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INTRODUCTION: The selection of the most optimal fixation method for fractures of the distal femur, whether intramedullary nail (NL), lateral locking plate (PL), or nail/plate (NP) is not always clear. This study retrospectively evaluates surgical patients with distal femur fractures and introduces a pilot study using cluster analysis to identify the most optimal fracture fixation method for a given fracture type. METHODS: This is a retrospective cohort study of patients 18 years and older with an isolated distal femur fracture who presented to our Level-1 trauma center between January 1, 2012, and December 31, 2022, and obtained NL, PL, or NP implants. Patients with polytrauma and those without at least six months of follow-up were excluded. A chart review was used to obtain demographics, fracture classification, fixation method, and postoperative complications. A cluster analysis was performed. The following factors were used to determine a successful outcome: ambulatory status pre-injury and 6-12 months postoperatively, infection, non-union, mortality, and implant failure. RESULTS: A total of 169 patients met inclusion criteria. No statistically significant association between the fracture classification and fixation type with overall outcome was found. However, patients treated with an NP (n = 14) had a success rate of 92.9% vs only a 68.1% success rate in those treated with a PL (n = 116) (p = 0.106). The most notable findings in the cluster analysis (15 total clusters) included transverse extraarticular fractures demonstrating 100% success if treated with NP (n = 6), 50% success with NL (n=2), and 78.57% success with PL fixation (n=14). NP constructs in complete articular fractures demonstrated success in 100% of patients (n = 5), whereas 77.78% of patients treated with NL (n = 9) and 61.36% of those treated with PL (n = 44). CONCLUSIONS: Plate fixation was the predominant fixation method used for distal third femur fractures regardless of fracture classification. However, NP constructs trended towards improved success rates, especially in complete intraarticular and transverse extraarticular fractures, suggesting the potential benefit of additional fixation with these fractures. Cluster analysis provided a heuristic way of creating patient profiles in patients with distal third femur fractures. However, a larger cohort study is needed to corroborate these findings to ultimately develop a clinical decision-making tool that also accounts for patient specific characteristics.
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BACKGROUND: Despite relatively high rates of surgical site infections (SSIs) after pediatric spine surgery, practice guidelines are absent. We performed a systematic review of the literature, determining the level of evidence for risk factors for SSIs and prevention practices to reduce SSIs following pediatric spine surgery. METHODS: The search utilized the root search words "spine," "scoliosis," and "infection" resulting in 9594 abstracts. Following removal of duplicate abstracts, those that assessed only SSI rates, SSI treatment, nonoperative spine infections, or adult populations, 57 relevant studies were rated for level of evidence and graded using previously validated scales. RESULTS: Very few studies lead to grade A (good evidence) or grade B (fair evidence) recommendations. Ceramic bone substitute did not increase the risk of SSIs when compared with autograft (grade A). Comorbid medical conditions, particularly cerebral palsy or myelodysplasia; urinary or bowel incontinence; nonadherence to antibiotic prophylaxis protocols; and increased implant prominence increase the risk of SSIs (grade B). SSIs caused by gram-negative bacilli were more frequent in neuromuscular populations and first-generation stainless steel implants increased the risk of delayed infection compared to newer generation titanium implants (grade B). Evaluations of other risk factors for SSIs yielded conflicting or poor-quality evidence (grade C); these included malnutrition or obesity; number of levels fused or fusion extended to the sacrum/pelvis; blood loss; and use of allograft. Insufficient evidence (0 to 1 published studies) was available to recommend numerous practices shown to reduce SSI risk in other populations such as chlorhexidine skin wash the night before surgery, preoperative nasal swabs for Staphylococcus aureus, chlorhexidine skin disinfection, perioperative prophylaxis with intravenous vancomycin, vancomycin, or gentamicin powder in the surgical site or graft. CONCLUSIONS: Few studies have evaluated risk factors and preventive strategies for SSIs following pediatric spine surgery. This systematic review documents the relative lack of evidence supporting SSI prevention practices and highlights priorities for research. LEVEL OF EVIDENCE: Level III therapeutic study.
