Symptomatic rib fracture nonunion: a systematic review of the literature.

INTRODUCTION: Rib fractures commonly occur in trauma patients with varying presentations. Though the literature in recent years has moved toward favoring more early intervention of acute rib fractures, little has been reported on the matter of surgical fixation for symptomatic rib fracture nonunions. MATERIALS AND METHODS: We performed a review of PubMed and Cochrane databases for articles published since 2000. Inclusion criteria were studies with greater than six months of follow-up, while case studies were excluded. A thorough analysis was performed on patient outcomes, complications reported, operative techniques utilized, and fixation systems used, among other parameters reported by the articles. RESULTS: One hundred and thirty-nine studies resulted from our review, and a total of nine studies met our inclusion criteria with a combined total of 182 patients who underwent open reduction and internal fixation for symptomatic rib fracture nonunions. All studies reported a significant reduction of pain with increased satisfaction in the majority of patients. There were a total of 71 postoperative complications, the most common of which included surgical site infections, hardware failure, and hematoma. The most serious complications were insulting injury to the lung parenchyma or pleura; however, these were extremely rare based off the current literature. The use of bone grafting was common with eight of the nine studies mentioning the benefits of grafting. CONCLUSION: Surgical stabilization of rib fracture nonunions appears to be an appropriate treatment alternative, and various techniques and approaches may be used with similar success. Further studies with higher level of evidence are recommended on the subject.

Reverse shoulder arthroplasty for proximal humerus fractures: a comparison of the deltoid split and deltopectoral approaches.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) is a common treatment for three- and four-part proximal humerus fractures. RSA is commonly performed through a deltopectoral (DP) surgical approach; however, a deltoid split (DS) approach has been described. The purpose of this study was to compare the intraoperative and postoperative outcomes of patients undergoing RSA for proximal humerus fractures through a DP and DS approach. MATERIALS AND METHODS: A retrospective study of patients who underwent RSA for proximal humerus fractures at our level 1 trauma center was performed. Patients were evaluated at a minimum 1-year follow-up. Intraoperative outcomes as well as patient-reported outcome measures (PROMs) were analyzed. Postoperative complications, reoperation rates, and radiographic outcomes were evaluated. RESULTS: Sixteen patients were included in the DP group and 13 patients in the DS group. The average follow-up was 28.6 months in the DP group and 21.1 months in the DS group. There were no significant differences in patient demographics or injury characteristics. Operative time was significantly shorter in the DS group (103 min) compared to the DP group (123 min). Tuberosity repair was performed in 81.3% of patients in the DP group and 92.3% of patients in the DS group. No significant differences were found in PROMs at final follow-up. There were no significant differences in postoperative complications. Three patients in the DP group and one patient in the DS group required reoperation. Lastly, 81.8% of patients achieved tuberosity union in the DS group and 66.7% in the DP group; however, this did not reach statistical significance. CONCLUSION: This study demonstrates that RSA for proximal humerus fractures performed through a DS or DP approach may result in similar intraoperative and postoperative outcomes, with no difference in reoperation or complication rates.

Operative fixation of rib fracture nonunions.

INTRODUCTION: Rib fractures are common injuries in trauma patients that often heal without intervention. Infrequently, symptomatic rib fracture nonunions are a complication after rib fractures. There is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe the efficacy of rib fracture nonunion operative fixation with particular focus on surgical technique, healing rates, and complications. MATERIALS AND METHODS: Patients aged ≥ 18 years with symptomatic rib fracture nonunions treated with open reduction and internal fixation (ORIF) with locking plates at a single urban level 1 trauma center were retrospectively reviewed. Pertinent demographic, clinical, radiographic, and surgical data were collected and analyzed. RESULTS: A total of 18 patients met inclusion criteria. The mean time from injury to undergoing ORIF for rib fracture nonunion was just under a year and the number of ribs plated was 2.95 ± 1.16 (1-5 ribs) with bone grafting used in six cases. All patients (100%) showed evidence of healing at an average of 2.65 ± 1.50 months (2-8 months). All patients reported a decrease in pain. No narcotic pain medication was used at an average of 3.88 ± 3.76 weeks (0-10 weeks) post-operatively. Intraoperative and postoperative complications were found in 4 (22.2%) patients. CONCLUSION: This study concluded that operative fixation of symptomatic rib fracture nonunion demonstrated favorable outcomes with reduction in preoperative pain levels, decreased use of narcotic pain medication, minimal complications, and a high rate of fracture union. This described method provides symptomatic relief, reduction in pain, and promotes bony healing of the fracture nonunion without development of major complications. We suggest that operative fixation should be considered as the primary method of treatment of symptomatic rib nonunions.

Correlation of Lisfranc Injuries With Regional Bone Density.

