Extraction of a Bent Tibial Nail After Refracture: A Case Report.

CASE: A 65-year-old man previously treated by intramedullary nailing for a left tibial shaft fracture presented 6 years later with an open refracture of his left tibia after a motorcycle accident. Treatment required extraction of the bent nail before revision nailing. CONCLUSIONS: Extraction of deformed intramedullary devices is a skill that will continue to be demanded of orthopaedic surgeons. In this case, standard extraction though the entry point proved successful. Standard extraction offers the safest form of removal and should be contemplated before considering more morbid methods of extraction while examining the fracture's morphology and the device's deformity.

Bilateral Forearm Pseudotumors in an Adult with Hemophilia A and Ollier Disease: A Case Report.

CASE: A 29-year-old man with mild hemophilia A and Ollier disease presented with bilateral atraumatic forearm pseudotumors. Both forearm pseudotumors were successfully treated surgically with staged radical extirpation and factor VIII replacement therapy. CONCLUSION: Pseudotumors typically occur in adolescents with severe, poorly controlled hemophilia A. The development of factor VIII replacement therapy has progressively reduced the incidence of pseudotumors in patients in the developed world. No standardized therapy exists for pseudotumors that continue to bleed into the muscles despite nonoperative measures. Persistent masses require surgical removal with careful preoperative planning and a team approach.

Radiographic Assessment of Fibular Length Variance: The Case for "Fibula Minus".

Given the high prevalence of ankle fractures and morbidity of malalignment after fixation, an appropriate anatomic relationship between the distal fibula and adjacent tibia and talus is important. The tip of the lateral malleolus of the fibula has often been described to be at the level of the lateral talar process. However, no studies to date have examined the relationship of the distal fibular tip to the lateral process of the talus. We assessed 66 weightbearing mortise radiographs for variability of the distal fibular tip in relation to the lateral process of the talus. The subjects were all skeletally mature, with a mean age of 45.3 ± 14.6 years. We used a paired t test with a null hypothesis that the true mean difference in the distance from the distal fibula to the lateral process was equal to 0. The mean distance of the distal tip of the fibula was 0.257 ± 0.127 cm proximal to the tip of the lateral process of the talus. The 95% confidence interval was 0.226 to 0.288. Of the 66 subjects, 65 had the distal tip of the fibula proximal to the lateral process of the talus, corresponding to a negative fibular variance. In the remaining subject, the distal tip of the fibula was at the same level of the tip as the lateral process of the talus. The distal tip of the fibula is most commonly not at the level of the talus lateral process, as often described in published reports. Instead, it has a variance analogous to the relationship between the lengths of the ulna compared with the radius. The distal tip of the fibula in our study was more often proximal to the tip of the lateral process of the talus and can be described as a negative fibular variance, or "fibula minus."

Complication rates following open reduction and internal fixation of ankle fractures.

BACKGROUND: Ankle fractures are among the most common injuries treated by orthopaedic surgeons. The purpose of the present investigation was to examine the risks of complications after open reduction and internal fixation of ankle fractures in a large population-based study. METHODS: With use of California's discharge database, we identified 57,183 patients who had undergone open reduction and internal fixation of a lateral malleolar, bimalleolar, or trimalleolar ankle fracture as inpatients in the years 1995 through 2005. Short-term complications were examined on the basis of the rates of readmission within ninety days after discharge. The intermediate-term rate of reoperation for ankle fusion or arthroplasty was also analyzed. Logistic regression and proportional hazard regression models were used to determine the strength of the relationships between the rates of complications and fracture type, patient demographics and comorbidities, and hospital characteristics. RESULTS: The overall rate of short-term complications was low, including the rates of pulmonary embolism (0.34%), mortality (1.07%), wound infection (1.44%), amputation (0.16%), and revision open reduction and internal fixation (0.82%). The intermediate-term rates of reoperation were also low, with ankle fusion or ankle replacement being performed in 0.96% of the patients who were observed for five years. Open fractures, age, and medical comorbidities were significant predictors of short-term complications. The presence of complicated diabetes was a particularly strong predictor (odds ratio, 2.30; p < 0.001), as was peripheral vascular disease (odds ratio, 1.65; p < 0.001). The intermediate-term rate of reoperation for ankle fusion or replacement was higher in patients with trimalleolar fractures (hazard ratio, 2.07; p < 0.001) and open fractures (hazard ratio, 5.29; p < 0.001). Treatment at a low-volume hospital was not significantly associated with either the aggregate risk of short-term complications or the risk of intermediate-term reoperation. CONCLUSIONS: By analyzing a large, diverse patient population, the present study clarifies the risks associated with open reduction and internal fixation of ankle fractures. Open injury, diabetes, and peripheral vascular disease were strong risk factors predicting a complicated short-term postoperative course. Fracture type was a strong predictor of reoperation for ankle fusion or replacement. Hospital volume did not play a significant role in the rates of short-term or intermediate-term complications.