RESUMO
BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).
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Anti-Infecciosos Locais , Clorexidina , Fixação de Fratura , Fraturas Ósseas , Iodo , Infecção da Ferida Cirúrgica , Humanos , 2-Propanol/administração & dosagem , 2-Propanol/efeitos adversos , 2-Propanol/uso terapêutico , Anti-Infecciosos Locais/administração & dosagem , Anti-Infecciosos Locais/efeitos adversos , Anti-Infecciosos Locais/uso terapêutico , Antissepsia/métodos , Canadá , Clorexidina/administração & dosagem , Clorexidina/efeitos adversos , Clorexidina/uso terapêutico , Etanol , Extremidades/lesões , Extremidades/microbiologia , Extremidades/cirurgia , Iodo/administração & dosagem , Iodo/efeitos adversos , Iodo/uso terapêutico , Cuidados Pré-Operatórios/efeitos adversos , Cuidados Pré-Operatórios/métodos , Pele/microbiologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Fraturas Ósseas/cirurgia , Estudos Cross-Over , Estados UnidosRESUMO
INTRODUCTION: Acute extremity compartment syndrome ("CS") is an under-researched, highly morbid condition affecting trauma populations. The purpose of this study was to analyze incidence rates and risk factors for extremity compartment syndrome using a high-quality population database. Additionally, we evaluated heritable risk for CS using available genealogic data. We hypothesized that diagnosis of extremity compartment syndrome would demonstrate heritability. MATERIALS AND METHODS: Adult patients with fractures of the tibia, femur, and upper extremity were retrospectively identified by ICD-9, ICD-10, and CPT codes from 1996 to 2020 in a statewide hospital database. Exposed and unexposed cohorts were created based on a diagnosis of CS. Available demographic data were analyzed to determine risk factors for compartment syndrome using logistic regression. Mortality risk at the final follow-up was evaluated using Cox proportional hazard modeling. Patients with a diagnosis of CS were matched with those without a diagnosis for heritability analysis. RESULTS: Of 158,624 fractures, 931 patients were diagnosed with CS. Incidence of CS was 0.59% (tibia 0.83%, femur 0.31%, upper extremity 0.27%). Male sex (78.1% vs. 46.4%; p < 0.001; RR = 3.24), younger age at fracture (38.8 vs. 48.0 years; p < 0.001; RR = 0.74), Medicaid enrollment (13.2% vs. 9.3%; p < 0.001; RR = 1.58), and smoking (41.1% vs. 31.1%; p < 0.001; RR 1.67) were significant risk factors for CS. CS was associated with mortality (RR 1.61, p < 0.001) at mean follow-up 8.9 years in the CS cohort. No significant heritable risk was found for diagnosis of CS. CONCLUSIONS: Without isolating high-risk fractures, rates of CS are lower than previously reported in the literature. Male sex, younger age, smoking, and Medicaid enrollment were independent risk factors for CS. CS increased mortality risk at long-term follow-up. No heritable risk was found for CS. LEVEL OF EVIDENCE: III.
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Síndromes Compartimentais , Fraturas Ósseas , Adulto , Estados Unidos , Humanos , Masculino , Estudos Retrospectivos , Fraturas Ósseas/complicações , Síndromes Compartimentais/epidemiologia , Tíbia , Extremidade SuperiorRESUMO
Synovial fluid was collected from 113 patients who had suffered tibial plateau (n = 48), tibial plafond (n = 29), or rotational ankle fractures (n = 36). Concentrations of IL-1ß, IL-1RA, IL-6, IL-8, IL-10, and MMP-1, -3, and -13 were quantified using multiplex assays. A cluster analysis of synovial fluid biomarker concentrations was performed. Patient demographics, fracture type, Injury Severity Score (ISS), Charlson Comorbidity Index (CCI), and biomarker concentrations were compared between clusters. A subset of patients demonstrated a dysregulated inflammatory response after articular fracture including elevated pro-inflammatory cytokines and degradative enzymes previously linked to the development of post-traumatic osteoarthritis.
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Citocinas , Líquido Sinovial , Biomarcadores , Fenótipo , Extremidade InferiorRESUMO
PURPOSE OF REVIEW: The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities. RECENT FINDINGS: There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.
