Topical Antibiotic Powder and Nonunion Risk in Surgically Treated Tibial Plateau and Pilon Fractures.

INTRODUCTION: High-energy periarticular tibia fractures are challenging injuries with a significant risk of complications. Postoperative infection rates, although improved, remain unacceptable. Intrawound topical antibiotic (TA) application has been popularized to reduce postoperative infections. Although TA may minimize infections, it remains unclear whether TAs have any impact on the development of nonunion. Recent investigations of TA use in fracture care have questioned its efficacy in vivo and suggested a potentially deleterious effect on fracture healing. This study investigates the impact of TA on nonunion rates in surgically treated high-energy periarticular tibia fractures. METHODS: Retrospective analysis of surgically treated periarticular tibia fractures at a single Level 1 trauma center was conducted. Intervention in question was the clinical effect of intrawound TA powder application at definitive closure. A total of 222 high-energy periarticular tibia fractures were included, 114 with TA use and 108 without. The primary outcome was the occurrence of nonunion, with secondary outcomes being superficial and deep postoperative surgical site infections. RESULTS: Twenty-seven patients (12.1%) were diagnosed with nonunions (14 pilons and 13 plateaus). There was no statistically significant difference in nonunion rates among patients who received topical antibiotics (15.8%) versus the group of patients who did not (8.3%) ( P = 0.23). Odds of developing nonunion was significant for open injuries (odds ratio 6.16, P < 0.001) and patients with a provisional external fixator (odds ratio 8.72, P = 0.03) before definitive fixation. No notable difference in the number of superficial and deep infections was identified between groups. CONCLUSION: The use of TA in high-energy periarticular tibia fractures showed no statistically significant increase in nonunion rates but did not conclusively rule out nonunion as a possible effect of intrawound TA. Additional large-scale multicenter prospective studies are needed to confirm these findings. The current body of literature regarding high-energy periarticular tibia fractures does suggest that TAs lower the risk of postoperative infections, but the nonunion risk remains unclear. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Vertical Shear Pelvic Ring Injury Adjacent to Retained Pelvic Hardware: A Case Report.

CASE: A 47-year-old obese woman presented with a vertical shear (VS) pelvic ring injury after a motor vehicle accident around her previous posterior pelvic hardware. The patient underwent closed reduction with percutaneous posterior screw fixation using combined fluoroscopy and O-arm (Medtronic). CONCLUSION: A rare case of VS pelvic injury with indwelling posterior pelvic hardware does not automatically preclude placement of percutaneous sacroiliac and transiliac-transsacral screws. Combining fluoroscopic imaging and O-arm enables safe screw placement, saving patients from invasive surgeries.

The Reamer-Irrigator-Aspirator in Nonunion Surgery.

The reamer-irrigator-aspirator (RIA) autograft provides large volumes of autogenous graft that exhibit excellent osteogenic, osteoinductive, and osteoconductive properties. These features, combined with the relative ease of graft harvest and low donor site morbidity when compared with the gold standard iliac crest bone graft (ICBG), have made RIA autograft a viable alternative to ICBG. Some suggest RIA autograft is superior to ICBG, particularly in the setting of large segmental bone defects managed with the induced membrane technique. Although significant complications such as fracture and cortical perforation have been reported, they are preventable if proper surgical strategy and tactics are used.

Repeat posterior wall acetabular fracture-dislocation: High-energy trauma as a 'second hit phenomenon'.

Acetabular fractures are injuries that require significant force transmission, especially when associated with a femoral head dislocation. The mechanism of injury is typically in the setting of a high-speed motor vehicle collision. In a similar manner, this is an injury that is highly demanding for the orthopaedic trauma surgeon to treat as well. We present a patient who sustained an initial posterior wall acetabular fracture with an associated posterior dislocation. This was treated surgically with open reduction, internal fixation without complication. The patient subsequently sustained a second posterior wall acetabular fracture with dislocation fifteen years later through the plated and healed previous fracture. Both injuries were sustained in high-speed motor vehicle collisions, so it is difficult to presume the patient was predisposed for the repeat injury. At any rate, the repeat injury makes the surgical management significantly more challenging. In complicated acetabular fractures like these, a post or intra-operative CT scan can be of utility to determine quality of reduction as well as assessing for retained bony fragments. Our patient underwent a post-operative CT scan with the finding of intra-articular bony fragments that subsequently required arthroscopic removal. Given the rare nature of this complicated injury occurring twice in a patient, it is difficult to make evidence-based comments on long-term prognosis and functional outcomes. This unique case and the applied treatment will serve as a guide for future similar cases.

Tranexamic Acid Use in Open Reduction and Internal Fixation of Fractures of the Pelvis, Acetabulum, and Proximal Femur: A Randomized Controlled Trial.