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Escoliose/cirurgia , Fusão Vertebral/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Criança , Humanos , Guias de Prática Clínica como Assunto , Fatores de RiscoRESUMO
BACKGROUND: Perioperative surgical site infection (SSI) after pediatric spine fusion is a recognized complication with rates between 0.5% and 1.6% in adolescent idiopathic scoliosis and up to 22% in "high risk" patients. Significant variation in the approach to infection prophylaxis has been well documented. The purpose of this initiative is to develop a consensus-based "Best Practice" Guideline (BPG), informed by both the available evidence in the literature and expert opinion, for high-risk pediatric patients undergoing spine fusion. For the purpose of this effort, high risk was defined as anything other than a primary fusion in a patient with idiopathic scoliosis without significant comorbidities. The ultimate goal of this initiative is to decrease the wide variability in SSI prevention strategies in this area, ultimately leading to improved patient outcomes and reduced health care costs. METHODS: An expert panel composed of 20 pediatric spine surgeons and 3 infectious disease specialists from North America, selected for their extensive experience in the field of pediatric spine surgery, was developed. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were as follows: (1) surveyed for current practices; (2) presented with a detailed systematic review of the relevant literature; (3) given the opportunity to voice opinion collectively; and (4) asked to vote regarding preferences privately. Round 1 was conducted using an electronic survey. Initial results were compiled and discussed face-to-face. Round 2 was conducted using the Audience Response System, allowing participants to vote for (strongly support or support) or against inclusion of each intervention. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. Repeat voting for consensus was performed. RESULTS: Consensus was reached to support 14 SSI prevention strategies and all participants agreed to implement the BPG in their practices. All agreed to participate in further studies assessing implementation and effectiveness of the BPG. The final consensus driven BPG for high-risk pediatric spine surgery patients includes: (1) patients should have a chlorhexidine skin wash the night before surgery; (2) patients should have preoperative urine cultures obtained; (3) patients should receive a preoperative Patient Education Sheet; (4) patients should have a preoperative nutritional assessment; (5) if removing hair, clipping is preferred to shaving; (6) patients should receive perioperative intravenous cefazolin; (7) patients should receive perioperative intravenous prophylaxis for gram-negative bacilli; (8) adherence to perioperative antimicrobial regimens should be monitored; (9) operating room access should be limited during scoliosis surgery (whenever practical); (10) UV lights need NOT be used in the operating room; (11) patients should have intraoperative wound irrigation; (12) vancomycin powder should be used in the bone graft and/or the surgical site; (13) impervious dressings are preferred postoperatively; (14) postoperative dressing changes should be minimized before discharge to the extent possible. CONCLUSIONS: In conclusion, we present a consensus-based BPG consisting of 14 recommendations for the prevention of SSIs after spine surgery in high-risk pediatric patients. This can serve as a tool to reduce the variability in practice in this area and help guide research priorities in the future. Pending such data, it is the unsubstantiated opinion of the authors of the current paper that adherence to recommendations in the BPG will not only decrease variability in practice but also result in fewer SSI in high-risk children undergoing spinal fusion. LEVEL OF EVIDENCE: Not applicable.
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Guias de Prática Clínica como Assunto , Fusão Vertebral/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Adolescente , Criança , Consenso , Técnica Delphi , Custos de Cuidados de Saúde , Humanos , Avaliação de Resultados em Cuidados de Saúde , Fatores de Risco , Escoliose/cirurgia , Infecção da Ferida Cirúrgica/economiaRESUMO
BACKGROUND: Geriatric hip fractures are common and associated with high morbidity and mortality. This study aimed to evaluate the incidence, timing, and risk factors of contralateral hip fracture after initial hip fracture. METHODS: Initial hip fractures in patients older than 65 years were abstracted from the national, administrative M91Ortho PearlDiver data set. Incidence and timing of contralateral hip fractures in the following 10 years were identified. Kaplan-Meier survival analysis until contralateral hip fracture was conducted. To account for patient mortality over the later years, 2-year univariate and multivariate analyses were used to determine factors predictive of contralateral hip fracture. RESULTS: Of the initial 104,311 hip fractures identified, contralateral hip fracture in the 10 years that followed was identified for 7,186 (6.9%), of which 68.4% occurred in the first 2 years. Kaplan-Meier survival analysis until contralateral fracture revealed the 10-year incidence to be 12.9% when controlling for those lost from the data set during the study period. Multivariate logistic regression revealed independent predictors of contralateral hip fracture in the 2 years after index hip fracture, when the incidence was greatest, to be female sex (odds ratio [OR] 1.15), body mass index < 20 (OR 1.30), and percutaneous pinning surgery for initial hip fracture fixation (OR 1.58) (P < 0.0001 for each). CONCLUSIONS: In a national cohort of 104,311 geriatric hip fractures, Kaplan-Meier analysis for contralateral hip fracture found the 10-year incidence to be 12.9%, of which nearly 70% were in the first 2 years, and predisposing factors were defined. As such, future research should aim to identify the cause and mitigate the risk of secondary contralateral hip fractures in geriatric patients.