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Fraturas Ósseas , Idoso , Humanos , Fraturas Ósseas/cirurgia , Extremidade Inferior , Suporte de Carga , Resultado do Tratamento , Fixação Interna de FraturasRESUMO
BACKGROUND: The outcomes of orthopaedic trauma are not solely determined by injury severity or surgical treatment. Studies of numerous orthopaedic outcomes have found that psychosocial factors are also important. Symptoms of anxiety have been linked to long-term pain and disability. Although the existence of a relationship between psychosocial factors and functional outcomes is accepted across multiple disciplines, quantification of this association in patients who have experienced orthopaedic trauma has remained limited. Measuring the anxiety experienced by these individuals and the association with long-term functional outcomes remain poorly understood. QUESTIONS/PURPOSES: (1) Is there an association between early postoperative anxiety symptoms and late recovery of self-reported physical function in patients with orthopaedic trauma? (2) What was the impact of other factors such as demographic variables and comorbidities on late recovery physical function scores, and how did the magnitude of these factors compare with the association with anxiety score? (3) Did patients who presented as trauma activations differ regarding their anxiety symptoms and late-recovery self-reported physical function? METHODS: A total of 1550 patients with lower extremity fractures and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and physical function scores treated between January 1, 2014, and January 1, 2021, at an academic Level I trauma center in North America were assessed. We performed a bivariate regression between the initial PROMIS anxiety and physical function, as well as a multivariate regression including age, gender, BMI, and American Society of Anesthesiologists class to control for potential confounding variables. In a subgroup of 787 patients presenting as trauma activations, we performed a separate regression including Injury Severity Score. RESULTS: PROMIS anxiety was associated with decreased late-recovery physical function (ß = -2.64 [95% CI -3.006 to -2.205]; p < 0.001). The relationship between PROMIS anxiety and physical function remained after controlling for confounding variables in our overall cohort (ß = -2.54 [95% CI -2.93 to -2.15]; p < 0.001) and in the trauma activation cohort (ß = -2.71 [95% CI -3.19 to -2.23]; p < 0.001). Age and American Society of Anesthesiologists score were associated with worse PROMIS physical function scores, while being a man was associated with better PROMIS physical function scores (age: ß= -1.26 [95% CI -1.50 to -1.02]; American Society of Anesthesiologists class: ß=-2.99 [95% CI -3.52 to -2.46]; men: ß = 0.95 [95% CI 0.16 to 1.75]). There were no differences in initial anxiety symptoms or late-recovery physical function between patients who presented as trauma activations and those who did not. Injury Severity Scores were independently associated with worse function (ß = -1.45 [95% CI -2.11 to -0.79]. CONCLUSION: Initial patient self-reported anxiety is negatively associated with patient-reported physical function at the final follow-up interval in a broad cohort of patients with orthopaedic lower extremity injuries undergoing surgery. Identifying patients with high initial PROMIS anxiety scores may allow us to determine which patients will report lower functional scores at the final follow-up. Future investigations could focus on the effect of psychosocial interventions such as cognitive behavioral therapy and mindfulness on functional scores. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Ortopedia , Masculino , Humanos , Ansiedade/diagnóstico , Ansiedade/etiologia , Ansiedade/psicologia , Dor , Autorrelato , Medidas de Resultados Relatados pelo Paciente , Estudos RetrospectivosRESUMO
OBJECTIVES: In patients with rotational ankle fracture, we compare the rate of venous thromboembolism development between patients who received chemoprophylaxis vs those patients that received none. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Between 2014 and 2018, we identified 483 patients with rotational ankle fracture that had no VTE risk factors, were under 70 years of age, and had an isolated injury. INTERVENTION: Chemoprophylaxis vs no chemoprophylaxis after open reduction internal fixation of a rotational ankle fracture. MAIN OUTCOME MEASUREMENTS: Development of VTE was the primary outcome. Secondary outcomes included wound problems, infection, hematoma, or non-union. RESULTS: There were 313 patients that received no prophylaxis and 170 patients that received chemoprophylaxis after operative fixation of an isolated ankle fracture. Demographics including age, gender, body mass index, and ASA class were similar between groups. The rate of DVT/PE was 3.5% in those without DVT prophylaxis, and 4.1% in those on DVT prophylaxis with no significant differences found (p = 0.8). There was no significant difference in wound complication (no VTE prophylaxis-3.7% vs VTE prophylaxis-2.5%, p = 0.7) or infection rates (no VTE prophylaxis-3.8% vs VTE prophylaxis 4.1%, p = 1.0) between groups. CONCLUSIONS: No difference was detected in the rate of symptomatic DVT or PE in patients based on chemoprophylaxis. Our results support the conclusion that the use of chemoprophylaxis may remain surgeon preference and based on patient risk factors for VTE development. LEVEL OF EVIDENCE: Level III-retrospective cohort study.
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Fraturas do Tornozelo , Embolia Pulmonar , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/tratamento farmacológico , Fraturas do Tornozelo/complicações , Embolia Pulmonar/etiologia , Estudos Retrospectivos , Fatores de Risco , Anticoagulantes/uso terapêuticoRESUMO
INTRODUCTION: Distal femur fractures are challenging injuries historically associated with high rates of nonunion and varus collapse with operative management. As a result, clinical and research interest in dual plating (DP) of distal femur fractures has seen a dramatic increase in recent years. The purpose of this study was to systematically review the literature regarding vascular anatomy and biomechanics of distal femur fractures treated with DP constructs. MATERIALS AND METHODS: A systematic literature review of two medical databases (PubMed & Scopus) was performed to identify peer-reviewed studies on the anatomy and biomechanics regarding DP of distal femur fractures. A total of 1,001 papers were evaluated and 14 papers met inclusion criteria (6 anatomy and 8 biomechanics). Methodological quality scores were used to assess quality and potential bias in the included studies. RESULTS: In the biomechanical studies, DP constructs demonstrated greater axial and rotational stiffness, as well as less displacement and fewer incidences of failure compared to all other constructs. Vascular studies showed that the femoral artery crosses the mid-shaft femur approximately 16.0-18.8 cm proximal to the adductor tubercle and it is located on average 16.6-31.1 mm from the femoral shaft at this location, suggesting that medial plate application can be achieved safely in the distal femur. The methodological quality of the included studies was good for biomechanical studies (Traa score 79.1; range 53-92.5) and excellent for anatomical studies (QUACs score 81.9; range 69.0-88.5). CONCLUSIONS: Existing biomechanics literature suggests that DP constructs are mechanically stronger than other constructs commonly used in the treatment of distal femur fractures. Furthermore, medial distal femoral anatomy allows for safe application of DP constructs, even in a minimally invasive fashion. Dual plating should be considered for patients with distal femur fractures that have risk factors for instability, varus collapse, or nonunion.
