Skin Antisepsis before Surgical Fixation of Extremity Fractures.

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.).

Introducing lifestyle medicine into family medicine: Theory and applications.

"Lifestyle medicine (LM) is an evidence-based therapeutic intervention delivered by clinicians trained and certified in this specialty to prevent, treat, and often reverse chronic disease". Eighty percent of the conditions primary care physicians routinely encounter in their offices, e.g., diabetes mellitus, hypertension, COPD, cardiovascular disease, have root causes in poor lifestyle choices, e.g., smoking, insufficient sleep, being sedentary, eating highly processed foods. Lifestyle is the foundation of most chronic disease management guidelines aimed at reducing morbidity and mortality. Studies have shown that changes in lifestyle can be achieved and the changes link almost directly to reduction in risk for chronic illness. Primary care physicians are ideally positioned to incorporate LM into their practices. It is important to recognize and find solutions to the many barriers to implementing LM from the patient, physician, and system level. There is an urgent need to increase opportunities for practicing physicians to increase their knowledge and skills related to LM and include this in medical school and residency curricula. Many resources exist that can provide the necessary training to seasoned physicians and students/residents to become competent in practicing LM and address barriers to implementing LM. LM has the potential to revolutionize clinical practice by placing a greater emphasis on disease prevention and the role of healthy lifestyle behaviors in disease management and remission.

Assessment of sacral osseous fixation pathways for same-level dual transiliac-transsacral screw insertion.

INTRODUCTION: The purpose of this study is to (1) describe a pre-operative planning technique using non-reformatted CT images for insertion of multiple transiliac-transsacral (TI-TS) screws at a single sacral level, (2) define the parameters of a sacral osseous fixation pathway (OFP) that will allow for insertion of two TI-TS screws at a single level, and (3) identify the incidence of sacral OFPs large enough for dual-screw insertion in a representative patient population. METHODS: Retrospective review at a level-1 academic trauma center of a cohort of patients with unstable pelvic injuries treated with two TI-TS screws in the same sacral OFP, and a control cohort of patients without pelvic injuries who had CT scans for other reasons. RESULTS: Thirty-nine patients had two TI-TS screws at S1. Eleven patients, all with dysmorphic osteology, had two TI-TS screws at S2. The average pathway size in the sagittal plane at the level the screws were placed was 17.2 mm in S1 vs 14.4 mm in S2 (p = 0.02). Twenty-one patients (42%) had screws that were intraosseous and 29 (58%) had part of a screw that was juxtaforaminal. No screws were extraosseous. The average OFP size of intraosseous screws was 18.1 mm vs. 15.5 mm for juxtaforaminal screws (p = 0.02). Fourteen millimeters was used as a guide for the lower limit of the OFP for safe dual-screw fixation. Overall, 30% of S1 or S2 pathways were ≥ 14 mm in the control group, with 58% of control patients having at least one of the S1 or S2 pathways ≥ 14 mm. CONCLUSIONS: OFPs ≥ 7.5 mm in the axial plane and 14 mm in the sagittal plane on non-reformatted CT images are large enough for dual-screw fixation at a single sacral level. Overall, 30% of S1 and S2 pathways were ≥ 14 mm and 58% of control patients had an available OFP in at least one sacral level.

A Randomized Trial of Preoperative Practice in a Simulated Operative Environment: 3D Printed Pilon Model Improves Resident Performance.

This study assessed the effect of preoperative planning using a 3D-printed periarticular fracture model on operative performance. A complex pilon fracture was 3D-printed, and a preoperative plan was developed. Orthopaedic surgery residents (n = 20) were randomized into two groups. Group 1 performed routine preoperative planning, while Group 2 was also practiced using a 3D-printed construct before performing fixation of the 3D-printed model. Resident performance was assessed using a video motion capture system and evaluated by blinded reviewers. Three residents (3D group) completed fixation within the allotted 45 minutes. The 3D group had less hand distance traveled for step 1 (89 m vs. 162 m, p = 0.04). The 3D group had better performance on three of the four components and more acceptable reductions (6 vs. 0, p = 0.009). Average global rating scale was higher in the 3D group (3.0 vs. 1.7, p = 0.0095). Use of 3D-printed models for preoperative planning improved resident performance. (Journal of Surgical Orthopaedic Advances 31(3):187-192, 2022).

Opioid Prescribing Risk Factors in Nonoperative Ankle Fractures: The Impact of a Prospective Clinical Decision Support Intervention.