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Fraturas do Quadril , Humanos , Feminino , Idoso , Estudos Retrospectivos , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/etiologia , Fraturas do Quadril/cirurgia , Fatores de Risco , Fixação de Fratura/efeitos adversosRESUMO
"Less-lethal" munitions are designed to cause incapacitation and are often used by law enforcement officers. Although these munitions are not designed to cause severe injury, recent reports have demonstrated that they can cause severe injury, permanent disability, and death. The long-term consequences of injury due to less-lethal munitions are not well understood. We present a case of osteomyelitis and pelvic abscess secondary to a retained beanbag munition following penetrating injury in the setting of a patient with delayed presentation for care. The patient underwent surgical removal of the retained beanbag munition and irrigation and debridement of the osteomyelitis and pelvic abscess with an excellent functional outcome. We discuss the public health and policy implications of serious injury due to less-lethal munitions.
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OBJECTIVES: To assess the reliability of the current computed tomography (CT)-based technique for determining femoral anteversion and quantify the prevalence and magnitude of side-to-side differences. DESIGN: Cross-sectional cohort study. SETTING: Academic trauma center. PATIENTS: We reviewed CT scans from 120 patients with bilateral full-length axial cuts of both femurs. Two hundred forty femurs with no fractures or other identifying features in their femora were included. Ten unique data sets were created to measure anteversion of the left and right sides. MAIN OUTCOME MEASUREMENTS: Intraobserver and interobserver reliability were calculated using intraclass correlation coefficients (ICCs) and pooled absolute differences. The mean absolute difference between the sides was determined using a fixed-effects model. RESULTS: Interobserver reliability was high (ICC: 0.85, 95% confidence interval [CI]: 0.83-0.88). The pooled mean absolute magnitude of variation between reviewers was small at 1.6 degrees (95% CI: 1.4-1.8 degrees) per scan. The intraobserver reproducibility was high (ICC: 0.91, 95% CI: 0.88-0.93) with a mean error of 2.7 degrees (95% CI: 2.2-3.1 degrees) per repeat viewing of the same scan by the same person. The magnitude of side-to-side variation was 2.0 degrees (95% CI: 1.5-2.6 degrees). Twenty-one subjects (18%, 95% CI: 12%-25%) had a mean side-to-side calculated femoral anteversion difference of ≥10 degrees, whereas 6 (5%, 95% CI: 2-10) subjects had a calculated mean side-to-side difference of ≥15 degrees. CONCLUSIONS: CT based femoral anteversion measurement techniques demonstrate good precision. Only 1 in 20 patients had side-to-side differences of 15 degrees or more.
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Fêmur , Tomografia Computadorizada por Raios X , Estudos Transversais , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Humanos , Reprodutibilidade dos Testes , RotaçãoRESUMO
Background. Syndesmotic disruption occurs in 20% of ankle fractures and requires anatomical reduction and stabilization to maximize outcomes. Although screw breakage is often asymptomatic, the breakage location can be unpredictable and result in painful bony erosion. The purpose of this investigation is to report early clinical and radiographic outcomes of patients who underwent syndesmotic fixation using a novel metal screw designed with a controlled break point. Methods. We performed a retrospective review of all patients who underwent syndesmotic fixation utilizing the R3lease Tissue Stabilization System (Paragon 28, Denver, CO) over a 12-month period. Demographic and screw-specific data were obtained. Postoperative radiographs were reviewed, and radiographic parameters were measured. Screw loosening or breakage was documented. Results. 18 patients (24 screws) met inclusion criteria. The mean follow-up was 11.7 months (range = 6.0-14.7 months). 5/24 screws (21%) fractured at the break point. No screw fractured at another location, nor did any fracture prior to resumption of weight bearing; 19 screws did not fracture, with 8/19 intact screws (42.1%) demonstrating loosening. There was no evidence of syndesmotic diastasis or mortise malalignment on final follow-up. No screws required removal during the study period. Conclusion. This study provides the first clinical data on a novel screw introduced specifically for syndesmotic fixation. At short-term follow up, there were no complications and the R3lease screw provided adequate fixation to allow healing and prevent diastasis. Although initial results are favorable, longer-term follow-up with data on cost comparisons and rates of hardware removal are needed to determine cost-effectiveness relative to similar implants.Level of Evidence: Level IV: Retrospective case series.