OBJECTIVE: To assess the safety and efficacy of tranexamic acid (TXA) use in fractures of the pelvic ring, acetabulum, and proximal femur. DESIGN: Prospective, randomized controlled trial. SETTING: Single Level 1 trauma center. PATIENTS: Forty-seven patients were randomized to the study group, and 46 patients comprised the control group. INTERVENTION: The study group received 15 mg/kg IV TXA before incision and a second identical dose 3 hours after the initial dose. MAIN OUTCOME MEASUREMENTS: Transfusion rates and total blood loss (TBL) [via hemoglobin-dilution method and rates of venous thromboembolic events (VTEs)]. RESULTS: TBL was significantly higher in the control group (TXA = 952 mL, no TXA = 1325 mL, P = 0.028). The total transfusion rates between the TXA and control groups were not significantly different (TXA 1.51, no TXA = 1.17, P = 0.41). There were no significant differences between the TXA and control groups in inpatient VTE events (P = 0.57). CONCLUSION: The use of TXA in high-energy fractures of the pelvis, acetabulum, and femur significantly decreased calculated TBL but did not decrease overall transfusion rates. TXA did not increase the rate of VTE. Further study is warranted before making broad recommendations for the use of TXA in these fractures. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Manipulation Under Anesthesia as a Treatment of Posttraumatic Elbow Stiffness.

OBJECTIVES: Evaluate the safety and efficacy of manipulation under anesthesia (MUA) for posttraumatic elbow stiffness. DESIGN: Retrospective, case series. SETTING: Single institution; level 1 trauma center. PATIENTS/PARTICIPANTS: Chart review of 45 patients over a 10-year period treated with MUA for posttraumatic elbow stiffness after elbow injuries treated both operatively and nonoperatively. INTERVENTION: None. MAIN OUTCOME MEASURES: Change in total flexion arc pre- to postmanipulation; time to manipulation; complications. RESULTS: Average time from most recent surgical procedure or date of injury to MUA was 115 days. Average premanipulation flexion arc was 57.9 degrees; average flexion arc at the final follow-up was 83.7 degrees. The improvement in elbow flexion arc of motion was statistically significant (P < 0.001). Post hoc analysis of the data revealed 2 distinct groups: 28 patients who underwent MUA within 3 months of their most recent surgical procedure (early manipulation), and 17 patients who underwent MUA after 3 months (late manipulation). Average improvement in elbow flexion arc in the early MUA group was 38.3 degrees (P < 0.001); improvement in the late MUA group was 3.1 degree. Comparison of improvement between the early and late MUA groups found a significant difference (P < 0.001) in mean flexion arc improvement from premanipulation to postmanipulation, favoring the early group. One patient had a complication directly attributable to MUA. Nineteen patients required additional procedures on the injured extremity after MUA. CONCLUSIONS: MUA is a safe and effective adjunct to improving motion in posttraumatic elbow stiffness when used within 3 months from the original injury or time of surgical fixation. After 3 months, MUA does not reliably increase elbow motion. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Modified Iliac Oblique-Outlet View: A Novel Radiographic Technique for Antegrade Anterior Column Screw Placement.

Percutaneous fixation of acetabular fractures can be challenging because of the complex anatomy of the anterior column. We have used a modified iliac oblique-outlet image view in conjunction with more traditional radiographic views to place antegrade anterior column screws. This technique does not replace the pelvic inlet but is a good alternative in the lateral decubitus position because it helps to mitigate the difficulties of obtaining the pelvic inlet radiograph in this position. The purpose of this study is to describe the radiographic technique, demonstrate proper and aberrant screw placement using Sawbones, and present a review of patients in which this technique was used in clinical practice.

Posterior wall acetabulum fracture-dislocation with subsequent ipsilateral pipkin IV fracture-dislocation: How many hits can a hip take?

The treatment of acetabulum fractures is a technically-demanding task for orthopaedic trauma surgeons. The treatment of femoral head fractures associated with acetabulum fractures, pipkin IV fractures, presents difficulty as usually the femoral head fracture requires treatment through an anterior approach and the acetabulum fracture, which is commonly a posterior wall fracture, requires treatment through a posterior approach. Recently, surgical dislocation of the hip has become an accepted option for treatment of these fractures as it allows treatment of the femoral head fracture and posterior wall acetabulum fracture through one approach. However, dual anterior and posterior approaches are acceptable. We present 15 year follow up of an 18 year old female who underwent open reduction internal fixation of a posterior wall acetabulum fracture through a Kocher-Langenbeck approach. Four months later the patient sustained a second fracture dislocation of the same hip, this time a femoral head fracture with an associated posterior wall acetabulum fracture that was treated with a Kocher-Langenbeck approach for the revision acetabulum and a approach for the femoral head fracture. At fifteen years the patient had a Merle d'Aubigne score of 15 and a Harris hip score of 71. She was gainfully employed and subjectively happy with her surgical result. While treatment of pipkin IV fracture dislocations can be treated through a surgical dislocation of the hip, dual surgical approaches are a viable option in certain cases.

