A graphic guide to the percutaneous tripod acetabular reconstruction for metastatic cancer.

Symptomatic peri-acetabular metastatic lesions are often treated with open surgery such as modified Harrington procedures. In an effort to avoid surgical complications inherently associated with open surgical approaches, we developed and recently reported a novel Tripod percutaneous screw technique. The tripod technique is minimally invasive and was found to yield excellent outcomes regarding both pain control and functionality. The procedure is performed in a standard operative theater using fluoroscopic guided percutaneous screws. Despite the simplicity of intraoperative set-up and instrumentation, it is technically demanding. Obtaining the correct fluoroscopic views and troubleshooting intraoperative hurdles can be challenging for even an experienced orthopedic surgeon. The technique and bony conduits were previously described in the trauma literature, however, there are key points of difference in the setting of metastatic disease. Here we provide a compilation of a stepwise graphic guide for the tripod model in the setting of metastatic peri-acetabular lesions, as well as the tips and tricks based on our own experience. These encompass preoperative preparation, operating room settings, intraoperative fluoroscopic guidance, postoperative care, and subsequent conversion to a cemented total hip arthroplasty, if needed.

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.

Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg.

OBJECTIVE: Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS: Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS: The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION: This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

Combined limited internal fixation and multiplanar external fixation for immediate weight bearing of fractures around the foot and ankle.

Treatment of fractures around the foot and ankle can be challenging in patients who are unable to remain non weight bearing on their lower extremity. Traditional implants are not sufficient to resist loads incurred during weight bearing and can also lead to complications related to wound healing and infection. We describe a technique for fracture fixation of the foot and ankle that uses low profile implants to minimize soft tissue insult combined with multiplanar external fixation to allow for immediate weight bearing.

Salvage of a recalcitrant humeral shaft septic nonunion using a linked nail-plate fixation construct with intercalary allograft.

Open humeral shaft fractures comprise approximately 2% of all fractures of the humerus. Nearly 20% of open humeral shaft fractures will develop deep infection, increasing the risk of nonunion regardless of treatment method. Recalcitrant septic nonunion of the humeral shaft is a complex and challenging problem. Operative treatment should aim to eradicate infection, address bony defects, and establish a stable construct that affords early motion. We describe the case of a 38-year-old male with a recalcitrant humeral shaft septic nonunion following fixation of an open humeral shaft fracture. Management of the infection consisted of periodic surgical debridement and IV antibiotics, resulting in a 10 cm segmental defect. Definitive fixation was achieved using the combination of an antegrade intramedullary nail, intercalary femoral shaft allograft, compression plating, and autologous bone graft. In addition to achieving bony union, the patient regained his pre-injury ROM and function, which was clinically sustained at 2-year follow-up.

The "Double Washer" Technique Is an Effective Strategy for Bicortical Fixation in Periprosthetic Fractures About a Femoral Stem: A Technical Trick and Case Series.

SUMMARY: Periprosthetic fractures about the hip and knee are challenging injuries to treat for the orthopaedic surgeon. The pre-existing femoral implant and poor bone quality provide for difficulties in achieving stable fixation. We present a surgical technique and clinical series of 5 patients describing the use and outcomes of a 3.5 screw with a "double washer" technique to achieve bicortical fixation around a femoral prosthesis.

Increased morbidity and mortality in elderly patients with lower extremity trauma and associated injuries: A review of 420,066 patients from the national trauma database.