Opioids are frequently used for acute pain management of musculoskeletal injuries, which can lead to misuse and abuse. This study aimed to identify the opioid prescribing rate for ankle fractures treated nonoperatively in the ambulatory and emergency department setting across a single healthcare system and to identify patients considered at high risk for abuse, misuse, or diversion of prescription opioids that received an opioid. A retrospective cohort study was performed at a large healthcare system. The case list included nonoperatively treated emergency department, urgent care and outpatient clinic visits for ankle fracture and was merged with the Prescription Reporting With Immediate Medication Mapping (PRIMUM) database to identify encounters with prescription for opioids. Descriptive statistics characterize patient demographics, treatment location and prescriber type. Rates of prescribing among subgroups were calculated. There were 1,324 patient encounters identified, of which, 630 (47.6%) received a prescription opioid. The majority of patients were 18-64 years old (60.3%). Patients within this age range were more likely to receive an opioid prescription compared to other age groups (p < .0001). Patients treated in the emergency department were significantly more likely to receive an opioid medication (68.3%) compared to patients treated at urgent care (33.7%) or in the ambulatory setting (16.4%) (p < .0001). Utilizing the PRIMUM tool, 14.2% of prescriptions were provided to patients with at least one risk factor. Despite the recent emphasis on opioid stewardship, 14.2% of patients with risk factors for misuse, abuse, or diversion received opioid analgesics in this study, identifying an area of improvement for prescribers.

Are Orthopaedic Trauma Surgeons Appropriately Compensated for Treating Acetabular Fractures? An Analysis of Operative Times and Relative Value Units.

OBJECTIVES: To evaluate the work relative value units (RVUs) attributed per minute of operative time (wRVU/min) in fixation of acetabular fractures, evaluate surgical factors that influence wRVU/min, and compare wRVU/min with other procedures. DESIGN: Retrospective. SETTING: Level 1 academic center. PATIENT SELECTION CRITERIA: Two hundred fifty-one operative acetabular fractures (62 A, B, C) from 2015 to 2021. OUTCOME MEASURES AND COMPARISONS: Work relative value unit per minute of operative time for each acetabular current procedural terminology (CPT) code. Surgical approach, patient positioning, total room time, and surgeon experience were collected. Comparison wRVU/min were collected from the literature. RESULTS: The mean wRVU per surgical minute for each CPT code was (1) CPT 27226 (isolated wall fracture): 0.091 wRVU/min, (2) CPT 27227 (isolated column or transverse fracture): 0.120 wRVU/min, and (3) CPT 27228 (associated fracture types): 0.120 wRVU/min. Of fractures with single approaches, anterior approaches generated the least wRVU/min (0.091 wRVU/min, P = 0.0001). Average nonsurgical room time was 82.1 minutes. Surgeon experience ranged from 3 to 26 years with operative time decreasing as surgeon experience increased ( P = 0.03). As a comparison, the wRVU/min for primary and revision hip arthroplasty have been reported as 0.26 and 0.249 wRVU/min, respectively. CONCLUSIONS: The wRVUs allocated per minute of operative time for acetabular fractures is less than half of other reported hip procedures and lowest for isolated wall fractures. There was a significant amount of nonsurgical room time that should be accounted for in compensation models. This information should be used to ensure that orthopaedic trauma surgeons are being appropriately supported for managing these fractures. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patients with glenohumeral arthritis are more likely to be prescribed opioids in the emergency department or urgent care setting.

