 2-chlorohexadecanal is oxidized to 2-chlorohexadecanoic acid (2-ClHA). This study demonstrates the catabolism of 2-ClHA by ω-oxidation and subsequent ß-oxidation from the ω-end. Mass spectrometric analyses revealed that 2-ClHA is ω-oxidized in the presence of liver microsomes with initial ω-hydroxylation of 2-ClHA. Subsequent oxidation steps were examined in a human hepatocellular cell line (HepG2). Three different α-chlorinated dicarboxylic acids, 2-chlorohexadecane-(1,16)-dioic acid, 2-chlorotetradecane-(1,14)-dioic acid, and 2-chloroadipic acid (2-ClAdA), were identified. Levels of 2-chlorohexadecane-(1,16)-dioic acid, 2-chlorotetradecane-(1,14)-dioic acid, and 2-ClAdA produced by HepG2 cells were dependent on the concentration of 2-ClHA and the incubation time. Synthetic stable isotope-labeled 2-ClHA was used to demonstrate a precursor-product relationship between 2-ClHA and the α-chlorinated dicarboxylic acids. We also report the identification of endogenous 2-ClAdA in human and rat urine and elevations in stable isotope-labeled urinary 2-ClAdA in rats subjected to intraperitoneal administration of stable isotope-labeled 2-ClHA. Furthermore, urinary 2-ClAdA and plasma 2-ClHA levels are increased in LPS-treated rats. Taken together, these data show that 2-ClHA is ω-oxidized to generate α-chlorinated dicarboxylic acids, which include α-chloroadipic acid that is excreted in the urine.