INTRODUCTION: There is a paucity of research addressing the morbidity and mortality associated with polytrauma in elderly patients. This study aimed to compare the outcomes of elderly trauma patients with an isolated lower extremity fracture, to patients lower extremity fractures and associated musculoskeletal injuries. METHODS: This study is a retrospective review from the National Trauma Database (NTDB) between 2008 and 2014. ICD 9 codes were used to identify patients 65 years and older with lower extremity fractures. Patients were categorize patients into three sub groups: patients with isolated lower extremity fractures (ILE), patients with two or more (multiple) lower extremity fractures (MLE) and, patients with at least one upper and at least one lower extremity fracture (ULE). Groups were stratified into patients age 65-80 and patients >80 years of age. RESULTS: A total 420,066 patients were included in analysis with 356,120 ILE fracture patients, 27,958 MLE fracture patients, and 35,988 ULE fracture patients. The MLE group reported the highest dispatch to ACS level 1 trauma centers at 31.8% followed by the ULE group at 28.5% and the ILE group at 24.7% of patients (p<0.001). The overall rate of complications was highest in the MLE group followed by the ULE and then the ILE group (41.4%, 40.3%, 36.1%, respectively p<0.001). Motility rates in patients >80 years old in the MLE group and ULE group were similar (1.483 vs 1.4432). However, in the 65-80 year group the odds of mortality was 1.260 in the MLE group and 1.450 in the ULE group (p<0.001), such that the odds of mortality after sustaining a MLE fracture increases with age, whereas this effect was not seen in the ULE group. CONCLUSION: Patients who sustained MLE and ULE fractures, had increased mortality, complications and in hospital care requirements as compared to patients with isolated lower extremity injuries. These outcomes are comparable between ULE and MLE fracture patients over the age of 80 however patients 65-80 with ULE fractures had increased mortality as compared patients 65-80 with MLE fractures. Understanding the unique considerations and requirements of elderly trauma patients is vital to providing successful outcomes.

Minimally invasive plate osteosynthesis of distal radius fractures using a pronator sparing approach.

Volar locking plates for fractures of the distal radius are a common option of care in many centers. Currently, these plates are placed through a standard approach, such as the flexor carpi radialis interval. However, in our opinion, the use of conventional plate application techniques is associated with more soft tissue dissection than is necessary for these new plates. This may contribute to postoperative pain and also to scarring, which may impede the range of motion. To avoid this, dorsal plates have been developed that can be inserted percutaneously. Historically, dorsal plating of the distal radius has been associated with increased morbidity relative to volar plates due to soft tissue depth. This article discusses a single surgeon's technique for insertion of volar locking plates through minimal incisions with sparing of the soft tissues.

Anterior tension band plating for anterior tibial stress fractures in high-performance female athletes: a report of 4 cases.

Stress fracture of the anterior tibial cortex is an extremely challenging fracture to treat, especially in the high-performance female athlete who requires rapid return to competition. Previous reports have not addressed treating these fractures in the world-class athlete with anterior plating. We hypothesize that anterior plating is a biomechanically sound approach to treatment of these fractures, and will lead to an earlier return to full activity than either nonoperative treatment or intramedullary nailing. We present a retrospective series of 4 case reports of 4 world-class female athletes with stress fractures of the anterior tibial cortex treated by anterior plating between 2001 and 2004. Average follow-up was 15 months (range 12 to 48 mo). Anterior tension band plating resulted in fracture healing in all 4 cases and return to full activity at a mean of 10 weeks. All patients returned to preinjury competitive levels. There were no complications of infection, nonunion, or malunion. Anterior tension-band plating of an anterior tibial stress fracture leads to rapid fracture healing and return to competition for high-performance female athletes. This approach should be considered in those athletes who wish to avoid the more prolonged convalescence associated with nonoperative treatment, or the problems, especially of the knee, associated with intramedullary nailing.

Treatment of Acetabular Fractures in Adolescents.

Although the treatment of acetabular fractures in adults has evolved substantially, treatment of these injuries in adolescents remains primarily nonoperative. We performed a retrospective review to evaluate outcomes of treatment of adolescent acetabular fractures. We identified 38 adolescent acetabular fractures (patient ages, 11-18 years), all treated by an experienced trauma surgeon. Open reduction and internal fixation (ORIF) was performed in 37 cases, and 1 case was treated nonoperatively. Mean follow-up was 38.2 months. All fractures healed. Reduction was anatomical in 30 cases, imperfect in 7. One patient had surgical secondary congruence, 1 had preoperative deep vein thrombosis, 1 developed a deep infection, and 2 had femoral head avascular necrosis and developed posttraumatic arthritis (both had hip dislocations). Of the 38 patients, 34 returned to full activity. At latest follow-up, 29 had no pain, and 6 had mild intermittent pain not limiting activity. ORIF was found to be safe and to result in predictable union. We therefore advocate a more aggressive strategy. Given our low complication rate, we recommend nonoperative management only for stable, minimally displaced fractures (<1 mm). Unstable fractures, fractures with any hip subluxation, and fractures displaced more than 1 mm should be managed with ORIF. As reported in adults, articular injury often is associated with secondary degenerative arthritis. This association is expected in adolescents as well. Given adolescents' life expectancy subsequent to injury and surgery, any late posttraumatic arthritis will have a significant impact on quality of life over the long term, with increased duration compared with adults.