OBJECTIVE: The objective is to quantify the rate of opioid and benzodiazepine prescribing for the diagnosis of shoulder osteoarthritis across a large healthcare system and to describe the impact of a clinical decision support intervention on prescribing patterns. DESIGN: A prospective observational study. SETTING: One large healthcare system. PATIENTS AND PARTICIPANTS: Adult patients presenting with shoulder osteoarthritis. INTERVENTIONS: A clinical decision support intervention that presents an alert to prescribers when patients meet criteria for increased risk of opioid use disorder. MAIN OUTCOME MEASURE: The percentage of patients receiving an opioid or benzodiazepine, the percentage who had at least one risk factor for misuse, and the percent of encounters in which the prescribing decision was influenced by the alert were the main outcome measures. RESULTS: A total of 5,380 outpatient encounters with a diagnosis of shoulder osteoarthritis were included. Twenty-nine percent (n = 1,548) of these encounters resulted in an opioid or benzodiazepine prescription. One-third of those who received a prescription had at least one risk factor for prescription misuse. Patients were more likely to receive opioids from the emergency department or urgent care facilities (40 percent of encounters) compared to outpatient facilities (28 percent) (p < .0001). Forty-four percent of the opioid prescriptions were for "potent opioids" (morphine milliequivalent conversion factor > 1). Of the 612 encounters triggering an alert, the prescribing decision was influenced (modified or not prescribed) in 53 encounters (8.7 percent). All but four (0.65 percent) of these encounters resulted in an opioid prescription. CONCLUSION: Despite evidence against routine opioid use for osteoarthritis, one-third of patients with a primary diagnosis of glenohumeral osteoarthritis received an opioid prescription. Of those who received a prescription, over one-third had a risk factor for opioid misuse. An electronic clinic decision support tool influenced the prescription in less than 10 percent of encounters.

Comparative study of short forms of the Tampa Scale for Kinesiophobia: fear of movement in a surgical spine population.

OBJECTIVE: To compare the factor structure of 6 short forms of the Tampa Scale for Kinesiophobia (TSK) by means of confirmatory factor analysis in patients after spinal surgery for degenerative conditions. DESIGN: A cross-sectional survey study. SETTING: University-based surgical clinic. PARTICIPANTS: Adults (N=137) treated by spinal surgery for a degenerative condition (ie, spinal stenosis, spondylosis with or without myelopathy, and spondylolisthesis). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Patients completed the TSK within 3 months of hospital discharge. RESULTS: Confirmatory factor analysis demonstrated that the 2-factor models of the TSK-13 and TSK-11 had a reasonable fit for the data, with internal consistency values >.70. A 1-factor TSK-4 (items 3, 6, 7, and 11) demonstrated an excellent fit for the data, but an adequate internal consistency was not maintained. A poor fit was noted for the 1-factor models of the TSK-13 and TSK-11, and a 4-item TSK (items 1, 2, 9, and 11). CONCLUSIONS: The current study provides further evidence that specific short-form versions of the TSK may be useful for assessing fear of movement in surgical populations. Results support the measurement of fear of movement using the 2-factor, 13- and 11-item versions of the TSK in patients after spinal surgery. A TSK-4 (items 3, 6, 7, and 11) offers a promising alternative to the TSK-13 and TSK-11. However, further research is needed to test the validity and reliability of the TSK-4 in patients undergoing spinal surgery in order to support its use in a clinical environment. Researchers and clinicians interested in a shorter measure of fear of movement should consider using the TSK-11.

Nonoperative Treatment of Select Lateral Compression Type II Pelvic Ring Injuries (OTA/AO 61B2.2) Results in a Low Rate of Radiographic Displacement.

OBJECTIVES: To quantify radiographic outcomes and to identify predictors of late displacement in the nonoperative treatment of lateral compression type II (LC-2) pelvic ring injuries. DESIGN: Retrospective review. SETTING: Two Level 1 trauma centers. PATIENTS/PARTICIPANTS: Thirty eight patients 18 years of age or older with LC-2 pelvic ring injuries were included in the study. INTERVENTION: Nonoperative treatment. MAIN OUTCOME MEASUREMENTS: Crescent fracture displacement (CFD) was measured on initial axial computed tomography scan. Change in pelvic ring alignment was measured by the deformity index, simple ratio, and inlet and outlet ratios on successive plain radiographs. RESULTS: Patients in this study had minimally displaced LC-2 pelvic ring injuries, with median initial CFD of 2 mm and median initial deformity index of 2%. No patients had a change of more than or equal to 10 percentage points in deformity index over the treatment period, but small amounts of displacement were seen on the other ratios. No patients initially selected for nonoperative treatment converted to operative treatment. No radiographic predictors of late displacement were identified. Bilateral pubic rami fractures and the presence of a complete sacral fracture ipsilateral to the crescent fracture were not associated with late displacement. CONCLUSIONS: A spectrum of injury severity and stability exists in the LC-2 pattern. Nonoperative treatment of LC-2 injuries with low initial deformity and CFD results in minimal subsequent displacement. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Single-Stage Treatment of Fracture-related Infections.

