Postoperative radial nerve palsy in humeral shaft nonunion reconstruction: Can the lateral paratricipital approach prevent this common complication?

BACKGROUND: Postoperative radial nerve palsy (RNP) is a well-known complication of nonunion reconstruction of the humerus. The purpose of the current study is to determine if the surgical approach for nonunion reconstruction of the humerus influences the rate of postoperative radial nerve palsy. METHODS: A retrospective case-control study of all humeral shaft and extraarticular distal humerus nonunion reconstructions performed between January 1, 2004, and August 31, 2021, was conducted. Patients included were over 18 years of age, had a non-pathologic humerus fracture nonunion and had intact radial nerve function prior to nonunion reconstruction. Exclusion criteria consisted of nonunions involving the proximal humerus, intraarticular fractures, and reconstructive treatment procedures with either intramedullary nail or external fixation methods. Perioperative variables were recorded and analyzed in regard to the development of postoperative RNP. A subgroup analysis was performed to assess the interaction of significant variables on the development of postoperative RNP. RESULTS: The overall rate of postoperative RNP in this series was 6/53 (11%). However, no cases of postoperative radial nerve palsy were observed in patients who underwent nonunion reconstruction with a lateral paratricipital approach. A new RNP was seen in 4/9 (44%) of those patients who underwent a triceps splitting approach, which was significantly higher than those utilizing either an anterolateral approach (2/28, 7%) or a lateral paratricipital approach (0/16, 0%, p = 0.007). DISCUSSION AND CONCLUSION: Our data suggests that the lateral paratricipital exposure decreases the risk of radial nerve injury with nonunion reconstruction of the humerus. The lateral paratricipital exposure offers the benefit of radial nerve exploration, decompression, neurolysis and protection prior to fracture manipulation and instrumentation. This study shows conventional approaches may predispose patients to a high rate of postoperative RNP, similar to that in the literature.

Male sex, Gustillo-Anderson type III open fracture and definitive external fixation are risk factors for a return to the or following the surgical management of geriatric low energy open ankle fractures.

INTRODUCTION: Open ankle fractures in geriatric (age > 60 years) patients are a source of significant morbidity and mortality. Surgical management includes plate and screw fixation (ORIF), retrograde hindfoot nail (HFN), definitive external fixation (ex-fix) and below knee amputation. However, each modality poses unique challenges for this population. We sought to identify predictors of unplanned OR and short-term mortality after geriatric open ankle fractures managed by our service. MATERIALS AND METHODS: In an IRB-approved protocol, we evaluated patients over 60 years of age managed for a low energy open ankle/distal tibia pilon fracture by trauma fellowship-trained surgeons from a single academic department that covers two level I trauma centers. Our primary outcome was an unplanned return to the OR. Secondary outcomes were a 90-day "event", defined as an all-cause hospital readmission or mortality, and 1-year mortality. Differences with a p-value < 0.1 measured on univariate analysis were evaluated using a multivariable logistic regression to identify independent outcome predictors. RESULTS: A total of 113 (60 ORIF, 36 HFN, 11 ex-fix, 6 amputations) were performed. Cohort mean age was 75.2 ± 9.8 years, and 31 patients (27.4%) were male. Mean age-adjusted charlson comorbidity index was 5.5 ± 2.0. Significant independent predictors of an unplanned return to the OR were male sex (OR 4.4, 95% CI 1.3 to 15.4), Gustilo Type III open fracture (OR 4.9, 95% CI 1.5 to 17.5) and ex-fix (OR 15.6, 95% CI 2.7 to 126.3). Independent predictors of a 90-day "event" were walker/minimal ambulation (OR 3.5, 95% CI 1.3 to 10.4), surgical site infection (OR 4.8, 95% CI 1.8 to 13.8) and reduced BMI (OR 0.9, 95% CI 0.9 - 0.99), while independent predictors of 1-year mortality were age (OR 1.1, 95% CI 1.003 to 1.2), ACCI (OR 1.4, 95% CI 1.02 to 2.0) and walker/minimal ambulator (OR 7.5, 95% CI 1.7 to 53) CONCLUSIONS: Host factors, particularly pre-operative mobility, were most predictive of 90-day event and 1-year mortality. Only definitive external fixation was found to influence patient morbidity as a significant predictor of unplanned OR. However, no surgical modality had any influence on short-term readmission or survival.

Increased Medial Displacement of the Humeral Shaft of at Least 40% Correlates With an Increased Incidence of Nerve Injury in Proximal Humerus Fractures.

