A Retrospective Comparative Analysis of the Use of Implantable Bone Stimulators in Nonunions.

This study details the use of implantable bone stimulators in the setting of nonunion. A retrospective comparative analysis was used to evaluate the efficacy of implantable bone stimulators in achieving union in the setting of atrophic or oligotrophic nonunion by two fellowship-trained orthopaedic trauma surgeons. Initially, 72 patients underwent surgical intervention for nonunion. Twenty-one patients had an implantable bone stimulator placed at the time of nonunion surgery. Thirty-eight patients had a minimum of 1-year follow-up. An implantable bone stimulator was used in 13 patients and 25 patients did not have a bone stimulator. The use of implantable bone stimulators was found to be significantly associated with increased union rates (p = .042). (Journal of Surgical Orthopaedic Advances.

Comparison of submuscular and open plating of pediatric femur fractures: a retrospective review.

BACKGROUND: Plate osteosynthesis is an accepted method of treatment of pediatric femur fractures. Historically, open plating has been used. Submuscular bridge plating has gained recent popularity due to the theoretical advantages of decreased operative time, decreased blood loss, and decreased risk for infection. The purpose of this study was to compare submuscular bridge plating to open plating of pediatric femur fractures. METHODS: We retrospectively reviewed 79 patients (80 treated femur fractures) between 1999 and 2011 that underwent either open plating (58 femur fractures) or submuscular bridge plating (22 femur fractures). The outcome measures evaluated were operative time, estimated blood loss, malunion, leg length discrepancy, time to union, infection, unplanned return to the operating room, and length of hospital stay after surgery. RESULTS: Among our outcome measures, there was no difference between the 2 groups in terms of operative time, leg length discrepancy, time to union, infection, or length of hospital stay after surgery. There was greater estimated blood loss in the open plating group (P≤0.0001) and greater rotational asymmetry in the submuscular bridge plating group (P=0.005). There was a trend of increased unplanned return to the operating room in the open plating group (5/58 vs. 0/22) although not statistically significant (P=0.32). CONCLUSIONS: Submuscular bridge plating and open plating seem to be equally viable options for the management of pediatric diaphyseal femur fractures. In this study, open plating had an increase in estimated blood loss and a trend of more unplanned returns to the operating room, whereas submuscular bridge plating had an increase in asymptomatic rotational asymmetry. Further larger, prospective, randomized studies are necessary to further evaluate these operative techniques. LEVEL OF EVIDENCE: Therapeutic Level III.

Pelvic Reduction Frame Facilitating Percutaneous Fixation to Pelvic Fractures.

This article is a retrospective report of the outcome of 43 unilateral unstable, vertically displaced pelvic ring injuries using a reduction frame which is attached to the OR table, along with special instruments allowing "unlocking" of the fracture to facilitate reduction. The frame utilized by the authors is a modification of the Starr Frame® (Starr Frame, LLC, Richardson), which has been refined to be lower profile, more accessible, and more versatile in pin placement. They have also reported a new attachment for the frame to apply lateral traction to the fractured hemipelvis. The authors provide a detailed description of the techniques involved in securing the patient to the frame and table, and then the stepwise application of multiplanar tractions to the fractured hemipelvis. Their technique of unlocking closed reduction (UCRT) involved controlled application of lateral distraction to disimpact the compressed or overlapping fractured bone surfaces, followed by distal and anterior traction through a femoral supracondylar pin, and direct manipulation of the hemipelvis through a supracetabular "LC-2" half pin. Reduction is followed by percutaneous fixation using 7.3-mm cannulated screws across the posterior ring and either external fixation or subcutaneous supra-acetabular pedicle screw internal fixation device (INFIX) anteriorly.

Bone Morphogenetic Protein-2 Rapidly Heals Two Distinct Critical Sized Segmental Diaphyseal Bone Defects in a Porcine Model.