SUMMARY: Fracture-related infections (FRIs) remain a significant problem. Many approach FRI cases in a staged fashion, focusing on infection eradication initially and fracture union during subsequent procedures. The literature quotes high success rates with this strategy. However, associated patient morbidity and economic impact are noteworthy. A single-stage FRI treatment, using an antibiotic-coated locked intramedullary nail, also exists. This video details low-cost, antibiotic-coated locked intramedullary nail fabrication in the operating room alongside preliminary results using this technique for acute FRI and septic nonunion treatment.

Why Make the Cut? Trochanteric Slide Osteotomy Can Improve Exposure to the Anterosuperior Acetabulum.

OBJECTIVE: To define relative increases in visual bony surface area and access to critical landmarks with the addition of a trochanteric slide osteotomy to a Kocher-Langenbeck approach. METHODS: A Kocher-Langenbeck approach followed by a trochanteric slide osteotomy was sequentially performed on 10, fresh-frozen, hemipelvectomy cadaveric specimens. Visual and palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J. RESULTS: The acetabular surface area exposed was 27.66 (±6.67) cm2 for a Kocher-Langenbeck approach. This increased to and 41.82 (±7.97) cm2 with the addition of a trochanteric osteotomy. The exposed surface area was increased by 51.2% for the trochanteric osteotomy (P < 0.001). The superior margin of the acetabulum could be visualized and palpably accessed in both exposures. Access to the more anterosuperior portions of the acetabulum was consistently possible in the trochanteric osteotomy but not with the Kocher-Langenbeck approach. CONCLUSIONS: A trochanteric osteotomy may visually improve access to the most anterosuperior acetabulum but does not significantly improve surgical access to relevant portions of the superior acetabulum when compared with a Kocher-Langenbeck approach.

Low Adherence to Recommended Guidelines for Open Fracture Antibiotic Prophylaxis.

BACKGROUND: Prompt administration of antibiotics is a critical component of open fracture treatment. Traditional antibiotic recommendations have been a first-generation cephalosporin for Gustilo Type-I and Type-II open fractures, with the addition of an aminoglycoside for Type-III fractures and penicillin for soil contamination. However, concerns over changing bacterial patterns and the side effects of aminoglycosides have led to interest in other regimens. The purpose of the present study was to describe the adherence to current prophylactic antibiotic guidelines. METHODS: We evaluated the antibiotic-prescribing practices of 24 centers in the U.S. and Canada that were participating in 2 randomized controlled trials of skin-preparation solutions for open fractures. A total of 1,234 patients were evaluated. RESULTS: All patients received antibiotics on the day of admission. The most commonly prescribed antibiotic regimen was cefazolin monotherapy (53.6%). Among patients with Type-I and Type-II fractures, there was 61.1% compliance with cefazolin monotherapy. In contrast, only 17.2% of patients with Type-III fractures received the recommended cefazolin and aminoglycoside therapy, with an additional 6.7% receiving piperacillin/tazobactam. CONCLUSIONS: There is moderate adherence to the traditional antibiotic treatment guidelines for Gustilo Type-I and Type-II fractures and low adherence for Type-III fractures. Given the divergence between current practice patterns and prior recommendations, high-quality studies are needed to determine the most appropriate prophylactic protocol.

Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center.

OBJECTIVES: Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic. DESIGN: Retrospective chart review. SETTING: Outpatient visits (in-person, telephone, virtual-Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic. INTERVENTION: Virtual visits utilizing the Doxy.me platform. MAIN OUTCOME MEASURES: Accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). METHODS: All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). RESULTS: Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028). CONCLUSION: A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.

Neurochemical characterization of tyrosine hydroxylase-immunoreactive interneurons in the developing rat cerebral cortex.

Understanding the development of cortical interneuron phenotypic diversity is critical because interneuron dysfunction has been implicated in several neurodevelopmental disorders. Here, tyrosine hydroxylase (TH)-immunoreactive neurons in the developing and adult rat cortex were characterized in light of findings regarding interneuron neurochemistry and development. Cortical TH-immunoreactive neurons were first observed 2 weeks postnatally and peaked in number 3 weeks after birth. At subsequent ages, the number of these cell profiles was gradually reduced, and they were seen less frequently in adults. No DNA fragmentation or active caspase 3 was observed in cortical TH cells at any age examined, eliminating cell death as an explanation for the decrease in cell number. Although cortical TH cells reportedly fail to produce subsequent catecholaminergic enzymes, we found that the majority of these cells at all ages contained phosphorylated TH, suggesting that the enzyme may be active and producing L-DOPA as an end-product. Morphological criteria and colocalization of some TH cells with glutamic acid decarboxylase suggest that these cells are interneurons. Previously, parvalbumin, somatostatin, and calretinin were demonstrated in non-overlapping subsets of interneurons. Cortical TH neurons colocalized with calretinin but not with parvalbumin or somatostatin. These findings suggest that the transitory increase in TH cell number is not due to cell death but possibly due to alterations in the amount of detectable TH present in these cells, and that at least some cortical TH-producing interneurons belong to the calretinin-containing subset of interneurons that originate developmentally in the caudal ganglionic eminence.