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Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Articulação do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/cirurgia , Parafusos Ósseos/efeitos adversos , Falha de Equipamento/estatística & dados numéricos , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Adolescente , Adulto , Idoso , Remoção de Dispositivo/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Surgical fixation of syndesmotic instability using quadricortical fixation, whether screws or suture-button devices, places structures on the medial side of the tibia at iatrogenic risk. This study aims to radiographically map the anatomic course of structures on the medial aspect of the distal tibia to be able to at-risk zones (ARZs) for syndesmotic fixation. METHODS: Eighteen fresh-frozen cadaveric ankle specimens were dissected. The saphenous neurovascular bundle (SNVB) and the posterior tibial tendon (PTT) were identified and marked with copper wiring. Standardized and calibrated lateral radiographs of the distal tibia and fibula were analyzed using a grid system consisting of 3 columnar zones from anterior to posterior and five 1-cm rows to chart the anatomic course of the SNVB and the PTT. RESULTS: The SNVB was located in the more anterior zones (1, 2, or anterior to Zone 1) in 97.3% of specimens. The SNVB traversed from posterior to anterior as it descended proximal to distal. The PTT was found in Zone 3 (most posterior zone) for all specimens. The PTT was noted to pass behind (radiographically overlap) the tibia in 83.3% (15 of 18) of specimens between 1 and 3â¯cm above the tibiotalar joint. CONCLUSIONS: Placement of quadricortical syndesmotic fixation places structures on the medial ankle at risk. The SNVB is at considerable risk along the anterior course of the distal tibial while the PTT is only at risk in zone 3 at the distal extent of the tibia.
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Articulação do Tornozelo/cirurgia , Fíbula/cirurgia , Tíbia/cirurgia , Traumatismos do Tornozelo/cirurgia , Parafusos Ósseos/efeitos adversos , Cadáver , Fíbula/anatomia & histologia , Fíbula/diagnóstico por imagem , Humanos , Ligamentos Articulares/cirurgia , Pessoa de Meia-Idade , Radiografia/métodos , Medição de Risco , Veia Safena/cirurgia , Técnicas de Sutura/efeitos adversos , Tíbia/anatomia & histologia , Tíbia/diagnóstico por imagemRESUMO
OBJECTIVES: The purpose of this study is to compare the reliability and accuracy of the screw protuberance method (SPM) and overlay method (OM) for measuring femoral neck shortening on anterior-posterior (AP) radiographs. The secondary aim is to investigate the changes in reliability and accuracy with varying femoral rotation. METHODS: Radio-opaque femur sawbone models were fitted with either 3 cancellous screws or a sliding hip screw implant. Anterior-posterior radiographs were obtained using C-arm fluoroscopy with femoral neck shortening up to 15 mm and with the femoral shaft in 30 degrees of internal rotation to 30 degrees of external rotation (ER). Four observers measured femoral neck shortening at 2 time points. Intraobserver and interobserver reliability were calculated using the intraclass coefficient. Accuracy was analyzed through a Bland-Altman agreement statistic stratified by femoral rotation. RESULTS: Both measurement techniques displayed excellent reliability, regardless of femoral rotation or implant. There was a significant difference in femoral neck shortening measurements with rotation for both the OM (P < 0.001) and SPM (P < 0.001). Both methods are accurate within 1 mm of the actual magnitude of shortening from 30-degree internal rotation to 15-degree ER. At 30-degree ER, shortening was underestimated by -2.10 mm using the OM (95% confidence interval, -2.43 to -1.76; P < 0.01) and by -1.64 mm using the SPM (95% confidence interval, -1.83 to -1.45; P < 0.01). CONCLUSION: This study demonstrates that both the OM and SPM are accurate and reliable assessments for femoral neck shortening; however, both methods are sensitive to extreme ER. Given the simplicity of the SPM technique, it may have increased utility for pragmatic research studies.