INTRODUCTION: Segmental bone defects (SBDs) are devastating injuries sustained by warfighters and are difficult to heal. Preclinical models that accurately simulate human conditions are necessary to investigate therapies to treat SBDs. We have developed two novel porcine SBD models that take advantage of similarities in bone healing and immunologic response to injury between pigs and humans. The purpose of this study was to investigate the efficacy of Bone Morphogenetic Protein-2 (BMP-2) to heal a critical sized defect (CSD) in two novel porcine SBD models. MATERIALS AND METHODS: Two CSDs were performed in Yucatan Minipigs including a 25.0-mm SBD treated with intramedullary nailing (IMN) and a 40.0-mm SBD treated with dual plating (ORIF). In control animals, the defect was filled with a custom spacer and a bovine collagen sponge impregnated with saline (IMN25 Cont, n = 8; ORIF40 Cont, n = 4). In experimental animals, the SBD was filled with a custom spacer and a bovine collage sponge impregnated with human recombinant BMP-2 (IMN25 BMP, n = 8; ORIF40 BMP, n = 4). Healing was quantified using monthly modified Radiographic Union Score for Tibia Fractures (mRUST) scores, postmortem CT scanning, and torsion testing. RESULTS: BMP-2 restored bone healing in all eight IMN25 BMP specimens and three of four ORIF40 BMP specimens. None of the IMN25 Cont or ORIF40 Cont specimens healed. mRUST scores at the time of sacrifice increased from 9.2 (±2.4) in IMN25 Cont to 15.1 (±1.0) in IMN25 BMP specimens (P < .0001). mRUST scores increased from 8.2 (±1.1) in ORIF40 Cont to 14.3 (±1.0) in ORIF40 BMP specimens (P < .01). CT scans confirmed all BMP-2 specimens had healed and none of the control specimens had healed in both IMN and ORIF groups. BMP-2 restored 114% and 93% of intact torsional stiffness in IMN25 BMP and ORIF40 BMP specimens. CONCLUSIONS: We have developed two porcine CSD models, including fixation with IMN and with dual-plate fixation. Porcine models are particularly relevant for SBD research as the porcine immunologic response to injury closely mimics the human response. BMP-2 restored healing in both CSD models, and the effects were evident within the first month after injury. These findings support the use of both porcine CSD models to investigate new therapies to heal SBDs.

A multicenter study on definitive surgery for isolated hip fracture within 24 hours.

INTRODUCTION: Isolated hip fractures (IHFs) in the elderly are high-frequency, life-altering events. Definitive surgery ≤24 hours of admission is associated with improved outcomes. An IHF process management guideline (IHF-PMG) to expedite definitive surgery ≤24 hours was developed for a multihospital network. We report on its feasibility and subsequent patient outcomes. METHODS: This is a prospective multicenter cohort study, involving 85 levels 1, 2, 3, and 4 trauma centers. Patients with an IHF between 65 and 100 years old were studied. Four cohorts were examined: (1) hospitals that did not implement any PMG, (2) hospitals that used their own PMG, (3) hospitals that partially used the network IHF-PMG, and (4) hospitals that used the network's IHF-PMG. Multivariable logistic regression with reliability adjustment was used to calculate the expected value of observed to expected (O/E) mortality. Statistical significance was defined as p < 0.05. RESULTS: Data on 24,457 IHF were prospectively collected. Following implementation of the IHF-PMG, overall IHF O/E mortality ratios decreased within the hospital network, from 1.13 in 2017 to 0.87 in 2018 and 0.86 in 2019. Hospitals that developed their own IHF-PMG or used the enterprise-wide IHF-PMG had the lowest inpatient O/E mortality at 0.59 and 0.65, respectively. CONCLUSION: Goal-directed IHF-PMG for definitive surgery ≤24 hours was implemented across a large hospital network. The IHF-PMG was associated with lower inpatient mortality. LEVEL OF EVIDENCE: Therapeutic/ Care management, Level III.