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Fraturas do Fêmur , Fixação Interna de Fraturas , Fenômenos Biomecânicos , Placas Ósseas , Fraturas do Fêmur/patologia , Fraturas do Fêmur/cirurgia , Fixação Interna de Fraturas/métodos , HumanosRESUMO
BACKGROUND: Precise reduction of a syndesmosis after disruption is critical to improve patient physical function. Intraoperative lateral radiographs of the unaffected ankle are often used in clinical practice as a template for anatomic syndesmotic reduction because sagittal plane malreduction is common. However, there is little data to suggest fibular station, or the position of the fibula in the AP plane on the lateral radiograph, is symmetric side-to-side in patients. QUESTIONS/PURPOSES: (1) Is the position of the fibula in the AP plane (fibular station) on lateral ankle radiographs symmetric in an individual? (2) Do the measurements used to judge the position of the fibula on lateral radiographs have good inter- and intraobserver reliability? METHODS: Over the period from August 2016 to October 2018, we identified 478 patients who presented to an orthopaedic clinic with forefoot and midfoot complaints. Skeletally mature patients with acceptable bilateral lateral ankle radiographs, which are common radiographs obtained for new patients to clinic for any complaint, were included. Based on that, 52% (247 of 478 patients) were included with most (22%, 107 patients) excluded for poor lateral radiographs. The most common diagnosis in the patient cohort was midfoot OA (14%, 35 patients). The median (range) age of the included patients was 54 years (15 to 88), and 65% (159 of 247) of the patients were female. Fibular station, defined as the position of the fibula in the AP plane, and fibular length were measured using a digital ruler and goniometer on lateral radiographs. A paired t-test was used to determine if no difference in fibular station existed between the left and right ankles. With 247 paired-samples, with 80% power and an alpha level of 0.05, we could detect a difference between sides of 0.008 for the posterior ratio, 0.010 for the anterior ratio, and 0.012 for fibular length. Two readers, one fellowship-trained orthopaedic traumatologist and one PGY-4, measured 40 patients to determine the inter- and intraobserver reliability by intraclass correlation coefficient (ICC). RESULTS: The posterior fibular station (mean right 0.147 [σ = 0.056], left 0.145 [σ = 0.054], difference = 0.03 [95% CI 0 to 0.06]; p = 0.59), anterior fibular station (right 0.294 [σ = 0.062], left 0.299 [σ = 0.061], difference = 0.04 [95% CI 0 to 0.08]; p = 0.20), and fibular length (right 0.521 [σ = 0.080], left 0.522 [σ = 0.078], difference = 0.05 [95% CI 0.01 to 0.09]; p = 0.87) ratios did not differ with the numbers available between ankles. Inter- and intraobserver reliability were excellent for the posterior ratio (ICC = 0.928 and ICC = 0.985, respectively) and the anterior ratio (ICC = 0.922 and ICC = 0.929, respectively) and moderate-to-good for the fibular length ratio (ICC = 0.732 and ICC = 0.887, respectively). CONCLUSION: The use of lateral radiographs of the contralateral uninjured ankle appears to be a valid template for determining the position of the fibula in the sagittal plane. However, further prospective studies are required to determine the efficacy of this method in reducing the syndesmosis over other methods that exists. LEVEL OF EVIDENCE: Level III, diagnostic study.
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Pontos de Referência Anatômicos , Traumatismos do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/diagnóstico por imagem , Fíbula/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Traumatismos do Tornozelo/fisiopatologia , Traumatismos do Tornozelo/cirurgia , Articulação do Tornozelo/fisiopatologia , Articulação do Tornozelo/cirurgia , Feminino , Fíbula/fisiopatologia , Fíbula/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Valor Preditivo dos Testes , Radiografia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: The aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement. METHODS: Six patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4±1.9years (range 1.0-6.5). RESULTS: One patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status. CONCLUSION: In the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.