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Parafusos Ósseos , Colo do Fêmur , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Colo do Fêmur/diagnóstico por imagem , Colo do Fêmur/cirurgia , Fixação Interna de Fraturas , Humanos , Reprodutibilidade dos TestesRESUMO
Type 2 diabetes mellitus (T2DM) is a multisystemic disease that afflicts more than 415 million people globally-the incidence and prevalence of T2DM continues to rise. It is well-known that T2DM has detrimental effects on bone quality that increase skeletal fragility, which predisposes subjects to an increased risk of fracture and fracture healing that results in non- or malunion. Diabetics have been found to have perturbations in metabolism, hormone production, and calcium homeostasis-particularly PTH expression-that contribute to the increased risk of fracture and decreased fracture healing. Given the perturbations in PTH expression and the establishment of hPTH (1-34) for use in age-related osteoporosis, it was determined logical to attempt to ameliorate the bone phenotype found in T2DM using hPTH (1-34). Therefore, the present study had two aims: (i) to establish a suitable murine model of the skeletal fragility present in T2DM because no current consensus model exists; and (ii) to determine the effects of hPTH (1-34) on bone fractures in T2DM. The results of the present study suggest that the polygenic mouse of T2DM, TALLYHO/JngJ, most accurately recapitulates the diabetic osteoporotic phenotype seen in humans and that the intermittent systemic administration of hPTH (1-34) increases fracture healing in T2DM murine models by increasing the proliferation of mesenchymal stem cells. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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To assess whether far-cortical locking (FCL) screws alter the fracture site strain environment and allow shorter bridge plate constructs for supracondylar femoral fractures, we tested the fracture site displacement under force of synthetic left femora with a 5-cm metaphyseal fracture gap, modeling comminution. Five models of nine constructs were tested (three types of diaphyseal screws [nonlocking, locking, and FCL] and two plate lengths [13 holes and 5 holes]). Long plate models using three or four diaphyseal screws (working length 13.5 or 7.5 cm, respectively) were compared with short plates with three diaphyseal screws (working length 7.5 cm). Models were loaded axially and torsionally; 100 cycles in random order. Primary outcome measures were axial and torsional fracture site stiffness. FCL screws decreased rotational stiffness 19% (P < .01) compared with baseline nonlocking screws in the same plate and working length construct, mirroring the effect (20% decrease in stiffness, P < .01) of nearly doubling the nonlocking construct working length (7.5-13.5 cm). Similarly, FCL screws decreased axial stiffness 23% (P < .01) in the same baseline comparison. Fracture site displacement under loading comparable to a long working length nonlocked plate construct was achieved using a shorter FCL plate construct. By closely replicating the biomechanical properties of a long plate construct, a fracture site strain environment considered favorable in promoting fracture healing might still be achievable using a shorter plate length. Clinical Significance: It might be possible to optimize fracture site strain environment and displacement under loading using shorter FCL plate constructs. Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 00:00-00, 2020.
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Placas Ósseas/estatística & dados numéricos , Parafusos Ósseos/estatística & dados numéricos , Fraturas do Fêmur/cirurgia , Fixação Interna de Fraturas/instrumentação , HumanosRESUMO
BACKGROUND: Removal of previously placed orthopaedic implants is a commonly performed procedure worldwide. Given the diversity of orthopaedic implant manufacturers, surgeons may be uncertain whether they have the appropriate screwdriver on site. The purpose of this study was to assess the compatibility of screw head and size configurations from various orthopaedic manufacturers with two commonly used universal screw removal sets. METHODS: Inclusion of orthopaedic implant manufacturers was determined by market share based on industry-monitoring financial firms. Screw size and drive type for the top grossing orthopaedic implant manufacturers were collected and recorded. Screw and screwdriver compatibility was assessed and compared with two commonly used universal screw removal sets. RESULTS: In total, six orthopaedic implant companies with commonly implanted screws throughout the appendicular skeleton were included. The data were compiled in table format with noncannulated, cannulated, and locking screw offerings separated by the screw size and manufacturer. Guidewire size compatibility for cannulated offerings was also assessed. CONCLUSIONS: Given the ubiquity of implanted orthopaedic implant, removal must be as safe, planned, and controlled as possible. The data in this article provide an inclusive, centralized resource for surgeons looking to confirm the compatibility of previously implanted screws and available removal equipment at their institution.