BACKGROUND: Peripheral nerve and infraclavicular brachial plexus injury following proximal humerus fractures are commonplace, but diagnosing a concomitant nerve injury in the acute setting is challenging. Fracture displacement has been identified as a qualitative risk factor for nerve injury, and additional attention should be paid to the neurologic exams of patients with proximal humerus fractures with significant medial shaft displacement. However, a quantitative relationship between the risk of nerve injury and medialization of the humeral shaft has not been shown, and additional risk factors for this complication have not been assessed. The aim of this study was to identify the risk factors for a neurologic deficit following a proximal humerus fracture, with particular interest in the utility of the magnitude of medial shaft displacement as a predictor of neurologic dysfunction. METHODS: A retrospective chart review was performed on all proximal humerus fractures in a 3-year period (2012-2015) at a level one trauma center. Isolated greater tuberosity fractures (OTA 11-A1) were excluded. Fracture displacement was measured on initial injury AP shoulder radiograph and expressed as a percentage of humeral diaphyseal width. All orthopedic inpatient documentation was assessed to identify clinical neurologic deficits. RESULTS: We identified 139 patients for inclusion. There were 22 patients (16%) with new neurologic deficits at presentation (8 axillary nerve, 2 radial nerve, 12 infraclavicular brachial plexus or multiple nerve injuries). The average shaft medial displacement in patients with neurologic injuries was 59% vs. 21% without nerve deficits (p=0.03). Using a 40% medial displacement threshold, the odds ratio for a nerve injury was 5.24 (95% CI 1.54 - 17.77, p=.008). CONCLUSION: Increased medial displacement of the humeral shaft following proximal humerus fracture is associated with an increased incidence of nerve injury at the time of initial presentation. This finding is not meant to be a surrogate for a high-quality neurologic exam in all patients with proximal humerus fractures. However, improved knowledge of the specific risk factors for an occult neurologic injury will improve the clinician's ability to accurately diagnose and properly treat proximal humerus fractures and their sequelae.Level of Evidence: III.

Temporizing External Fixation vs Splinting Following Ankle Fracture Dislocation.

BACKGROUND: Closed reduction and splinting followed by outpatient management is standard of care for temporizing most ankle fractures. However, ankle fracture-dislocation potentially warrants a different approach based on the propensity for loss of reduction. The purpose of this study was to determine the rate of complications associated with closed reduction and splinting of unstable ankle fracture-dislocations. Further, we sought to determine the efficacy of immediate external fixation as an alternative to splinting in cases too swollen for acute operation. METHODS: This retrospective chart review analyzed all ankle-fracture dislocations that came through a large health care system from 2008 to 2018. Patients managed with acute open reduction internal fixation (ORIF) and open fractures were excluded. In patients managed late, the cohorts were divided into those temporized with closed reduction/splinting vs external fixation. Reduction quality and splint technique were additionally assessed in splinted patients. A total of 354 closed ankle fracture-dislocations were identified: 298 patients (84%) underwent ORIF within 48 hours and were excluded; 28 (15 female/13 male, average age 46.8 years) were placed in an external fixator and 28 (22 female/6 male, average age 57.2 years) were reduced, splinted, and discharged. RESULTS: At follow-up, 14 of the patients (50%) in the splint group developed loss of reduction and 5 of these patients (17.6%) developed anteromedial skin necrosis from skin tenting. None of the patients in the ex-fix group developed loss of reduction or skin necrosis. The rate of redislocation and the rate of development of skin necrosis was statistically higher in cases temporized with a splint versus an external fixator (P < .01 and P = .05, respectively). CONCLUSION: We found that in ankle fracture-dislocations not treated with acute ORIF, splint immobilization was associated with an increased risk of complications, including redislocation and skin necrosis, when compared to a temporizing external fixator. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Determining the efficacy of screw and washer fixation as a method for securing olecranon osteotomies used in the surgical management of intraarticular distal humerus fractures.