Lisfranc injuries present a challenge due to their ubiquity though frequent missed diagnoses. A paucity of data exists associating the contribution of bone density to injury type. This investigation compares the regional bone density between Lisfranc injury types using computed-tomography (CT)-derived Hounsfield units. A retrospective chart review identified patients with gross ligamentous and avulsion-type Lisfranc injuries determined by CT examination of the second metatarsal base and medial cuneiform. Regional bone density was assessed by averaging the Hounsfield units of the first metatarsal base, navicular, cuboid, calcaneus, and talus between 2 reviewers. Density was compared between injury type, isolated concomitant forefoot, and mid/hindfoot fractures. One hundred thirty-four patients were separated into avulsion (n = 85) and ligamentous (n = 49) groups. No statistically significant difference in patient body mass index, age, smoking status, or Quenu and Kuss injury pattern was observed between groups. The regional bone density of the cuboid (p = .03) and talus (p = .04) was greater in the ligamentous group. Lower extremity concomitant mid/hindfoot fracture patients exhibited greater regional bone density in the ligamentous group in all assessed bones (p ≤ .04) except the calcaneus. Ligamentous injuries of the Lisfranc complex are associated with increased regional bone density among patients sustaining concomitant mid/hindfoot fractures. This study expands the utility of regional bone density analysis in foot and ankle trauma.

Intramedullary Screw Fixation Versus Traditional Plating for Distal Fibula Fractures.

The traditional method of treating fibular fractures in unstable ankle injuries involves open reduction and internal fixation with a plate and screw construct. Less invasive percutaneous fixation techniques with intramedullary fibular screws have been utilized for many years to reduce wound and implant complications while maintaining a stable ankle mortise. However, there have been no direct case-control studies comparing percutaneous intramedullary fibular screw fixation to the traditional open reduction and internal fixation with plates and screws. In our study, we compared radiographic and clinical outcomes for unstable ankle fractures in which the fibula fracture was treated with either a percutaneous intramedullary screw or by open reduction and internal fixation with a plate and screw construct. We retrospectively reviewed 69 consecutive patients from 2011 to 2019 with unstable ankle fractures treated with intramedullary fibular screws and compared them to 216 case-control patients treated with traditional plate and screw construct over the same time period. The average follow-up for the intramedullary screw group was 11.5 months and 15.2 months for the plate and screw group. We collected general demographic data, measured intraoperative and final follow-up talocrural angles, Kellgren-Lawrence osteoarthritis grade, union rates, implant removal rates, infection rates, and American Orthopedic Foot and Ankle Society ankle-hindfoot scores. The intramedullary screw group had a statistically significant lower rate of delayed implant removal (8.7% vs 23.6%) and there was no detectable difference in other measures.

The Intercalary Fragment in Posterior Malleolus Fractures: Characterization and Significance.

Methods of fixation in ankle fractures involving the posterior malleolus have become increasingly scrutinized. With the increase in computed tomography (CT), an intercalary fracture fragment (ICF) adjacent to the posterior malleolus has been oft described. Treatment of the ICF remains controversial and the purpose of this study was to evaluate radiographic and clinical outcomes in patients who had direct reduction and fixation of this fragment compared to those where the ICF was not fixed. This retrospective study included 249 trimalleolar and posterior pilon ankle fractures grouped into those who had the ICF reduced and fixed (n = 74) and those where the ICF was not directly addressed (n = 175). CT scans were evaluated for size and location of the ICF. Demographic, radiographic and intraoperative variables were collected and analyzed. The group which had the ICF reduced and fixed had decreased Kellgren-Lawrence scores (p = .001). There was also a higher rate of repeat surgery in the group who had the ICF fixed, although not meeting statistical significance. There were no differences in size or location of the ICF fragment between groups. We did identify similarities with other studies in regard to size and posterolateral location of the ICF between groups. However, based on worsening radiographic outcomes of the group where the ICF was reduced and fixed, we do not necessarily recommend universal treatment of this fragment. The surgeon's goal should always be a concentric articular reduction and treatment of the ICF should be considered on a case-by-case basis.

Ankle Fracture Fixation: Medial or Lateral First?

In unstable ankle fractures, the importance of reducing the lateral malleolus first to obtain an anatomic reduction of the talus is well established. Although this is a time-tested and common surgical approach, current surgical practice does not always follow the established dogma. Medial-first fixation may be a worthwhile alternative to lateral-first fixation in select instances. We performed a retrospective, cohort study in an urban level I trauma center to compare medial malleolus-first fixation of unstable ankle fractures with lateral malleolus-first fixation. Patient demographics, injury characteristics, and radiographic metrics including pre-, intra-, and final postoperative talocrural angles, medial clear space, and tibiofibular overlap were assessed. Complications were also reviewed. A total of 280 adult patients with operative bimalleolar ankle fractures from January 2010 to January 2015 met inclusion criteria. There were more open fractures (23.2% vs 9.4%, p = .01) and less isolated injuries in the medial-first group (59.2% vs 71.0%, p = .02). There were less isolated operative procedures (80.3% vs 89.1%, p = .04) and more intramedullary screw placement of the lateral malleolus (11.2% vs 4.3% p = .02) in the medial-first fixation group. There was also a strong trend in identifying more posterior tibial tendon injuries in the medial-first group compared with the lateral-first group (3.5% vs 0%, p = .06). There were no significant differences in fluoroscopy times or radiographic variables in the preoperative, intraoperative, or most recent postoperative images between either group. This approach demonstrates equivalent radiographic outcomes to lateral-first fixation and may be appropriate in select cases.