Dorsal percutaneous cannulated screw fixation for delayed union and nonunion of the scaphoid.

BACKGROUND: Percutaneous fixation of fractures of the scaphoid is well documented in the acute setting by both dorsal and volar methods. What is not commonly discussed is the use of this method for delayed unions and nonunions of the scaphoid. The authors present their case series of patients who underwent dorsal percutaneous fixation for delayed union or nonunion of the scaphoid. METHODS: This study retrospectively reviewed eight consecutive patients (six male patients and two female patients) with a delayed union (8 to 12 weeks) or nonunion (≥13 weeks) of the scaphoid waist treated with dorsal percutaneous cannulated screw fixation. The indications for surgery included failure of conservative treatment, pain with loss of wrist mobility, and prevention of long-term osteoarthritis. Exclusion criteria included previous surgery, dorsal intercalated segmental instability, fracture displacement of more than 1.0 mm, osteoarthritis, avascular necrosis, and proximal pole nonunion. RESULTS: The union rate was 100 percent, with an average time to union of 7 weeks for the delayed union group (three of eight) and 13 weeks for the nonunion group (five of eight). No statistically significant difference was found between the preoperative and postoperative radiolunate angles, scapholunate angles, and height-to-length scaphoid ratio. All patients were able to return to their preinjury employment after an average of 10 weeks. CONCLUSION: This pilot study demonstrates that the dorsal percutaneous approach to treatment of delayed union and nonunion of stable scaphoid waist fractures can result in predictable union, with minimal morbidity and complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The use osteochondral allograft in the treatment of a severe femoral head fracture.

This study reviews the second case in the literature involving the use of frozen osteochondral allograft to reconstruct a femoral head fracture-dislocation. The case involved significant, unreconstructable damage to the weightbearing area of the femoral head in an 18-year-old male. Clinical and diagnostic imaging follow up at 46 months revealed that despite magnetic resonance imaging and radiographic evidence of progressive arthrosis in the hip, including subchondral cystic change in the femoral head and localized cartilage loss in the acetabulum and femoral head, the patient had excellent function with no complications (Harris hip score 100, hip dysfunction and osteoarthritis outcome score 62, musculoskeletal function assesment score 22, SF-36 score 81). The use of osteochondral allograft may serve as a useful tool for the orthopaedic surgeon faced with an unreconstructable femoral head fracture-dislocation in a young patient.

Open reduction and internal fixation of coronal fractures of the capitellum.

In this article, we describe a technique for internal fixation of coronal shear fractures of the distal humerus. It follows basic AO principles utilizing lag screw fixation combined with an antiglide plate to neutralize shearing forces. We have used this technique successfully for the treatment of isolated shear fractures of the capitellum, including those with extension into the trochlea.

Atlantoaxial fusion using anterior transarticular screw fixation of C1-C2: technical innovation and biomechanical study.

This study is an attempt to describe a new technique for anterior transarticular screw fixation of the atlantoaxial joints, and to compare the stability of this construct to posterior transarticular screw fixation with and without laminar cerclage wiring. Nine human cadaveric specimens were included in this study. The C1-C2 motion segment was instrumented using either anterior transarticular screws (group 1), posterior transarticular screws alone (group 2), or posterior screws with interlaminar cerclage wires (group 3). Using an unconstrained mechanical testing machine, the specimens were tested in rotation, lateral bending, and flexion-extension using nondestructive loads of +/-2 N m. The specimens were also tested in translation using nondestructive loads of +/-100 N. All values for the three groups with regards to anterior-posterior displacement, rotation, and lateral bending were similar as determined using a Kruskal-Wallis rank sum test with a significance level of p<0.05. The only significant difference was registered in flexion-extension where the cerclage wire added some strength to the construct. Anterior transarticular screw fixation of the atlantoaxial spine has several advantages over posterior fixation techniques, and is as stable as posterior transarticular fixation in all clinically significant planes of motion. The addition of posterior interlaminar cerclage wiring further improves resistance to flexion-extension forces. Anterior transarticular screw fixation of the atlantoaxial joint is a useful technique for achieving C1-C2 stabilization.