OBJECTIVES: The purpose of this study was to critically evaluate the efficacy of single screw and washer fixation in comparison with other methods for securing olecranon osteotomies. The hypothesis is that screw and washer fixation is a safe and effective means of olecranon osteotomy fixation with fusion and complication rates similar to other methods of fixation. DESIGN: Retrospective review. SETTING: Two Level I Urban Trauma Centers. PATIENTS/PARTICIPANTS: Patients were treated within the last 20 years and received 1 of 4 types of fixation (screw and washer alone, screw and washer augmented with tension band, tension band alone, or plate and screws) after osteotomy. INTERVENTION: Open reduction and internal fixation of OTA/AO 13B/C distal humerus fractures with an olecranon osteotomy. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was the presence of osteotomy union. Secondary outcome measures were olecranon nonunion, loss of articular reduction, and removal of hardware. Logistic regression was used to determine the associations between method of osteotomy fixation and removal of hardware or nonunion rates. Comorbidities were stratified using the Charlson comorbidity index. RESULTS: One hundred sixty patients met the inclusion criteria. Thirty-nine patients underwent screw fixation alone, 47 had tension band fixation, 16 had plate fixation, and 58 had tension band and screw fixation. Screw fixation demonstrated equal or better rates of union, maintenance of reduction, absence of infection, and implant removal compared with alternative fixation techniques. Higher Charlson scores were associated with higher rates of nonunion. CONCLUSIONS: Screw and washer fixation is a safe and effective means of securing an olecranon osteotomy. Charlson comorbidity score is one factor that may influence the development of nonunion after osteotomy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bicolumnar 90-90 plating of low-energy distal humeral fractures in the elderly patient.

Fragility fractures of the distal humerus in elderly patients, especially the low transcondylar fracture pattern, can be difficult to optimally manage. Although the fractures are typically low energy resulting in either extra-articular or simple intra-articular patterns, gaining fixation into the distal fragments can be difficult with open reduction internal fixation (ORIF) using traditional 90-90 or parallel plating techniques. Anatomy preserving reconstruction with ORIF is preferred over total elbow arthroplasty (TEA) if possible. In this study, 15 patients were managed with a bicolumnar 90-90 plating construct as a novel method of enhancing distal fixation in these fractures. Fourteen patients went on to radiographic union at an average of 77 days after surgery with an average arc of motion of 105°. One patient was lost to follow-up. Bicolumnar 90-90 plating of distal humerus fractures in elderly patients may represent a viable alternative to traditional ORIF or TEA.

Staged treatment of high energy midfoot fracture dislocations.

BACKGROUND: Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious. METHODS: One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed. RESULTS: The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred. CONCLUSION: Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures.

OBJECTIVES: To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach. DESIGN: Retrospective review. SETTING: Two level one trauma centres. PATIENTS: Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up. INTERVENTION: Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients). MAIN OUTCOME MEASUREMENTS: Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p=0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p<0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p=0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p=0.333). CONCLUSIONS: A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome. LEVEL OF EVIDENCE: Level III.

Open reconstruction of complex proximal metadiaphyseal fragility fractures of the humerus.

PURPOSE: A proactive surgical and rehabilitation protocol was implemented to manage humeral fractures involving both the proximal end and shaft in an older patient population. Primary treatment goals were early return to function and reliable fracture union with minimal complications. METHODS: From 2008 to 2012, 21 such operations were performed; 18 were considered "fragility" fractures based on mechanism, patient age, and evidence of osteopenia or osteoporosis. Open reduction and internal fixation (ORIF) was employed using direct reduction and fixation with a long periarticular locking plate. Physiotherapy was commenced 2 weeks postoperatively. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was used to assess functional outcome at a time point greater than 1 year postoperative. RESULTS: The study group consisted primarily of elderly females (83% with a median age of 69 years) whom sustained complex metadiaphyseal proximal humeral fractures after simple mechanical fall (78%). Uneventful union occurred in all cases. Local complications included 1 case of partial radial nerve palsy, which had resolved completely by 1 year. No cases of infection were identified. Long-term return to functionality was evident with a median DASH score of 12 (mean = 21, standard deviation = 20, n = 13). Seventy five percent of patients reported minimal or no pain (question [Q] 24), and 75% achieved return of overhead function (Q6, 12, and 15). CONCLUSION: Treatment of complex metadiaphyseal fragility fractures with anatomic reduction, fixed angle plating, and early physiotherapy returns the older patient to optimized functionality with minimal risk of complication. The DASH outcomes are equivalent to ORIF of isolated proximal humerus fractures and clinically indistinguishable from the general population.

Treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty implant: span the whole bone.

