An alternative technique for greater tuberosity fractures: use of the mesh plate.

INTRODUCTION: Isolated greater tuberosity (GT) fractures (AO 11-A1) tend to occur in the younger patient population and are poorly managed by most precontoured proximal humerus locking plates. The goal of this study was to identify and assess an alternative treatment strategy for greater tuberosity fractures. MATERIALS AND METHODS: A retrospective review of all cases of isolated greater tuberosity fractures treated with a 2.4/2.7 mesh plate (Synthes) between 2010 and 2015 was conducted. Patient demographics, operative reports, and clinical notes were reviewed. The time to radiographic union was assessed. Clinical outcomes were retrieved from patients at their follow-up visits or via mailed Disabilities of the Arm, Shoulder, Hand (DASH) questionnaires. RESULTS: Ten patients with isolated GT fractures treated with mesh plating were identified with an average age of 47.1 years. The average radiographic follow-up was 7.2 months and the average clinical follow-up was 8.0 months. The mean time to union was 8.5 weeks. Two patients underwent elective hardware removal. The mean DASH at final follow-up was 28.2 (±22.4), while the mean DASH work was 13.6 (±19.1). CONCLUSION: We have identified a viable alternative treatment option for the surgical management of isolated greater tuberosity fractures using a mesh plate that can be contoured to the patient's anatomy. Surgeons should be aware of this option for select patients.

A surgical approach algorithm for transverse posterior wall fractures aids in reduction quality.

BACKGROUND: Transverse posterior wall fractures are difficult to treat and historically have been associated with stiffness, posttraumatic arthritis, and pain, which correlate with the reduction. The Kocher-Langenbeck approach is used most often, whereas the extended iliofemoral approach has been reserved for more complex injury patterns. The latter approach has substantially more risks. No data to our knowledge exist on the use of sequential anterior and posterior approaches for this pattern. QUESTIONS/PURPOSES: The purpose of this study is to evaluate an algorithmic method to determine the choice of surgical approach(es) for transverse posterior wall fractures. The main question is: will this approach-based algorithm allow for adequate reduction and stabilization to union? Our secondary endpoints were Merle d'Aubigne scores, reoperations, and radiographic sequelae including arthritis, avascular necrosis, and heterotopic ossification. METHODS: A retrospective study was conducted in which patients were drawn from an existing database. The inclusion criterion was transverse posterior wall fractures with adequate imaging treated by one surgeon. All but one patient were treated within 2 weeks of injury. Mean followup was 23 months (range, 3 months to 11 years). Between November 5, 1999, and August 22, 2012, 74 patients were treated with open reduction internal fixation for this injury; nine were excluded as a result of percutaneous treatment or inadequate preoperative imaging. The remaining 65 patients (88%) comprised the study group. All patients were treated by the senior surgeon with an algorithm that consisted of either a Kocher-Langenbeck or sequential approach based on the location, magnitude, and direction of displacement of the ischiopubic segment. Indomethacin was prescribed to all patients for heterotopic ossification prophylaxis for a total of 6 weeks postoperatively. Based on the algorithm, 82% (53 patients) were treated with Kocher-Langenbeck and 18% (12 patients) with the sequential approach. Adequacy of reduction was measured using AP and Judet views of the pelvis; union was determined empirically by pain-free weightbearing and lack of displacement over time. Outcomes were the Merle d'Aubigne score and radiographic findings of avascular necrosis or arthrosis. RESULTS: The algorithm resulted in 100% reduction within 1 mm on plain radiographs. Initial displacement was greater in the patients undergoing the sequential approach (p=0.01, 7.7 versus 12.4 mm). The average d'Aubigne score was 15.3. Radiographic arthritis scores were 68% excellent/good. Avascular necrosis developed in five patients (8%). Five patients (8%) went on to THA, and four patients (6%) developed superficial or deep infection. Only one patient developed Brooker III heterotopic ossification and this was not symptomatic. CONCLUSIONS: This algorithm helps guide appropriate selection of the surgical approach and results in accurate reduction with functional and radiographic results that are comparable with existing series while avoiding extended approaches. However, like any operative decision, the choice of approach should not depend entirely on an algorithm; rather, the algorithm is best used as a guide to understand the factors involved in treating these rare and complex injuries and to help make an appropriate choice for an individual patient. LEVEL OF EVIDENCE: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Percutaneous posterior to anterior screw fixation through achilles tendon for posterior malleolus fractures: technique description and case series.