Internal Fixation Construct and Defect Size Affect Healing of a Translational Porcine Diaphyseal Tibial Segmental Bone Defect.

BACKGROUND AND OBJECTIVE: Porcine translational models have become the gold-standard translational tool to study the effects of major injury and hemorrhagic shock because of their similarity to the human immunologic response to trauma. Segmental bone defects (SBDs) typically occur in warfighters with associated severe limb trauma. The purpose of this study was to develop a translational porcine diaphyseal SBD model in Yucatan minipigs (YMPs), which could be used in bone healing investigations that simulate injury-relevant conditions. We were specifically working toward developing a critical sized defect (CSD). METHODS: We used an adaptive experimental design in which both 25.0 mm and 40.0 mm SBDs were created in the tibial mid-diaphysis in skeletally mature YMPs. Initially, eight YMPs were subjected to a 25.0 mm SBD and treated with intramedullary nailing (intramedullary nail [IMN] 25mm). Due to unanticipated wound problems, we subsequently treated four specimens with identical 25.0 mm defect with dual plating (open reduction with internal fixation [ORIF] 25mm). Finally, a third group of four YMPs with 40.0 mm defects were treated with dual plating (ORIF 40mm). Monthly radiographs were made until sacrifice. Modified Radiographic Union Score for Tibia fractures (mRUST) measurements were made by three trauma-trained orthopedic surgeons. CT scans of the tibias were used to verify the union results. RESULTS: At 4 months post-surgery, mean mRUST scores were 11.7 (SD ± 1.8) in the ORIF 25mm YMPs vs. 8.5 (SD ± 1.4) in the IMN 25mm YMPs (P < .0001). All four ORIF 25mm YMPs were clinically healed. In contrast, none of the IMN 25mm YMPs were clinically healed and seven of eight IMN 25mm YMPs developed delayed wound breakdown. All four of the ORIF 40mm YMPs had flail nonunions with complete hardware failure by 3 months after surgery and were sacrificed early. CT scanning confirmed that none of the IMN 25mm YMPs, none of the ORIF 40mm YMPs, and two of four ORIF 25mm YMPs were healed. A third ORIF 25mm specimen was nearly healed on CT scanning. Inter-rater and intra-rater reliability interclass coefficients using the mRUST scale were 0.81 and 0.80, respectively. CONCLUSIONS: YMPs that had a 40 mm segment of bone removed from their tibia and were treated with dual plating did not heal and could be used to investigate interventions that accelerate bone healing. In contrast, a 25 mm SBD treated with dual plating demonstrated delayed but successful healing, indicating it can potentially be used to investigate bone healing adjuncts or conversely how concomitant injuries may impair bone healing. Pigs treated with IMN failed to heal and developed consistent delayed wound breakdown presumably secondary to chronic limb instability. The porcine YMP SBD model has the potential to be an effective translational tool to investigate bone healing under physiologically relevant injury conditions.

Adult trauma: getting through the night.

It is now recognized that the treatment of many orthopaedic injuries can be, and in many cases should be, deferred until a later date. For example, surgical repair of most fractures of the proximal and distal tibia is now delayed until soft-tissue healing has occurred. Acute treatment involves only provisionally reducing and stabilizing such fractures using a joint-spanning external fixator. However, situations occur in the emergency department in which emergency treatment, even if it is just temporizing in nature, must be done immediately. Often, such treatment is outside the comfort zone of the responsible orthopaedic surgeon, even physicians with training and experience in orthopaedic trauma. Orthopaedic surgeons will benefit from updated information on current methods for the emergency management of limb- and/or life-threatening injuries in adults. Such treatment is often provisional in nature, treating only the urgent component of the injury (such as a compartment syndrome associated with a complex tibial plateau fracture). It is important for orthopaedic surgeons to understand how to get "through the night" so that later appropriate definitive care is facilitated to optimize patient outcomes.

Locking plates for extremity fractures.