Utility of Routine Postoperative Radiographs After Fixation of Lower Extremity Fractures.

INTRODUCTION: The goal of this study was to investigate the clinical utility of radiographs at all time points after internal fixation of lower extremity fractures. METHODS: A retrospective chart review was conducted at a level I trauma center. Four hundred eighty-five patients with 586 fractures of the femur, tibia, and ankle were included. Data were analyzed to investigate the effect of radiographs on changes in management at all postoperative time points for each fracture type. RESULTS: Each fracture received, on average, 4.8 radiographs after fixation for a total cost of $938,469. The management of 31% (179 of 586) of fractures deviated from the expected postoperative course. Of the 179 fractures with a deviation, 93 (31%) resulted from radiographic findings alone and occurred (1) in the immediate postoperative period (2%) and (2) in the period from consideration of advancement to full weight bearing up until confirmation of fracture union (98%). Notable cost savings can be realized by using the findings to eliminate nonclinically indicated imaging at both the institutional and national levels. CONCLUSION: Routine radiographs in isolation contribute to changes in management (1) in the immediate postoperative period in select cases and (2) during the period when advancement to full weight bearing is being considered up until clinical fracture union. LEVEL OF EVIDENCE: Level III.

A Prospective Multicenter Evaluation of the Value of the On-Call Orthopedic Resident.

BACKGROUND: Funding for graduate medical education is at risk despite the services provided by residents. OBJECTIVE: We quantified the potential monetary value of services provided by on-call orthopedic surgery residents. METHODS: We conducted a prospective, cross-sectional, multicenter cohort study design. Over a 90-day period in 2014, we collected data on consults by on-call orthopedic surgery residents at 4 tertiary academic medical centers in the United States. All inpatient and emergency department consults evaluated by first-call residents during the study period were eligible for inclusion. Based on their current procedural terminology codes, procedures and evaluations for each consult were assigned a relative value unit and converted into a monetary value to determine the value of services provided by residents. The primary outcome measures were the total dollar value of each consult and the percentage of resident salaries that could be funded by the generated value of the resident consult services. RESULTS: In total, 2644 consults seen by 33 residents from the 4 institutions were included for analysis. These yielded an average value of $81,868 per center for the 90-day study period, that is, $327,471 annually. With a median resident stipend of $53,992, the extrapolated average percentage of resident stipends that could be funded by these consult revenues was 73% of the stipends of the residents who took call or 36% of the stipends of the overall resident cohort. CONCLUSIONS: The potential monetary value generated by on-call orthopedic surgery residents is substantial.

Surgical Approaches to the Proximal Humerus: A Quantitative Comparison of the Deltopectoral Approach and the Anterolateral Acromial Approach.

BACKGROUND: Debate exists over the optimal approach for addressing fractures of the proximal humerus. The purpose of this study was to objectively quantify the surface area of the humerus exposed using the deltopectoral (DP) and anterolateral acromial (ALA) approaches and to compare visualized and palpable anatomic landmarks. METHODS: Ten arms on five fresh-frozen torsos underwent the DP and ALA approaches. The arms were positioned to simulate a supine patient and held in a fixed position. Visual and/or palpable access to relevant surgical landmarks and the myotendinous junctions were recorded. The myotendinous junctions were used as a rough approximation of consistent proximal exposure of a clinically retracted tuberosity. Landmarks were grouped into quadrants based on the location. Calibrated digital photographs of each approach were analyzed to calculate the surface area and the length of the exposed bone. RESULTS: The DP and ALA approaches exposed 22.9 ± 6.3 cm2 and 16.3 ± 6.4 cm2, respectively (P = 0.03). The DP and ALA approaches provided equivalent visual and palpable access to all landmarks in the superior and inferior quadrants. The ALA allowed improved visual (80% versus 70%) and palpable (100% versus 70%) access to the myotendinous junction of the infraspinatus in the posterior quadrant. The DP approach allowed better access to anterior quadrant structures, including improved ability to visualize the myotendinous junction of the subscapularis (100% versus zero), the subscapularis insertion (100% versus 80%), and the medial anatomic neck (100% versus 20%). Palpable access to the myotendinous junction of the subscapularis (100% versus 70%) and medial anatomic neck (100% versus 60%) was also improved with the DP. CONCLUSIONS: In a cadaver model with fixed arm position, the DP provides increased exposure to the proximal humerus and more reliable access to anterior surgical landmarks, whereas the ALA allows improved access to the most posterior aspect of the shoulder.