Posterior malleolus fractures (PMFs) (OTA 43B1.1) are frequently seen in combination with fractures of the fibula, medial malleolus, and distal tibia; they can rarely be seen in isolation. PMFs affect the alignment of the ankle mortise and the stability of syndesmosis. Techniques described for fixation of PMFs include open reduction internal fixation through a posterolateral or posteromedial approach or anterior-to-posterior screw fixation. For selected minimally displaced or nondisplaced fractures of the posterior malleolus, we developed a percutaneous technique through the Achilles tendon for the insertion of a posterior-to-anterior cannulated screw. The technique is described, and a clinical series is reviewed.

Pulmonary embolism in orthopaedic patients: diagnosis and management.

Orthopaedic patients are at particularly high risk for pulmonary embolism. There has been a trend recently toward overdiagnosis of pulmonary embolism; thus, evaluation of the nature of a clinically relevant pulmonary embolism is needed, as is assessment of the timing, risks, and outcomes of therapeutic anticoagulation in surgical patients. Recent literature shows the incidence of pulmonary embolism to be increasing without a corresponding increase in mortality, suggesting that not all emboli may be clinically relevant and that increasingly sensitive tests may be picking up small emboli. The size and location of a clot or clots may matter when deciding on management. A risk-benefit evaluation can assist in deciding treatment.

Proximal tibia and tibial plateau nail-plate combinations: technical trick and case series.

Proximal tibia fractures and combined tibial shaft-plateau injuries are increasingly common. Prolonged nonweightbearing may result in poor outcomes, particularly in elderly patients. Nail-plate combination constructs offer an attractive solution to facilitate early weight-bearing in these complex problems. We describe strategies and tips for these constructs and present the results of a small patient series treated with this technique.

Use of Tourniquets in Limb Trauma Surgery.

Although tourniquets are commonly used in patients with limb trauma patients, both in the acute and elective settings, no set protocols exist for their indications, contraindications, or proper use. This article addresses the current literature on optimal pressure, timing, cuff design, and complications of tourniquets in trauma patients. General issues are discussed, followed by those specific to upper and lower extremities. Lastly, serious complications, such as pulmonary embolism, are described.

Periprosthetic Atypical Femoral Fractures in Patients on Long-term Bisphosphonates: A Multicenter Retrospective Review.

OBJECTIVES: To define the characteristics of periprosthetic atypical femoral fractures (PAFFs) in patients on long-term bisphosphonate treatment and to provide a guide to the diagnosis and long-term treatment of these patients based on the literature. DESIGN: Multicenter retrospective review. SETTING: Fifteen orthopaedic centers in the United States and Canada, including members of the Canadian Orthopaedic Trauma Society. PATIENTS/PARTICIPANTS: Patients on long-term bisphosphonates who presented with either periprosthetic fractures or femoral fractures, over a 10-year period. MAIN OUTCOME MEASUREMENTS: Time to union and complications. RESULTS: Clinically significant differences were identified in time to union, mortality, and complications. There was a statistically significant difference in complications. Imaging review demonstrated identical features in both atypical femoral fractures (AFFs) and PAFFs. CONCLUSIONS: This is the largest comparative case series reported on PAFFS and AFFs and provides compelling evidence that PAFFs in patients on long-term bisphosphonates are indeed a subset of periprosthetic fractures that exhibit atypical femoral fracture (AFF) characteristics. As such, these fractures pose serious diagnostic and management challenges to trauma and arthroplasty surgeons. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Knee Injury Associated With Acetabular Fractures: A Multicenter Study of 1273 Patients.