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Parafusos Ósseos , Remoção de Dispositivo/instrumentação , Planejamento de Assistência ao Paciente , Próteses e Implantes , Humanos , Desenho de Prótese , Estatística como AssuntoRESUMO
BACKGROUND: Orthopaedic surgery frequently requires the use of metal plate and screw constructs for osteosynthesis. These constructs may be subsequently removed for a variety of indications. In the lower extremity in particular, implants (ie, hardware) can lead to prominence and pain secondary to a thin soft-tissue envelope with little subcutaneous tissue. Often, removal is performed without knowledge of the exact type of screw head configuration and/or size, which can make removal technically challenging. The purpose of this study is to consolidate screw head sizes and configurations from commonly utilized orthopaedic foot and ankle implant manufacturers matched against 2 commonly used universal implant removal sets to aid in the expeditious removal of hardware. METHODS: Orthopaedic manufacturers of foot and ankle-specific implants were included based on market share. Publicly available information on screw size, head configuration, and driver size was collected and recorded. This information was cross-referenced against the drivers available in 2 commonly utilized universal implant removal sets. RESULTS: Seven foot and ankle implant manufacturers were included. The data were compiled in table format according to manufacturer and subcategorized by noncannulated screws, cannulated screws, and locking screws. CONCLUSION: Many factors affect the success of hardware removal, and it is imperative that the surgeon knows which drivers are compatible with the implanted hardware. The expanding magnitude and diversity of orthopaedic implants makes removal of hardware more challenging. A guide of compatible drivers for various screw types helps expedite this procedure. LEVELS OF EVIDENCE: Level V.
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Tornozelo/cirurgia , Remoção de Dispositivo/métodos , Pé/cirurgia , Procedimentos Ortopédicos/métodos , Cirurgiões Ortopédicos , Procedimentos de Cirurgia Plástica/métodos , Próteses e Implantes , Traumatismos do Tornozelo/cirurgia , Placas Ósseas , Parafusos Ósseos , Humanos , Desenho de PróteseRESUMO
BACKGROUND: Considerable debate exists regarding how soft-tissue edema should influence timing of surgery for ankle and other lower extremity fractures. Assessment of swelling is subjective, and timing varies among surgeons. However, timing of surgery is one of the few modifiable factors in fracture care. Ultrasonography can objectively measure swelling and help determine optimal timing. The purposes of this study were to determine whether objective measures of swelling, timing to surgery, and patient-specific risk factors correlated with wound complications and to try to create a prediction model for postoperative wound complications based on identified modifiable and nonmodifiable risk factors. METHODS: Patients with closed ankle and other lower extremity fractures requiring surgery with an uninjured, contralateral extremity were included. Demographic information and sonographic measurements on both lower extremities were obtained pre-operatively. Subjects were followed for 3 months and wound complications were documented. A predictive algorithm of independent risk factors was constructed, determining wound complication risk. Given that patients with ankle fractures made up the majority of the study cohort (75/93 or 80%), a separate statistical analysis was performed on this group. A total of 93 subjects completed the study, with 75/93 sustaining ankle fractures. RESULTS: Overall wound complication rate was 18.3%. Timing to surgery showed no correlation with wound complications. A heel-pad edema index >1.4 was independently associated with wound complications. Subgroup analysis of ankle fractures demonstrated a 3.4× increase in wound complications with a heel-pad edema index >1.4. Tobacco history and BMI >25 were independent predictors of wound complications. An algorithm was established based on heel-pad edema index, BMI >25, and tobacco history. Patients with none of the 3 factors had a 3% probability of a wound complication. Patients with 1/3, 2/3 and 3/3 factors had a 12-36%, 60-86% and 96% probability of a wound complication, respectively. CONCLUSIONS: Timing to surgery had no correlation with wound complications. Heel-pad edema index >1.4, BMI >25, and tobacco-use correlated with wound complications. When separately analyzing the cohort that sustained ankle fractures, the heel-pad edema index of >1.4 was still demonstrated to be predictive of wound complications corresponding to a 3.4× increase in wound complication rates (11.1% vs 37.5%). Risk of wound complications significantly increased with each factor. In patients with increased BMI and/or tobacco use, resolution of heel edema may significantly reduce wound complications in lower extremity trauma. LEVEL OF EVIDENCE: Level II, prognostic, prospective cohort study.