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Articulação do Tornozelo/cirurgia , Artrodese/métodos , Artroplastia de Substituição do Tornozelo/métodos , Calcâneo/cirurgia , Tálus/cirurgia , Tíbia/cirurgia , Idoso , Articulação do Tornozelo/diagnóstico por imagem , Artralgia/cirurgia , Artrodese/efeitos adversos , Calcâneo/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Próteses e Implantes , Reoperação/métodos , Tálus/diagnóstico por imagem , Tíbia/diagnóstico por imagem , Resultado do TratamentoRESUMO
BACKGROUND: Restoring normal femoral rotation is an important consideration when managing femur fractures. Femoral malrotation after fixation is common and several preventive techniques have been described. Use of the lesser trochanter profile is a simple method to prevent malrotation, because the profile changes with femoral rotation, but the accuracy of this method is unclear. QUESTIONS/PURPOSES: The purposes of this study were (1) to report the rotational profiles of uninjured femora in an adult population; and (2) to determine if the lesser trochanter profile was associated with variability in femoral rotation. METHODS: One hundred fifty-five consecutive patients (72% female and 28% male) with a mean age of 32 years (range, 12-56 years) with a CT scanogram were retrospectively evaluated. Patients were included if CT scanograms had adequate cuts of the proximal and distal femur. Patients were excluded if they had prior hip/femur surgery or anatomic abnormalities of the proximal femur. CT scanogram measurements of femoral rotation were compared with the lesser trochanter profile (distance from the tip of the lesser trochanter to the medial cortex of the femur) measured on weightbearing AP radiographs. These measurements were made by a single fellowship-trained orthopaedic surgeon and repeated for intraobserver reliability testing. Presence of rotational differences based on sex and laterality was assessed and correlation of the difference in lesser trochanter profile to the difference in femoral rotation was determined using a coefficient of determination (r). RESULTS: The mean femoral rotation was 10.9° (SD ± 8.8°) of anteversion. Mean right femoral rotation was 11.0° (SD ± 8.9°) and mean left femoral rotation was 10.7° (SD ± 8.7°) with a mean difference of 0.3° (95% confidence interval [CI], -1.7° to 2.3°; p = 0.76). Males had a mean rotation of 9.4°(SD ± 7.7°) and females had a mean rotation of 11.5° (SD ± 9.1°) with a mean difference of 2.1° (95% CI, -0.1° to 4.3°; p = 0.06). Mean lesser trochanter profile was 6.6 mm (SD ± 4.0 mm). Mean right lesser trochanter profile was 6.6 mm (SD ± 3.9 mm) and mean left lesser trochanter profile was 6.5 mm (SD ± 4.0 mm) with a mean difference of 0.1 mm (-0.8 mm to 1.0 mm, p = 0.86). The lesser trochanter profile varied between the sexes; males had a mean of 8.3 mm (SD ± 3.4), and females had a mean of 5.9 mm (SD ± 4.0). The mean difference between sexes was 2.5 mm (1.5-3.4 mm; p < 0.001). The magnitude of the lesser trochanter profile measurement and degree of femoral rotation were positively correlated such that increasing measures of the lesser trochanter profile were associated with increasing amounts of femoral anteversion. The lesser trochanter profile was associated with femoral version in a linear regression model (r = 0.64; p < 0.001). Thus, 64% of the difference in femoral rotation can be explained by the difference in the lesser trochanter profile. Intraobserver reliability for both the femoral version and lesser trochanter profile was noted to be excellent with intraclass correlation coefficients of 0.94 and 0.95, respectively. CONCLUSIONS: This study helps define the normal femoral rotation profile among adults without femoral injury or bone deformity and demonstrated no rotational differences between sexes. The lesser trochanter profile was found to be positively associated with femoral rotation. Increasing and decreasing lesser trochanter profile measurements are associated with increasing and decreasing amounts of femoral rotation, respectively. CLINICAL RELEVANCE: The lesser trochanter profile can determine the position of the femur in both anteversion and retroversion, supporting its use as a method to restore preinjury femoral rotation after fracture fixation. Although some variability in the rotation between sides may exist, matching the lesser trochanter profile between injured and uninjured femora can help reestablish native rotation.