OBJECTIVES: The purpose of this study was to determine the incidence and pattern of the knee injury associated with acetabular fractures. DESIGN: Retrospective cohort study. SETTING: Three level I and one level II trauma centers. PATIENTS: A total of 1273 skeletally mature patients treated at 4 trauma centers between November 2004 and December 2013 for acetabular fractures were retrospectively identified from orthopaedic trauma databases. INTERVENTION: Analysis of all acetabular fractures with knee injury regarding type of acetabular fracture, mechanism of injury, energy of injury, pattern of the knee injury, knee examination findings at initial presentation, intraoperative and on follow-up, requirement for surgery/conservative management, and the associated injuries. The clinical data entered during inpatient stay and office visits were analyzed. MAIN OUTCOME MEASURES: Incidence and pattern of the knee injury. RESULTS: One hundred ninety-three of 1273 patients (15%) were found to have ipsilateral knee symptoms within a period of 1 year from the date of injury. The patterns of knee injury included 56 fractures (29%), 49 ligamentous lesions (25%), and 88 miscellaneous (46%) causes including bone bruises, wounds, and swelling. Associated injuries included 85 patients with ipsilateral hip dislocation (45%), 59 pelvic injuries (31%), 61 extremity injuries (32%), 38 head injuries (20%), 37 chest injuries (20%), 23 abdominal and genitourinary injuries (12%), and 7 injuries of the spine (4%). CONCLUSION: Based on this study, we conclude that knee injuries associated with high-energy acetabular fractures constitute a significant portion of the patient population. Ligament injuries are frequently overlooked and thorough clinical evaluation and utilization of magnetic resonance imaging in selected cases will help in early detection and prevention of long-term complications. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Healing Time and Complications in Operatively Treated Atypical Femur Fractures Associated With Bisphosphonate Use: A Multicenter Retrospective Cohort.

OBJECTIVES: The purpose of this study was to characterize demographics, healing time, and complications of a large series of operatively treated atypical femur fractures. DESIGN: Retrospective multicenter review. SETTING: Seventeen academic medical centers. PATIENTS: Bisphosphonate-related fractures as defined by American Society of Bone and Mineral Research. Fractures had to be followed for at least 6 months or to union or revision. INTERVENTION: Operative treatment of bisphosphonate-related fracture. MAIN OUTCOME MEASUREMENTS: Union time and complications of treatment, as well as information about the contralateral limb. RESULTS: There were 179 patients, average age 72, average body mass index 27.2. Average follow-up was 17 months. Twenty-one percent had a previous history of fragility fracture; 34% had prodromal pain. Most (88%) lived independently before injury. Thirty-one percent had radiographic changes suggesting stress reaction. Surgical fixation was with cephalomedullary nail (51%), IM nail (48%), or plate (1%). Complications included death (4), PE (3), and wound infection (6). Twenty (12%) patients underwent revision at an average of 11 months. Excluding revisions, average union time was 5.2 months. For revisions, union occurred at an average of 10.2 months after intervention. No association was identified between discontinuation of bisphosphonates and union time (P = 0.5) or need for revision (P = 0.7). Twenty-one percent sustained contralateral femur fractures; 32% of these had pain and 59% had stress reaction before contralateral fracture. CONCLUSIONS: In this series, surgery had a 12% failure rate and delayed average time to union. Twenty-one percent developed contralateral femur fractures within 2 years, underscoring the need to evaluate the contralateral extremity. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can We Tell if the Syndesmosis Is Reduced Using Fluoroscopy?

OBJECTIVE: To evaluate the ability of surgeons to determine whether the fibula is reduced in the sagittal plane in relation to the tibia based on the fluoroscopic images by comparison with the known normal for both the ipsilateral and contralateral ankles. METHODS: Perfect lateral radiographs of both ankles were obtained in 7 cadaveric specimens. The fibula was translated 2.5 and 5 mm in the anterior and posterior directions. Four orthopaedic trauma-trained surgeons were presented with a fictitious case consisting of a "normal" image, followed by 10 randomly selected images from both ankles, and were asked to determine whether the fibula was reduced, or displaced anteriorly or posteriorly. The ability of the surgeons to identify displacement and interobserver reliability was assessed. RESULTS: The surgeons were better able to identify malreduction than reduction (negative predictive value (NPV) 95% ipsilateral, 85% contralateral). The overall sensitivity for reduction was 94% for the ipsilateral ankle, but only 68% for the contralateral ankle. Anterior displacement and greater magnitudes of displacement were most easily diagnosed. All reviewers had the most difficulty with 2.5 mm of posterior displacement. The intraobserver agreement was excellent for anterior displacement and 5 mm of displacement in either direction (kappa = 0.71/0.75). Surgeons who routinely used the contralateral lateral radiograph were more accurate. CONCLUSIONS: Although it is unknown how much translational displacement of the syndesmosis is acceptable, it seems that the experienced surgeon will be able to reduce the joint within 2.5 mm and that fluoroscopic comparisons to the normal ankle are helpful in determining malreduction.