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Fraturas do Tornozelo/complicações , Edema/etiologia , Traumatismos da Perna/complicações , Lesões dos Tecidos Moles/etiologia , Tempo para o Tratamento , Doença Aguda , Adulto , Idoso , Fraturas do Tornozelo/cirurgia , Feminino , Fixação Interna de Fraturas , Humanos , Traumatismos da Perna/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Prospectivos , Lesões dos Tecidos Moles/diagnóstico por imagem , UltrassonografiaRESUMO
While broken or loose syndesmotic screws are typically of no clinical consequence, occasionally breakage can result in pain, metal fretting, or bony erosion. Despite quad-cortical syndesmotic screws being relatively easy to remove due to the prominent screw tip penetrating the medial tibial cortex, removal of a broken tri-cortical screw can be technically challenging. The purpose of this manuscript is to describe a safe technique for removing the buried, broken tri-cortical screw fragment via a minimally invasive medial tibial approach by verifying the screw location using intra-operative fluoroscopy.
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Traumatismos do Tornozelo/cirurgia , Parafusos Ósseos/efeitos adversos , Remoção de Dispositivo/métodos , Fixação Interna de Fraturas/efeitos adversos , Radiografia , Adulto , Remoção de Dispositivo/instrumentação , Feminino , Consolidação da Fratura/fisiologia , Guias como Assunto , Humanos , Amplitude de Movimento Articular , Resultado do TratamentoRESUMO
BACKGROUND: Surgical fixation of Jones fractures is often recommended to facilitate recovery and achieve union. Iatrogenic fracture displacement during intramedullary screw fixation is a commonly encountered technical issue. This may be related to fracture location in relation to the surrounding ligamentous attachments, namely the robust intermetatarsal ligaments found at the proximal articulation of the 4th and 5th metatarsals. This study examines the relationship between fracture line and its location in regards to the surrounding ligamentous structures and its effect on Jones fracture displacement, reduction and fixation in a cadaveric model. METHODS: Eighteen fresh-frozen cadaveric feet were dissected with preservation of all ligamentous attachments. Given the similar anatomic distal extent of the dorsal and plantar intermetatarsal ligaments on the 5th metatarsal, measurements were obtained detailing the anatomic position of the dorsal intermetatarsal ligament (DIL) only. The specimens were divided into two groups with modelled fractures created at the 4th & 5th metatarsal articulation proximal to the distal extent of the DIL (Group 1) or just distal to the DIL (Group 2). Fractures were fixed in standard fashion with serial fluoroscopic images obtained to study fracture gapping and rotation. RESULTS: There was approximately 5â¯mm of fracture gapping created iatrogenically during tapping with no statistically significant differences between Group 1 and Group 2 (4.53â¯mm versus 5.25â¯mm, pâ¯=â¯0.5430). The distal aspect of the DIL was anatomically located 2.77â¯mm (Range 1.58â¯mm-4.46â¯mm) distal to the 4th & 5th metatarsal articulation. CONCLUSIONS: Considerable iatrogenic fracture gapping occurs during intramedullary screw fixation of Jones fractures in a cadaveric model regardless of fracture location in relation to the intermetatarsal ligamentous attachments. Specific techniques may be required to maintain anatomic alignment during tapping and screw fixation to prevent iatrogenic displacement. LEVEL OF EVIDENCE: V, Expert Opinion.