INTRODUCTION: Periprosthetic femur fractures are a growing problem in the geriatric population. This study examines Vancouver B1 periprosthetic femur fractures treated with open reduction internal fixation using a laterally based plate. Outcomes using plates which spanned the length of the femur to the level of the femoral condyles were compared to those which did not. The hypothesis was that spanning internal fixation would result in a decreased rate of refracture and subsequent reoperation. MATERIALS AND METHODS: Patients admitted to three affiliated academic hospitals treated with open reduction internal fixation for a periprosthetic femur fracture in the setting of a preexisting total hip arthroplasty or hemiarthroplasty stem were identified. Patient data were reviewed for age, gender, fracture classification, operative intervention, time to union, as well as complications related to treatment and need for further surgery. RESULTS: Over a 5-year period, 58 patients were treated with open reduction internal fixation using a laterally based plate for Vancouver B1 femur fractures. Twenty-one patients were treated with plates that extended to the level of the femoral condyles. In that group there were no nonunions or subsequent periprosthetic fractures reported. Of 36 patients treated with short plates, 3 went on to nonunion resulting in plate failure and refracture and 2 sustained a subsequent fracture distal to the existing fixation. CONCLUSIONS: In this series, fixation for periprosthetic femur fractures around a well-fixed arthroplasty stem which spans the length of the femur to the level of the femoral condyles is associated with a decreased rate of nonunion and refracture. By decreasing the rate of refracture and nonunion, spanning fixation decreases the morbidity and mortality associated with additional surgery in a fragile geriatric population.

A paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: single-column plating.

OBJECTIVES: The study aimed (1) to examine if there are equivalent results in terms of union, alignment and elbow functionally comparing single- to dual-column plating of AO/OTA 13A2 and A3 distal humeral fractures and (2) if there are more implant-related complications in patients managed with bicolumnar plating compared to single-column plate fixation. DESIGN: This was a multi-centred retrospective comparative study. SETTING: The study was conducted at two academic level 1 trauma centres. PATIENTS/PARTICIPANTS: A total of 105 patients were identified to have surgical management of extra-articular distal humeral fractures Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 13A2 and AO/OTA 13A3). INTERVENTION: Patients were treated with traditional dual-column plating or a single-column posterolateral small-fragment pre-contoured locking plate used as a neutralisation device with at least five screws in the short distal segment. MAIN OUTCOME MEASUREMENTS: The patients' elbow functionality was assessed in terms of range of motion, union and alignment. In addition, the rate of complications between the groups including radial nerve palsy, implant-related complications (painful prominence and/or ulnar nerve neuritis) and elbow stiffness were compared. RESULTS: Patients treated with single-column plating had similar union rates and alignment. However, single-column plating resulted in a significantly better range of motion with less complications. CONCLUSIONS: The current study suggests that exposure/instrumentation of only the lateral column is a reliable and preferred technique. This technique allows for comparable union rates and alignment with increased elbow functionality and decreased number of complications.

Open supracondylar femur fractures with bone loss in the polytraumatized patient - Timing is everything!

INTRODUCTION: Open supracondylar femur fractures are rare, complex injuries which occur in polytrauma patients and are complicated by bone loss, contamination, compromised soft tissues, and poor host condition. The purpose of this study is to demonstrate a successful treatment protocol for these challenging injuries. METHODS: A consecutive series of 15 open supracondylar femur fractures in 14 polytrauma patients (ages 16-75, mean 41) were treated at one Level I trauma centre by a single surgeon. Fracture patterns included seven AO/OTA Type C2 and eight Type C3 fractures. All fractures were open and classified by Gustillo/Anderson as type IIIA (10 fractures) and type IIIB (five fractures). Stage I was performed within 24h and included thorough open fracture care and early definitive fixation with a laterally based locking device and antibiotic bead placement. Stage II was performed several months later (average 3.6 months) when the soft tissue envelope had revascularized and the polytrauma patient had recovered from their other injuries. Stage II consisted of either an anterior incision or subvastus approach to the distal femur, bone grafting, BMP application, and addition of medial column support to create rigid fixation. RESULTS: All fractures (15/15) healed uneventfully. Union was determined by absence of pain and radiographic union in 3/4 cortices. Mean time to union was 4 months. There were no deep infections and alignment was maintained (average tibiofemoral angel of 5° of valgus) although several limbs were complicated by knee stiffness. CONCLUSIONS: Healing of open supracondylar femur fractures with critical sized bone defects requires diligent surgical timing in order to optimise the host and wound bed. Thorough initial debridement and early definitive fixation halt ongoing soft tissue injury, restores length and alignment, and allow for sterilisation of the wound. After patients have recovered from their other injuries and the soft tissue sleeve has revascularized, bone grafting with BMP supplementation and medial column plating allows for rigid fixation of the femur and offers the biology these fracture patterns require for successful union without infection.

Dysphagia after anterior cervical spine surgery: a prospective study using the swallowing-quality of life questionnaire and analysis of patient comorbidities.