Neurologic Injury in Operatively Treated Acetabular Fractures.

OBJECTIVES: The purpose of this study is to evaluate a series of operatively treated acetabular fractures with neurologic injury and to track sensory and motor recovery. METHODS: Operatively treated acetabular fractures with neurologic injury from 8 trauma centers were reviewed. Patients were followed for at least 6 months or to neurologic recovery. Functional outcome was documented at 3 months, 6 months, and final follow-up. Outcomes included motor and sensory recovery, brace use, development of chronic regional pain syndrome, and return to work. RESULTS: One hundred thirty-seven patients (101 males and 36 females), average age 42 (17-87) years, met the criteria. Mechanism of injury included MVC (67%), fall (11%), and other (22%). The most common fracture types were transverse + posterior wall (33%), posterior wall (23%), and both-column (23%). Deficits were identified as preoperative in 57%, iatrogenic in 19% (immediately after surgery), and those that developed postoperatively in 24%. A total of 187 nerve deficits associated with the following root levels were identified: 7 in L2-3, 18 in L4, 114 in L5, and 48 in S1. Full recovery occurred in 54 (29%), partial recovery in 69 (37%), and 64 (34%) had no recovery. Forty-three percent of S1 deficits and 29% of L5 deficits had no recovery. Fifty-five percent of iatrogenic injuries did not recover. Forty-eight patients wore a brace at the final follow-up, all for an L5 root level deficit. Although 60% (42/70) returned to work, chronic regional pain syndrome was seen to develop in 19% (18/94). CONCLUSIONS: Peripheral neurologic injury in operatively treated acetabular fractures occurs most commonly in the sciatic nerve distribution, with L5 root level deficits having only a 26% chance of full recovery. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment and complications in orthopaedic trauma patients with symptomatic pulmonary embolism.

OBJECTIVES: The purpose of this study is to characterize the presentation, size, treatment, and complications of pulmonary embolism (PE) in a large series of orthopaedic trauma patients who developed PE after injury. METHODS: We reviewed the records of orthopaedic trauma patients who developed a PE within 6 months of injury at 9 trauma centers and 2 tertiary care facilities. RESULTS: There were 312 patients, 186 men and 126 women, average age 58 years. Average body mass index was 29.6, and average Injury Severity Score was 18. Seventeen percent received anticoagulation before injury, and 5% had a history of PE. After injury, 87% were placed on prophylactic anticoagulation and 68% with low-molecular weight heparin. Fifty-three percent of patients exhibited shortness of breath or chest pain. Average heart rate and O2 saturation before PE diagnosis were 110 and 94%, respectively. Thirty-nine percent had abnormal arterial blood gas, and 30% had abnormal electrocardiogram findings. Eighty-nine percent had computed tomography pulmonary angiography for diagnosis. Most clots were segmental (63%), followed by subsegmental (21%), lobar (9%), and central (7%). The most common treatment was unfractionated heparin and Coumadin (25%). Complications of anticoagulation were common: 10% had bleeding at the surgical site. Other complications of anticoagulation included gastrointestinal bleed, anemia, wound complications, death, and compartment syndrome. PE recurred in 1% of patients. Four percent died of PE within 6 months. CONCLUSIONS: This is the first large data set to evaluate the course of PE in an orthopaedic trauma population. The complications of anticoagulation are significant and were as common in patients with lower risk clots as those with higher risk clots.

Management of acute complicated and uncomplicated type B dissection of the aorta: focus on endovascular stent grafting.

Endovascular repair of aortic dissection is the subject of multiple studies. This article aims to review the current literature on Type B complicated and uncomplicated dissection, including indications for medical therapy, open surgical therapy, and endovascular therapy. The review suggests a benefit for thoracic endovascular aortic repair in complicated dissection and medical therapy for uncomplicated dissection. Upcoming trials may shed more light on this issue.