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Traumatismos do Pé/cirurgia , Fixação Intramedular de Fraturas/instrumentação , Fraturas Ósseas/cirurgia , Ossos do Metatarso/cirurgia , Fenômenos Biomecânicos , Parafusos Ósseos/efeitos adversos , Cadáver , Fixação Intramedular de Fraturas/efeitos adversos , Humanos , Doença Iatrogênica , Ossos do Metatarso/lesões , Pessoa de Meia-Idade , Modelos BiológicosRESUMO
BACKGROUND: The extensile lateral approach (EL) has been associated with increased wound complications such as apical necrosis which may be due partially from violation of the lateral calcaneal artery (LCA). Traditionally, the vertical limb has been placed half-way between the fibula and Achilles tendon, which may be suboptimal given the proximity to the LCA. We hypothesized that placing the vertical limb further posterior (ie, modified EL [MEL]) would increase the distance from the LCA. The purposes of this study were to quantify the location of the LCA in relation to the vertical limb of the traditional EL approach and to determine if utilizing the MEL approach endangered the LCA to a lesser extent. METHODS: 20 cadavers were used. For the EL approach, the fibula and Achilles tendon were palpated and a line parallel to the plantar foot was drawn between the two. A vertical line (VL), representing the vertical limb of the approach, was drawn at the midway point as a perpendicular extending proximally from the junction of the glabrous/non-glabrous skin (JGNG). For the MEL approach, the anterior border of the Achilles tendon was palpated and a similar vertical line (MVL) was drawn 0.75 cm anterior. Dissection was performed and if the LCA was identified crossing the line VL/MVL, the distance from the JGNG was documented. RESULTS: For the EL approach, the LCA was identified in 17/20 (85%) cadavers at an average distance of 5.0 cm (range 3-7 cm, SD = 1.3 cm) from JGNG. For the ML approach, the LCA was identified in 4/20 (20%) cadavers at an average distance of 5.9 cm (range 3-6.5 cm, SD = 1.7 cm) from the JGNG ( P < .001). CONCLUSIONS: The LCA was encountered 4 times more often during the EL approach as compared to the MEL approach. CLINICAL RELEVANCE: A modification of the EL approach may decrease iatrogenic injury to the LCA and may decrease wound complications.
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Tendão do Calcâneo/fisiopatologia , Artérias/lesões , Calcâneo/lesões , Fíbula/fisiopatologia , Artérias/fisiopatologia , Cadáver , Calcâneo/fisiopatologia , Pé , HumanosRESUMO
BACKGROUND: Patients who sustain orthopaedic trauma in the form of fractures commonly ask treating providers whether the bone is "fractured" or "broken". While orthopaedic surgeons consider these terms synonymous, patients appear to comprehend the terms as having different meanings. Given the commonality of this frequently posed question, it may be important for providers to assess patients' level of understanding in order to provide optimal care. The purpose of this study is to evaluate patients' comprehension and understanding regarding the use of the terms fractured and broken. METHODS: A survey was administered as a patient-quality measure to patients, family members and/or other non-patients presenting to an orthopaedic outpatient clinic at an academic teaching hospital. RESULTS: 200 responders met inclusion criteria. Only 45% of responders understood the terms fractured and broken to be synonymous. Age, gender, nor ethnicity correlated with understanding of terminology. Responders described a "fractured" bone using synonyms of less severe characteristics for 55.7% of their answers and chose more severe characteristics 44.3% of the time, whereas responders chose synonyms to describe a "broken" bone with more severe characteristics as an answer in 62.1% of cases and chose less severe characteristics 37.9% of the time. The difference for each group was statistically significant (P=0.0458 and P ≤0.00001, respectively). There was no correlation between level of education nor having a personal orthopaedic history of a previous fracture with understanding the terms fracture and broken as synonymous. Having an occupation in the medical field (i.e. physician or physical/occupational therapist) significantly improved understanding of terminology. CONCLUSION: The majority of people, regardless of the age, gender, race, education or history of previous fracture, may not understand that fractured and broken are synonymous terms. Providers need to be cognizant of the terminology they use when describing a patient's injury in order to optimize patient understanding and care.
RESUMO
INTRODUCTION: This study was to determine the angle of bend that can be placed in a ball-tip guide wire while still allowing passage of reamers and nails of several commonly utilized nailing systems. METHODS: Ball-tip guide wires, opening reamer tips, femoral nails, and tibial nails were collected from several manufacturers. Guide wires were incrementally bent 3 cm from the tip and passed through the reamer tip, tibial nail, and femoral nail until unable to pass. RESULTS: All systems tested demonstrated that the reamer, with its relative smaller diameter cannula as compared to the nails themselves, determined the smallest tolerable bend to be able to pass the bent guide wire. The bend angle tolerated by reamer tips was on average 7° (4-9°). The bend angle tolerated by femoral nails was more consistent between the tested systems and was on average 15.5° (12-18°). The bend angle tolerated by tibial nails had the most variability between manufacturers and was on average 16° (13-21°). DISCUSSION: Knowing the degree of guide wire bend which is tolerated can save time in equipment preparation as well as allow one to pre-bend the guide wire and know the intramedullary nail and/or reamers will likely pass. We hope the information provided in this work increases awareness of the potential technical issues with guide wire over-bending and that surgeons may err on the side of minimizing the bend in order to save time in the OR, decrease frustration and eliminate intraoperative complications that can occur.