STUDY DESIGN: Prospective study of 29 patients who underwent anterior cervical (AC) or posterior lumbar (PL) spinal surgery. A validated measure of dysphagia, the Swallowing-Quality of Life (SWAL-QOL) survey, was used to assess the degree of postoperative dysphagia. OBJECTIVE: To determine the degree of dysphagia preoperatively and postoperatively in patients undergoing AC surgery compared with a control group that underwent PL surgery. SUMMARY OF BACKGROUND DATA: Dysphagia is a well-known complication of AC spine surgery and has been shown to persist for up to 24 months or longer. METHODS: A total of 18 AC patients and a control group of 11 PL patients were prospectively enrolled in this study and were assessed preoperatively and at 3 weeks and 1.5 years postoperatively using a 14-item questionnaire from the SWAL-QOL survey to determine degree of dysphagia. Other patient factors and anesthesia records were examined to evaluate their relationship to dysphagia. RESULTS: There were no significant differences between the AC and PL groups with respect to age, sex, body mass index, or length of surgery. The SWAL-QOL scores at 3 weeks were significantly lower for the AC group than for the PL group (76 vs. 96; P = 0.001), but there were no differences between the groups preoperatively or at final follow-up. Smokers, patients with chronic obstructive pulmonary disease, and women had lower SWAL-QOL scores at one or more time point. CONCLUSION: Patients undergoing AC surgery had a significant increase in the degree of dysphagia 3 weeks after surgery compared with patients undergoing PL surgery. By final follow-up, swallowing in the AC group recovered to a level similar to preoperative and comparable to that in patients undergoing lumbar surgery at 1.5 years. Smoking, chronic obstructive pulmonary disease, and female sex are possible factors in the development of postoperative dysphagia.

Soft tissue and biomechanical challenges encountered with the management of distal tibia nonunions.

A thoughtful treatment algorithm is required to optimally treat distal tibia nonunion. A healthy respect for the tenuous soft tissue envelope, compromised vascularity, and challenging mechanical environment is advisable. Achieving osseous union and improved functionality requires an individualized plan of care based on the personality of the nonunion and host. Attention must be focused on providing mechanical stability at the site of nonunion and providing biologic supplementation.

External adjuncts to enhance fracture healing: what is the role of ultrasound?

Current methods of fracture care use various adjuncts aimed at decreasing time to fracture union and improving fracture union rates. Among the most commonly used modalities, low-intensity pulsed ultrasound is emerging as a safe, cost-effective and reliable treatment for both fresh fractures and fracture nonunions. Both in vivo and in vitro basic science studies have helped to elucidate potential mechanisms of ultrasound action and a number of prospective, randomised, double-blind, placebo-controlled trials exist demonstrating the clinical efficacy of low-intensity pulsed ultrasound. This article will review the evidence for the use of low-intensity pulsed ultrasound in fracture care.

Efficacy of intraoperative cell saver in decreasing postoperative blood transfusions in instrumented posterior lumbar fusion patients.

STUDY DESIGN: A retrospective study. OBJECTIVE: To determine the efficacy of using intraoperative cell saver in decreasing the need for blood transfusion. SUMMARY OF BACKGROUND DATA: Lumbar spine surgery is associated with potential large intraoperative blood loss, which may put patients at risk for blood transfusions. Preoperative autologous blood donation mitigates the need for allogenic blood transfusion, but does not eliminate it. Cell-saver use has been advocated to further reduce the need for transfusion, but recent reports have called its efficacy into question. METHODS: Data were collected from 188 patients undergoing consecutive instrumented lumbar laminectomy and fusion. One hundred and forty-one of these patients had cell saver used during their procedures, whereas 47 did not. In addition, previously published data from similarly treated patients were used for analysis. Operative blood loss, autologous and allogenic blood transfusions, discharge hematocrit, and patient factors were analyzed. RESULTS: A significant increase in the number of blood transfusions was found in the cell-saver group. The cell-saver group also had a significantly increased blood loss compared with the non-cell-saver group. Using analysis of covariance, we determined the effect of blood loss on the need for transfusion. The results showed that correcting for blood loss eliminated the significance in the transfusion difference, but cell saver still was not able to decrease the transfusion need. Comparing our current results with our previously published results also demonstrated no benefit of cell saver use. CONCLUSION: Use of cell saver in instrumented lumbar fusion cases was not able to decrease the need for blood transfusion. Cell-saver use was associated with a significantly higher blood loss.