Thirty-three peer-reviewed studies met the inclusion criteria for the Overview. Criteria were framed by three key questions regarding indications for the use of locking plates, their effectiveness in comparison with traditional nonlocking plates, and their cost-effectiveness. The studies were divided into seven applications: distal radius, proximal humerus, distal femur, periprosthetic femur, tibial plateau (AO/OTA type C), proximal tibia (AO/OTA type A or C), and distal tibia. Patient enrollment criteria were recorded to determine indications for use of locking plates, but the published studies do not consistently report the same enrollment criteria. Regarding effectiveness, there were no statistically significant differences between locking plates and nonlocking plates for patient-oriented outcomes, adverse events, or complications. The literature search did not identify any peer-reviewed studies that address the cost-effectiveness or cost-utility of locking plates.

The management of complications associated with tibial fractures.

Tibial fractures are common and frequently require surgical stabilization. These two factors mean that complications when treating this difficult injury are to be expected. The objectives in the treatment of open tibial shaft fractures are to prevent sepsis, achieve union, and restore function of the limb. However, these goals are often compromised by infection, compartment syndromes, and bone loss associated with many tibial shaft fractures. Recent studies provide a better understanding of the factors involved in the initial care of patients with open tibial fractures and have challenged prior dogmas and practices. An example is studies that define the relationship between the time to débridement of open fractures and subsequent infection. The diagnosis of compartment syndromes continues to be challenging. Careful review of clinical criteria will assist physicians in the early recognition and the management of compartment syndromes. Despite uncomplicated initial care, infections will occur. However, improved knowledge in the basic science of infections, specifically infections about orthopaedic implants, has led to the development of protocols for treatment and obtaining union. Bone loss, a result of either infection or trauma, is one of the most difficult complications to manage. Research regarding bone morphogenesis and the synthesis of multiple compounds has created new options for treating tibial fractures with bone loss.

Avoiding complications in the treatment of humeral fractures.

Three of the most common complications that may occur after the treatment of humeral fractures are nonunion, loss of fixation, and nerve injury. Nonunion may occur in up to 15% of patients who have been treated surgically. Loss of fixation often is caused by poor quality bone in the osteopenic humeral head. Nerve injury can occur as a result of trauma or from treatment.

Prevention of complications after treatment of proximal femoral fractures.

Two factors are primarily responsible for complications after treatment of proximal femoral fractures. First, the strong deforming forces across the hip joint and proximal femur can make fracture reduction difficult. Second, the placement of the implant affects fracture healing and outcome more dramatically than in other areas of the body. In subtrochanteric fractures, the use of appropriate reduction and stabilization techniques can prevent varus malreduction and subsequent failure of the fixation device. In intertrochanteric fractures, lag screw cutout can be prevented by correct implant positioning. In femoral neck fractures, nonunion can be avoided by careful attention to reduction and hardware positioning.

Prevention of complications after treatment of femoral shaft and distal femoral fractures.

The need for surgical treatment of femoral shaft and distal femoral fractures is undisputed. The treatment options are varied, and often the choice is based on the surgeon's preference rather than orthopaedic science. The decision should be determined by the predicted functional outcome rather than by the type of implant to be used. The entry point for intramedullary femoral nailing is of no consequence, if the nailing is performed correctly and the patient has a good functional outcome. The primary goal of treatment for a supracondylar femoral fracture is to restore limb alignment while preventing angular deformity. Proper technique, not the choice of a nail or plate, is key to recovery.

Avoiding complications in the care of fractures of the tibia.

Tibial fractures are the most common long-bone fractures. Orthopaedic surgeons, regardless of their subspecialty, often must treat these injuries, which range from low-energy, minimally displaced fractures to limb-threatening injuries with neurologic and vascular damage and significant damage to the soft-tissue envelope. Tibial shaft fractures are often prone to complications, such as apex-anterior and valgus malalignments after nailing of the fractures in the proximal one third of the tibia, infection after open fractures, and aseptic nonunions. Understanding the common complications will aid in preventing them and will allow recognition and provide treatment strategies when such problems occur.