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Fraturas do Fêmur/fisiopatologia , Fêmur/fisiopatologia , Fixação de Fratura , Recuperação de Função Fisiológica , Rotação , Adolescente , Adulto , Fenômenos Biomecânicos , Criança , Feminino , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/cirurgia , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Reprodutibilidade dos Testes , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: In patients with painful ankle arthrodesis, the surgical treatment is challenging, and may include takedown of ankle arthrodesis and conversion to a total ankle replacement (TAR). This procedure is technically demanding given the altered anatomy after arthrodesis. Few studies have evaluated TAR in the setting of prior arthrodesis. QUESTIONS/PURPOSES: (1) What intraoperative and perioperative complications were observed in patients who underwent conversion of an ankle arthrodesis to a TAR? (2) Was durable fixation achieved at short term, and what was the alignment of the components? (3) What subsequent surgical procedures were performed, including revisions? (4) What improvements were observed in pain, tibiotalar range of motion (ROM), and quality of life? METHODS: Between January 2007 and December 2014, 18 patients with a painful ankle arthrodesis underwent conversion to TAR at our tertiary referral center. During this period, the indications for conversion of ankle arthrodesis to TAR were tibiotalar nonunion or malunion after attempted arthrodesis in patients who declined revision ankle arthrodesis. The goal of revision surgery was to help patients regain hindfoot mobility and to decrease pain. During the study period, all patients who met indications were treated with a conversion procedure. Of the 18 patients included, 14 were men and four were women. The mean age of the patients was 51 ± 7 years. The mean followup was 54 ± 27 months, with no loss to follow up observed. The initial ankle arthrodesis was performed 6 ± 3.5 years before conversion to TAR. In all patients, the conversion to TAR was performed using a nonconstrained cementless three-component prosthesis. Intraoperative and postoperative complications, revision procedures, and prosthesis component loosening were evaluated. Weightbearing radiographs were used to determine the angular alignment of the tibial and talar components using α/ß/γ angles and to analyze the bone-implant interface. Osseointegration was defined as visible trabecular structures at the bone-implant interface without radiolucent lines. The criteria for radiographic loosening was defined as subsidence or migration of prosthesis components and/or a cystic lesion with a diameter at least 2 mm. Clinical assessment included pain evaluation, measurement of ankle ROM, and quality of life. RESULTS: Two of the 18 patients sustained an intraoperative medial malleolar fracture. In three patients, delayed wound healing was observed. At latest followup, four patients had incomplete osseointegration (posterior quarter of the bone-prosthesis interface on the tibial side). None of the 18 patients had prosthesis loosening. In all patients, both components were neutrally aligned. Two patients had painful arthrofibrosis with reduced ROM, which we treated with an open arthrolysis and exchange of mobile-bearing inlay; one other patient is considering a revision for substantial tibial component medial tilt with collapse of the medial arch. At the latest followup, the mean dorsiflexion and plantar flexion were 8.5° ± 3° and 15° ± 5°, respectively. The mean visual analog scale (VAS) score decreased from 9 ± 0.8 to 1.7 ± 1.6 (p < 0.001). The Short Form Health Survey questionnaire (SF-36) physical and mental outcome scores improved from 34 ± 5 to 74 ± 11 (p < 0.001) and from 49 ± 4 to 75.5 ± 7 (p < 0.001). CONCLUSIONS: Conversion of an ankle arthrodesis to a TAR is a technically challenging procedure. In this small series, it was associated with frequent complications including arthrofibrosis, and functional outcomes including postoperative ROM were lower than reported for primary TAR. However, pain and function did improve. Further studies are necessary to address long-term clinical and radiographic outcomes in this patient cohort. LEVEL OF EVIDENCE: Level IV, therapeutic study.
Assuntos
Artrodese/métodos , Artroplastia de Substituição do Tornozelo/métodos , Prótese Articular , Desenho de Prótese , Reoperação/métodos , Adulto , Idoso , Articulação do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/cirurgia , Artralgia/etiologia , Artrodese/efeitos adversos , Artroplastia de Substituição do Tornozelo/efeitos adversos , Interface Osso-Implante/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Complicações Pós-Operatórias/etiologia , Falha de Prótese , Radiografia , Amplitude de Movimento Articular , Reoperação/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Suporte de CargaRESUMO
OBJECTIVES: To assess trends in Patient-Reported Outcome Measurement Information Systems (PROMIS) Physical Function (PF) and Pain Interference (PI) in surgically treated tibial shaft fracture patients progressing to union versus nonunion. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients with operatively treated tibial shaft fractures (AO/OTA 42-A, B, C) using an intramedullary nail. OUTCOME MEASURES AND COMPARISONS: PROMIS PF and PI were compared between patients progressing to union and patients requiring nonunion repair. RESULTS: A total of 234 patients (196 union, 38 nonunion) were included consisting 144 men and 90 women. The mean age of included patients was 40.8 years. A significant difference in mean PROMIS PF between union and nonunion patients was observed at 1-3 months ( P = 0.005), 3-6 months ( P < 0.001), 6-9 months ( P = 0.003), and 6-12 months ( P = 0.018). The odds of developing nonunion for every unit decrease in PROMIS PF was significant at 3-6 months (OR 1.07, P = 0.028) and 6-9 months (OR 1.17, P = 0.015). A significant difference in mean PROMIS PI between union and nonunion patients was observed at 1-3 months ( P = 0.001), 3-6 months ( P = 0.005), and 6-9 months ( P = 0.005). The odds of developing nonunion for every unit increase in PROMIS PI was significant at 1-3 months (OR 1.11, P = 0.005), 3-6 months (OR 1.10, P = 0.011), and 6-9 months (OR 1.23, P = 0.011). CONCLUSIONS: Poorly trending PROMIS PF and PI in the clinical setting is a factor that can be used to evaluate progression to nonunion following tibial shaft repair where imaging studies may lag behind. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fixação Intramedular de Fraturas , Fraturas não Consolidadas , Medidas de Resultados Relatados pelo Paciente , Fraturas da Tíbia , Humanos , Fraturas da Tíbia/cirurgia , Fixação Intramedular de Fraturas/métodos , Fixação Intramedular de Fraturas/efeitos adversos , Feminino , Masculino , Adulto , Fraturas não Consolidadas/cirurgia , Estudos Retrospectivos , Pessoa de Meia-Idade , Medição da Dor , Consolidação da Fratura , Estudos de CoortesRESUMO
Objective: To investigate current practices among orthopaedic trauma surgeons in treating geriatric distal femur fractures and evaluate current postoperative weight-bearing recommendations. Methods: A 26-question survey was emailed to Major Extremity Trauma Research Consortium surgeon members to characterize current practice with different fixation methods for distal femur fractures and the surgeon-directed postoperative weight-bearing recommendations for each approach. Results: Surveys were completed by 123 orthopaedic trauma surgeons with a response rate of 37% (123/332). Retrograde intramedullary nailing (IMN) was commonly performed by 88% of surgeons, and lateral locked plate was commonly performed by 74% of surgeons. Retrograde IMN with a lateral plate was commonly performed by 51% of surgeons. Dual femoral plating was commonly performed by 18% of surgeons and sometimes performed by 39% of surgeons. Surgeons were significantly more likely to allow immediate postoperative weight-bearing for retrograde IMN (P < 0.001), retrograde IMN with lateral plate (P < 0.001), and dual plate (P < 0.001) as compared with locked lateral plate. Most surgeons (79%) would be interested in participating in a randomized controlled trial (RCT) investigating single implant versus dual implant for distal femur fractures and believe that a trial incorporating immediate weight-bearing is important. Conclusion: A variety of implants are commonly used to treat geriatric distal femur fractures. Patients with distal femur fracture commonly have weight-bearing restrictions in the immediate postoperative period. A large proportion of orthopaedic trauma surgeons have clinical equipoise for an RCT to investigate the impact of surgical construct and weight-bearing on geriatric distal femur fracture patient recovery.