A Preoperative Planning Tool: Aggregate Anterior Approach to the Humerus With Quantitative Comparisons.

Extensile approaches to the humerus are often needed when treating complex proximal or distal fractures that have extension into the humeral shaft or in those fractures that occur around implants. The 2 most commonly used approaches for more complex fractures include the modified lateral paratricipital approach and the deltopectoral approach with distal anterior extension. Although the former is well described and quantified, the latter is often associated with variable nomenclature with technical descriptions that can be confusing. Furthermore, a method to expose the entire humerus through an anterior extensile approach has not been described. Here, we illustrate and quantify a technique for connecting anterior humeral approaches in a stepwise fashion to form an aggregate anterior approach (AAA). We also describe a method for further distal extension to expose 100% of the length of the humerus and compare this approach with both the AAA and the lateral paratricipital in terms of access to critical bony landmarks, as well as the length and area of bone exposed.

A Comparison of Exposure Between the Classic and Modified Judet Approaches to the Scapula.

OBJECTIVES: A debate exists over the optimal approach for addressing fractures of the scapula and glenoid. The purpose of this study is to (1) quantify and compare osseous exposure using modified Judet (MJ) and classic Judet (CJ) approaches and (2) assess the change in scapular exposure after triceps release from the inferior glenoid. METHODS: Ten arms on 5 fresh-frozen torsos underwent MJ and CJ approaches. A triceps release was performed following the CJ approach in all specimens. Visual and/or palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J (NIH, Bethesda, MD) to calculate the surface area of exposed bone. RESULTS: The MJ and CJ approaches exposed 16.8 (±7.58) cm(2) and 98.6 (±25.39) cm(2) of bone, respectively (P < 0.001). The full medial and lateral borders of the scapula were visualized in all approaches with mobilization of the teres minor. Palpable access to the full scapular spine was possible in all cadavers. Although the MJ and CJ approaches only allowed the inferior gleniod neck to be visualized in 1 and 2 specimens, respectively, performing a triceps release provided access to this structure. It also increased the CJ exposure by 12.6 cm(2) (P < 0.001) and allowed palpation of the anterior glenoid margin in 100% of specimens. CONCLUSIONS: In conclusion, the MJ approach allows similar access to landmarks important for reduction and fixation while exposing only 20% of the surface area typically visualized with the CJ approach.

A Quantitative Exposure Planning Tool for Surgical Approaches to the Sacroiliac Joint.

OBJECTIVES: To aid in surgical planning by quantifying and comparing the osseous exposure between the anterior and posterior approaches to the sacroiliac joint. METHODS: Anterior and posterior approaches were performed on 12 sacroiliac joints in 6 fresh-frozen torsos. Visual and palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J. RESULTS: The average surface areas of exposed bone were 44 and 33 cm for the anterior and posterior approaches, respectively. The anterior iliolumbar ligament footprint could be visualized in all anterior approaches, whereas the posterior aspect could be visualized in all but one posterior approach. The anterior approach provided visual and palpable access to the anterior superior edge of the sacroiliac joint in all specimens, the posterior superior edge in 75% of specimens, and the inferior margin in 25% and 50% of specimens, respectively. The inferior sacroiliac joint was easily visualized and palpated in all posterior approaches, although access to the anterior and posterior superior edges was more limited. The anterior S1 neuroforamen was not visualized with either approach and was more consistently palpated when going posterior (33% vs. 92%). CONCLUSIONS: Both anterior and posterior approaches can be used for open reduction of pure sacroiliac dislocations, each with specific areas for assessing reduction. In light of current plate dimensions, fractures more than 2.5 cm lateral to the anterior iliolumbar ligament footprint are amenable to anterior plate fixation, whereas those more medial may be better addressed through a posterior approach.