Avoiding complications in the treatment of pronation-external rotation ankle fractures, syndesmotic injuries, and talar neck fractures.

Fractures of the foot and ankle are common injuries that often are successfully treated nonsurgically; however, some injuries require surgical intervention. To restore anatomy and avoid the need for additional surgery, surgeons must pay attention to detail and understand common, avoidable complications. The surgeon should have an understanding of the pathologic characteristics of three common injuries of the foot and ankle as well as the potential complications and their prevention.

Softer Tissue Issues in Orthopaedic Trauma.

There are number of significant issues outside of the bone and/or fracture that are important to consider in the treatment of orthopaedic trauma. Joint contractures, heterotopic bone formation, managing a traumatized soft-tissue envelope or substantial soft-tissue defects represent a few of these important issues. This article reviews these issues, including the best available evidence on how to manage them.

The floating hip: complications and outcomes.

BACKGROUND: To perform a descriptive study of the course, treatment decisions, complications, and outcome of patients suffering simultaneous ipsilateral fractures of the femur and pelvis. METHODS: Medical records and radiographs of 57 patients were reviewed retrospectively. RESULTS: The average follow-up was 28 months. Fifteen patients (26%) had an acetabular fracture, 17 (30%) had a pelvic ring fracture, and 25 (44%) had both fractures concomitant with the ipsilateral femoral fracture. Eighty percent of acetabular fractures and 55% of pelvic ring fractures were treated surgically. Femur fractures underwent operation in 94% of cases. When multiple operative settings were used, the femur fracture was always fixed at the first operation. Complications included deep venous thrombosis (DVT) (12%), heterotopic ossification (HO) (34%), femoral head avascular necrosis (AVN) (2%), osteoarthritis (OA) (16%), and traumatic sciatic nerve palsy (33%). At least partial nerve palsy resolution occurred in 53% of patients. CONCLUSIONS: Ipsilateral injuries to the femur and the pelvis or acetabulum ("floating hip") are severe injuries usually caused by high-energy trauma. The acetabulum and pelvic ring are more commonly fractured together than either alone. The femur fracture will most commonly be addressed first, as in 65% of our cases in which both components were addressed at the same setting, and 100% of cases in which they were addressed in separate settings. Delays of surgery were common because of severity of systemic trauma. Surgeons should be aware of the high incidence of sciatic nerve palsy as well as treatment options and potential complications associated with this devastating combination of injuries.

Locking plates: tips and tricks.

Locking plates are fracture fixation devices that allow the insertion of fixed-angle/angular-stable screws or pegs and do not require friction between the plate and bone. The clinical care impetus for the development of these plates has been a combination of factors, including the increasing survival of patients with high-energy injuries, aging Western European and North American populations with an increasing rate of fragility fractures, and dissatisfaction of patients and surgeons with the outcomes of treatment of specific periarticular fractures. Nonclinical factors likely include a push by industry for new technology and new markets as well as the general interest of the public in "minimally invasive" surgery.

External fixation: how to make it work.

The external fixator has been in use for more than a century. Wutzer (1789-1863) used pins and an interconnecting rod-and-clamp system. Parkhill (1897) and Lambotte (1900) used devices that were unilateral with four pins and a bar-clamp system. By 1960, Vidal and Hoffmann had popularized the use of an external fixator to treat open fractures and infected pseudarthroses. The complications associated with the use of external fixation in the late 20th century were predominantly caused by a lack of understanding of the principles of application, the principles of fracture healing with external fixation, and old technology. Its use was reserved for the most severe injuries and for cases complicated by infection. Thus, pin problems, nonunions, and malunions were common. Better technology and understanding have since allowed for greater versatility and better outcomes. Simultaneous with developments in the Western world, Ilizarov developed the principles of external fixation with use of ring and wire fixation. It was not until the late 1980s and early 1990s, when more interaction and exchange between the West and East (Russia) became possible, and with the help of Italians who embraced the philosophy of external fixation, that the use of external fixation was proven to be successful. Several variations of external fixation have been developed, and its use is now widespread. However, in the United States, all but a minority of surgeons still have substantial apprehension about the use of external fixation.