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OBJECTIVES: Evaluate whether intraoperatively repaired lateral meniscus injuries impact midterm patient-reported outcomes in those undergoing operative fixation of tibial plateau fracture. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENT SELECTION CRITERIA: All patients (n = 207) who underwent operative fixation of a tibial plateau fracture from 2016 to 2021 with a minimum of 10-month follow-up. OUTCOME MEASURES AND COMPARISONS: The Patient-Reported Outcomes Measurement Information System Physical Function, Knee Injury and Osteoarthritis Outcome Score, and the PROMIS-Preference health utility score. RESULTS: Overall, 207 patients were included with average follow-up of 2.9 years. Seventy-three patients (35%) underwent intraoperative lateral meniscus repair. Gender, age, body mass index, Charlson comorbidity index, days to surgery, ligamentous knee injury, open fracture, vascular injury, polytraumatic injuries, Schatzker classification, and Orthopaedic Trauma Association classification were not associated with meniscal repair ( P > 0.05). Rates of reoperation (42% vs. 31%, P = 0.11), infection (8% vs. 10%, P = 0.60), return to work (78% vs. 75%, P = 0.73), and subsequent total knee arthroplasty (8% vs. 5%, P = 0.39) were also similar between those who had a meniscal repair and those without a meniscal injury, respectively. There was no difference in Patient-Reported Outcomes Measurement Information System Physical Function (46.3 vs. 45.8, P = 0.707), PROMIS-Preference (0.51 vs. 0.50, P = 0.729), and all Knee Injury and Osteoarthritis Outcome Score domain scores at the final follow-up between those who had a meniscal repair and those without a meniscal injury, respectively. CONCLUSIONS: In patients with an operatively treated tibial plateau fracture, the presence of a concomitant intraoperatively identified and repaired lateral meniscal tear results in similar midterm PROMs and complication rates when compared with patients without meniscal injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Traumatismos do Joelho , Menisco , Osteoartrite , Fraturas da Tíbia , Fraturas do Planalto Tibial , Humanos , Estudos Retrospectivos , Meniscos Tibiais/cirurgia , Traumatismos do Joelho/cirurgia , Traumatismos do Joelho/complicações , Fraturas da Tíbia/complicações , Medidas de Resultados Relatados pelo PacienteRESUMO
BACKGROUND: The sustentaculum tali is a biomechanically important stabilizer of the hindfoot and contributes to articular congruency of the subtalar joint. Sustentaculum injury associated with a talus fracture has been described infrequently and treatment of this combined injury varies. The purpose of this study was to describe and evaluate the outcomes of the combined talus and sustentaculum fracture. METHODS: Retrospective chart and radiographic review was performed on all talus fractures (n = 436) requiring operative fixation over a 21-year period at a single Level-1 trauma center. All talus fractures with sustentaculum fractures were included. Statistical analysis was performed using Chi-squared and Fishers exact tests where appropriate. RESULTS: Sustentaculum fractures occurred in 6.2 % (n = 27) of patients with talus fractures. Average follow-up was 14 months; 18.5 % were open fractures, 88.8 % were from high-energy mechanisms, and 44.4 % were polytraumas. Diagnosis of the sustentaculum fracture was missed on presenting radiographs in 69.2 % (n = 18). The most common associated talus fracture was a talar neck fracture (40.7 %) and the majority (73.7 %) were Hawkins II. Overall, 40.7 % (n = 11) of the sustentaculum fractures were treated with independent fixation and 7.4 % (n = 2) were treated with acute subtalar arthrodesis. Subtalar post-traumatic osteoarthritis (PTOA) at final follow-up was seen in 23.1 % of combined injuries. Independent sustentaculum fixation did not influence the rate of PTOA or re-operation (p = 0.92, p = 0.91, respectively). CONCLUSION: Talar fractures have an associated sustentaculum fracture in approximately 6 % of cases, especially with Hawkins II fracture-dislocations. Over two-thirds of the associated sustentaculum fractures were missed on presenting radiographs, reiterating the need for heightened awareness and consideration of advanced imaging for all talus fractures. The rate of PTOA following these combined injuries at mean follow-up of 24 months does not exceed established rates after isolated talus fractures. Further research is required to determine the optimal management of the sustentaculum in these combined injuries. LEVEL OF EVIDENCE: IV.