The reamer-irrigator-aspirator as a device for harvesting bone graft compared with iliac crest bone graft: union rates and complications.

OBJECTIVES: This study was performed to compare patient outcomes after Reamer-Irrigator-Aspirator (RIA)-harvested bone grafting with the current gold standard, either anterior or posterior iliac crest bone graft (ICBG). DESIGN: Prospective randomized controlled trial. SETTING: Multicenter study at 3 geographically separate Level 1 trauma centers. PATIENTS/PARTICIPANTS: One hundred thirty-three patients with nonunion or posttraumatic segmental bone defect requiring operative intervention. INTERVENTION: Patients were prospectively randomized to receive ICBG or RIA autograft. Supplemental internal fixation was performed per surgeon preference. MAIN OUTCOME MEASUREMENTS: Operative data included amount of graft, time of harvest, and associated surgical costs. The Short Musculoskeletal Functional Assessment and the Visual Analog Scale were used to document baseline and postoperative function and pain. Clinical and radiographic union was the defined end point; patients considered to have failed treatment if they either developed an infection requiring operative treatment or had a persistent nonunion of the grafted extremity. RESULTS: One hundred thirteen of the 133 enrolled patients were followed until union and included in the final analysis. Intraoperative data showed anterior ICBG to yield 20.7 ± 12.8 (5-60) cm of autograft with an average harvest time of 33.2 ± 16.2 minutes, posterior ICBG yielded 36.1 ± 21.3 (20-100) cm of autograft in 40.6 ± 11.2 minutes, and RIA yielded 37.7 ± 12.9 (5-90) cm in 29.4 ± 15.1 minutes. Anterior ICBG produced significantly less bone graft than either RIA or posterior ICBG (P < 0.001). The RIA harvest was completed in significantly less operative time compared with posterior ICBG (P = 0.005). At $738, the RIA setup was considerably more expensive than the ∼$100 cost of a bone graft tray; however, when compared with posterior ICBG, the longer operative time required for a posterior harvest came at an additional incremental cost of $990-1880, making RIA the less expensive option. Patients were followed for an average of 56.9 ± 42.1 (11-250) weeks. Forty-nine of 57 patients (86.0%) who received ICBG united in an average of 22.5 ± 13.2 weeks; 46 of 56 patients (82.1%) who received RIA healed in an average of 25.8 ± 17.0 weeks. Union rates and time to union were comparable between the 2 procedures. There was no difference in complications requiring reoperation for persistent nonunion or infection at the grafted site, nor there was any difference in donor-site complications. Postoperative follow-up showed that RIA patients had significantly lower donor-site pain scores throughout follow-up. CONCLUSIONS: When compared with autograft obtained from the iliac crest, autograft harvested using the RIA technique achieves similar union rates with significantly less donor-site pain. RIA also yields a greater volume of graft compared with anterior ICBG and has a shorter harvest time compared with posterior ICBG. For larger volume harvests, cost analysis favors using RIA. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical analysis of a novel femoral neck locking plate for treatment of vertical shear Pauwel's type C femoral neck fractures.

BACKGROUND: The purpose of this study is to determine the biomechanical stability of a novel prototype femoral neck locking plate (FNLP) for treatment of Pauwels type C femoral neck fractures compared with other current fixation methods. METHODS: Forty femur sawbones were divided into groups and a vertical femoral neck fracture was made. Each group was repaired with one of the following: (CS) three parallel cancellous screws; (XCS) two cancellous lag screws into the head and one transverse lag screw into the calcar; and (FNLP) a novel FNLP with two 5.7 mm locking, one lag screw into the calcar and two screws into the shaft; and (AMBI) a two-hole, 135° AMBI plate with a derotation screw. All groups were tested for change in axial stiffness over 20000 cycles, and rotational stiffness was measured before and after cyclic testing. A maximum load to failure test was also conducted. Results were compared with one-way analysis of variance (ANOVA) and Fisher protected least significant difference (PLSD). RESULTS: Results for axial stiffness show that AMBI, CS, XCS and FNLP are 2779.0, 2207.2, 3029.9 and 3210.7 N-m mm(-1), respectively. Rotational rigidity results are 4.5, 4.1, 17.1 and 18.7 N-m mm(-1). The average cyclic displacements were 0.75, 0.88, 0.80 and 0.65 mm, respectively. Destructive failure loads for AMBI, CS, XCS and FNLP were 2.3, 1.7, 1.6 and 1.9 kN, respectively. CONCLUSIONS: The results of this experiment show statistically significant increases in axial stiffness for the FNLP compared with three traditional fixation methods. The FNLP demonstrates increased mechanical stiffness and combines the desirable features of current fixation methods.