Technical tips in fracture care: fractures of the hip.

Hip fracture is an increasingly common and clinically significant injury with substantial economic impact. Associated risk factors are age, gender, race, bone density, activity level, and medical disorders. Prevention efforts include treatment of osteoporosis and programs to reduce the risks of a fall. Nondisplaced or impacted fractures of the femoral neck can be treated with screw fixation. Displaced femoral neck fractures in younger, more active patients may be treated with reduction and fixation. In physiologically older patients, joint arthroplasty is indicated for displaced fractures. In patients with systemic arthritis or preexisting hip disease, total hip arthroplasty may be an appropriate treatment choice. Intertrochanteric fractures are treated with reduction and fixation using either a sliding hip screw and side plate or intramedullary nail with cephalic interlock. Key technical points for successful outcomes include proper patient positioning, using a correct starting point for the nail, achieving acceptable reduction before fixation, and the use of various reduction techniques and aids.

Muscle strength recovery and its effects on outcome after open reduction and internal fixation of acetabular fractures.

OBJECTIVE: To determine the relationship between muscle strength recovery and functional outcome in patients who were treated for an acetabular fracture via an anterior approach. DESIGN: Case series. SETTING: University Medical Center. PATIENTS: Fifteen patients with a displaced acetabular fracture treated via an anterior, ilioinguinal approach were studied. Hip muscle strength of these patients was then compared with the muscle strength of a similar group of patients treated via a Kocher-Langenbeck approach (posterior approach). These patient groups were then combined and muscle strength recovery was compared with the functional outcome. MAIN OUTCOME MEASURE: Primary outcome measures included hip muscle strength, including work (J/min) and maximum torque (Nm/kg) for abductors/adductors and flexors/extensors. Clinical outcome was assessed with the Musculoskeletal Function Assessment (MFA) questionnaire and the results correlated with muscle strength. Secondary outcome measures included adequacy of fracture reduction, radiographic grade, severity of heterotopic ossification, and range of motion of the affected and unaffected hips. RESULTS: At an average follow-up of 44 months, patients treated via an anterior approach had an overall muscle strength deficit of 9%. Hip extension strength was affected to the least extent (6% deficit when compared with the unaffected hip) whereas abduction, adduction, and flexion strength was affected to a greater degree. For each measure the affected side was typically weaker than the unaffected side. The average MFA score for the anterior approach group was 17 (range, 0 to 47) with most patients reporting poorest results in those domains assessing activities of the arms and legs, and those involving life changes and feelings. When MFA scores were compared with the muscle strength, a relationship was found between hip extension/flexion work and maximum torque and hip adduction work and maximum torque and MFA score. For each of these muscle groups, patients reported worsening function with decreased muscle strength. Assessment of the most recent radiographs revealed 9 patients with an excellent radiographic grade, 3 patients with a good grade, 1 patient with a fair grade, and 2 patients with a poor grade. Hip range of motion was not statistically different when the affected hip was compared with the unaffected hip, and none of these variables correlated with outcome. Heterotopic ossification was found in 8 patients; 4 with grade 1, and 4 with grade 2. CONCLUSIONS: Standardized muscle strength determination and completion of an MFA questionnaire provided a thorough evaluation of patients who had undergone open reduction and internal fixation of a displaced acetabular fracture. In these patients, hip muscle strength after operative treatment of a displaced acetabular fracture directly influences patient outcome. Therefore, in order to maximize the outcome of these patients, particular attention must be paid to postoperative muscle strengthening protocols and accurate and validated methods to assess strength and outcomes.