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Background: Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse. Description: Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed. Alternatives: Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace1. There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate. Rationale: Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength2,3. Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone4-7. Adjunctive use of a medial plate also has been suggested to prevent varus collapse, particularly with metaphyseal comminution and poor bone quality2,3,8. Finally, in the periprosthetic fracture population, dual plating also removes the concern of incompatibility with a retrograde nail. Expected Outcomes: The outcomes of dual plating are promising, given the severity of the injury. When comparing operative to nonoperative treatment outcomes, nonoperatively managed patients had worse functional outcomes and higher rates of complications related to immobility1. Dual plating of supracondylar fractures and intra-articular distal femoral fractures yields nonunion rates ranging from 0% to 12.5%, lower than the 18% to 20% reported with lateral locking plates4-7,9-12. This reduction in nonunions has been shown to lead to fewer revisions when compared with single-plating techniques7. In prior studies, 95% of nonunions treated with the dual-plating technique achieved union postoperatively11. One concern when utilizing the medial approach is critical damage to medial vascularity; however, this result has not been reported in the literature, and there is a safe operating window13. Despite the benefits of dual plating, there are relatively high rates of infection following dual plating (0% to 16.7%) compared with lateral plating alone (3.6% to 8.5%)5,14-17. However, many of these studies are small case series, highlighting that a surgeon's comfort and skill with these procedures is paramount to patient outcomes. Important Tips: Meticulous placement and contouring of lateral and medial plates are required to prevent malreduction of the articular block that creates a "golf-club deformity."18,19During the medial approach, be aware of descending geniculate artery-particularly its muscular branch, which is â¼5 cm from the adductor tubercle/medial epicondyle, and its root, which enters the compartment at the adductor hiatus at â¼16 cm13.
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SUMMARY: Tibial plateau fractures with severely displaced articular injuries and significant deformity to the surrounding metaphyseal bone (including the hyperextension varus bicondylar pattern) can be challenging to stabilize due to resulting large bone voids uncontained by metaphyseal cortex. The purpose of this report was to describe a technique to support the plateau articular surface in these cases and report on outcomes of a small series. This technique uses a small or mini fragment plate, contoured to function as an intraosseous shelf plate, with the "shelf" portion inserted into the bone beneath the articular surface to support it. This technique provides fixed-angle support to the fragment. There are some advantages of this technique compared to structural allograft, large volume ceramic bone void filler, a spine cage, or other trabecular metal object, including the ability to remove the plate later, ability to tension the plate against the depressed articular surface, ability to place screws or other allograft near the implant, wide availability of the implant, and familiarity of orthopaedic trauma surgeons with placing plates and screws to hold reductions. The technique is particularly useful in patterns with uncontained articular depression and a large metaphyseal void.
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Placas Ósseas , Fixação Interna de Fraturas , Fraturas da Tíbia , Humanos , Fraturas da Tíbia/cirurgia , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/instrumentação , Masculino , Pessoa de Meia-Idade , Feminino , Adulto , Resultado do Tratamento , Idoso , Adulto Jovem , Fraturas do Planalto TibialRESUMO
OBJECTIVES: Compare patient-reported outcome measures between hyperextension varus tibial plateau (HEVTP) fracture patterns to non-HEVTP fracture patterns. DESIGN: Retrospective study. SETTING: Single academic Level 1 Trauma Center. PATIENT SELECTION CRITERIA: All patients who underwent fixation of a tibial plateau fracture from 2016 to 2021 were collected. Exclusion criteria included inaccurate Current Procedural Terminology code, ipsilateral compartment syndrome, bilateral fractures, incomplete medical records, or follow-up <10 months. OUTCOME MEASURES AND COMPARISONS: In patients who underwent fixation of a tibial plateau fracture, compare Patient-Reported Outcomes Measurement Information System-Physical Function, PROMIS Preference, and Knee Injury and Osteoarthritis Outcome Score (KOOS) between patients with a HEVTP pattern with those without. RESULTS: Two-hundred and seven patients were included, of which 17 (8%) had HEVTP fractures. Compared with non-HEVTP fracture patterns, patients with HEVTP injuries were younger (42.6 vs. 51.0, P = 0.025), more commonly male (71% vs. 44%, P = 0.033), and had higher body mass index (32.8 vs. 28.0, P = 0.05). HEVTP fractures had significantly more ligamentous knee (29% vs. 6%, P = 0.007) and vascular (12% vs. 1%, P = 0.035) injuries. Patient-Reported Outcomes Measurement Information System-Physical Function scores were similar between groups; however, PROMIS-Preference (0.37 vs. 0.51, P = 0.017) was significantly lower in HEVTP fractures. KOOS pain, activities of daily living, and quality-of-life scores were statistically lower in HEVTP fractures, but only KOOS quality-of-life was clinically relevant (41.7 vs. 59.3, P = 0.004). CONCLUSIONS: The HEVTP fracture pattern, whether unicondylar or bicondylar, was associated with a higher rate of ligamentous and vascular injuries compared with non-HEVTP fracture patterns. They were also associated with worse health-related quality of life at midterm follow-up. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fraturas da Tíbia , Fraturas do Planalto Tibial , Humanos , Masculino , Estudos Retrospectivos , Fixação Interna de Fraturas/efeitos adversos , Qualidade de Vida , Atividades Cotidianas , Fraturas da Tíbia/complicações , Resultado do TratamentoRESUMO
OBJECTIVES: To determine the postoperative trajectory and recovery of patients who undergo Lisfranc open reduction and internal fixation using Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI). DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients who underwent Lisfranc open reduction and internal fixation between January 2002 and December 2022 with documented PROMIS PF and/or PI scores after surgery. OUTCOME MEASURES AND COMPARISONS: PROMIS PF and PI were mapped over time up to 1 year after surgery. A subanalysis was performed to compare recovery trajectories between high-energy and low-energy injuries. RESULTS: A total of 182 patients were included with average age of 38.7 (SD 15.9) years (59 high-energy and 122 low-energy injuries). PROMIS PF scores at 0, 6, 12, 24, and 48 weeks were 30.2, 31.4, 39.2, 43.9, and 46.7, respectively. There was significant improvement in PROMIS PF between 6 and 12 weeks ( P < 0.001), 12-24 weeks ( P < 0.001), and 24-48 weeks ( P = 0.022). A significant difference in PROMIS PF between high and low-energy injuries was seen at 0 week (28.4 vs. 31.4, P = 0.010). PROMIS PI scores at 0, 6, 12, 24, and 48 weeks were 62.2, 58.5, 56.6, 55.7, and 55.6, respectively. There was significant improvement in PROMIS PI 0-6 weeks ( P = 0.016). A significant difference in PROMIS PI between high-energy and low-energy injuries was seen at 48 weeks with scores of (58.6 vs. 54.2, P = 0.044). CONCLUSIONS: After Lisfranc open reduction and internal fixation, patients can expect improvement in PF up to 1 year after surgery, with the biggest improvement in PROMIS PF scores between 6 and 12 weeks and PROMIS PI scores between 0 and 6 weeks after surgery. Regardless the energy type, Lisfranc injuries seem to regain comparable PF by 6-12 months after surgery. However, patients with higher energy Lisfranc injuries should be counseled that these injuries may lead to worse PI at 1 year after surgery as compared with lower energy injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Avaliação de Resultados em Cuidados de Saúde , Medidas de Resultados Relatados pelo Paciente , Humanos , Adulto , Estudos Retrospectivos , Prognóstico , DorRESUMO
OBJECTIVES: To quantify how patients with lateral compression type 1 (LC1) pelvis fracture value attributes of operative versus nonoperative treatment. DESIGN: Discrete choice experiment. SETTING: Three US Level 1 trauma centers. PATIENT SELECTION CRITERIA: Adult survivors of an LC1 pelvis treated between June 2016 and March 2023 were identified from institutional registries. The choice experiment was administered as a survey from March through August 2023. OUTCOME MEASURES AND COMPARISONS: Participants chose between 12 hypothetical comparisons of treatment attributes including operative or nonoperative care, risk of death, severity of pain, risk of secondary surgery, shorter hospital stay, discharge destination, and independence in ambulation within 1 month of injury. The marginal utility of each treatment attribute, for example, the strength of participants' aggregate preference for an attribute as indicated by their survey choices, was estimated by multinomial logit modeling with and without stratification by treatment received. RESULTS: Four hundred forty-nine eligible patients were identified. The survey was distributed to 182 patients and collected from 72 patients (39%) at a median 2.3 years after injury. Respondents were 66% female with a median age of 59 years (IQR, 34-69 years). Before injury, 94% ambulated independently and 75% were working; 41% received operative treatment. Independence with ambulation provided the highest relative marginal utility (21%, P < 0.001), followed by discharge to home versus skilled nursing (20%, P < 0.001), moderate versus severe postdischarge pain (17%, P < 0.001), shorter hospital stay (16%, P < 0.001), secondary surgery (15%, P < 0.001), and mortality (10%, P = 0.02). Overall, no relative utility for operative versus nonoperative treatment was observed (2%, P = 0.54). However, respondents strongly preferred the treatment they received: operative patients valued operative treatment (utility, 0.37 vs. -0.37, P < 0.001); nonoperative patients valued nonoperative treatment (utility, 0.19 vs. -0.19, P < 0.001). CONCLUSIONS: LC1 pelvis fracture patients valued independence with ambulation, shorter hospital stay, and avoiding secondary surgery and mortality in the month after their injury. Patients preferred the treatment they received rather than operative versus nonoperative care.