Distal Radius Skyline View: How to Prevent Dorsal Cortical Penetration.

Volar locked plating has become a standard treatment for operative stabilization of distal radius fractures. It is assumed that volar plating portends a low risk of extensor tendon irritation and rupture, especially when compared with dorsal plating constructs; however, extensor tendon tenosynovitis and rupture is a well-described complication after volar plating of the distal radius. Dorsal cortical penetration of screws may go unnoticed with traditional intraoperative fluoroscopic techniques and may contribute to extensor tendon irritation. This article presents the authors' experience with an additional fluoroscopic dorsal tangential radiograph helping the surgeon ascertain dorsal screw prominence following volar plate fixation. (Journal of Surgical Orthopaedic Advances.

Biomechanical Evaluation of 6.5-mm Cannulated Screws.

Although biomechanical and clinical evidence exists regarding smaller compression screws, biomechanical data regarding the larger headless screws are not currently available. Headed and headless 6.5-mm cannulated compression screws were examined, with analysis of interfragmentary compression, insertion torque, and resistance of the construct to a shear force. No significant differences were seen between the maximum insertion torque of the headless or headed screws. Maximum and steady-state compression forces were also not significantly different between groups. Countersinking the headless model 2 mm led to a 77.01% decrease in steady-state compression levels. Shear testing did not reveal any significant differences in peak load at ultimate failure, specimen stiffness, or final block displacement, although a trend to increased peak load and stiffness was seen with the headless specimens.

Obtaining Volar Tilt in Distal Radius Fixation: Use of a Screw as a Proximal Post.

Volar plating of distal radius fractures was introduced as a means to circumvent some of the issues with dorsal-based plating but has been shown not to be a complete panacea, as other advantages and challenges have subsequently been discovered. Careful attention and proper technique must be utilized to restore and maintain volar tilt. This study reports a technique of using a locking screw as a proximal peg to reliably obtain the volar tilt in a simple fashion.

Treatment of acetabulum fractures through the modified Stoppa approach: strategies and outcomes.

BACKGROUND: Since the original description by Letournel in 1961, the ilioinguinal approach has remained the predominant approach for anterior acetabular fixation. However, modifications of the original abdominal approach described by Stoppa have made another option available for reduction and fixation of pelvic and acetabular fractures. QUESTIONS/PURPOSES: We evaluated our results in patients with acetabulum fractures with the modified Stoppa approach in terms of (1) hip function as measured by the Merle d'Aubigne hip score; (2) complications; and (3) quality of fracture reduction and percentage of fractures that united. METHODS: Between September 2008 and August 2012, 289 patients with acetabular fractures were treated at our Level I trauma center. Twelve percent (36 of 289) of patients were treated operatively using the modified Stoppa approach. Ninety-seven percent (35 of 36) of our patients had fracture patterns involving displacement of the posterior column. Six (17%) were converted early to a total hip arthroplasty, and 14 (39%) were lost to final followup, leaving 22 of 36 for subjective clinical outcome analysis at a mean of 32 months (range, 9-59 months). Our general indications for this approach during the period in question were fractures of the anterior column and anterior wall, anterior column with posterior hemitransverse fractures, both column fractures, transverse fractures, and T-type fractures. Followup included regularly scheduled office visits with radiographs (AP pelvis, Judet views) that were graded by the treating surgeon and by the authors of this study (MJI, BCT) and patient outcome surveys. RESULTS: Merle d'Aubigne hip scores were very good in 55% (12 of 22), good in 9% (two of 22), medium in 18% (four of 22), fair in 5% (one of 22), and poor in 14% (three of 22), and 70% (23 of 33) of patients were able to ambulate without any assistive devices. Complications included one superficial infection and three deep infections, two patients with temporary lateral thigh numbness, no obturator nerve palsies, and one inguinal hernia. Three deaths in the cohort were seen in followup as a result of unrelated causes. Radiographic grading of fracture reductions after surgery revealed that 27 (75%) were anatomic, six (17%) were satisfactory, and three (8%) were unsatisfactory. A total of 94% of the fractures united. CONCLUSIONS: In agreement with prior published data, our results show good functional outcomes with minimal complications using the modified Stoppa approach for a variety of acetabular fractures. Our results highlight the difficulty but feasibility in treating posterior column displacement through an anterior approach. Consideration for dual approaches with posterior column involvement may be warranted to optimize fracture reduction and functional outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Lisfranc Open Reduction and Internal Fixation.

VIDEO AVAILABLE AT: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/lisfranc-open-reduction-and.

The Effect of Obesity on Hemiarthroplasty and Total Hip Arthroplasty for Femoral Neck Fractures.

Obesity is a well-recognized global epidemic that can lead to longer operative times as well as a greater technical demand. Despite this, the available literature evaluating the impact of obesity on hip hemiarthroplasty (HA) and total hip arthroplasty (THA) when treating fractures about the femoral neck is scarce. Between 2015 and 2018, we retrospectively reviewed all patients that had a HA or THA performed as treatment for an isolated fracture of the femoral neck. Patients were classified as obese and nonobese depending on current body mass index (BMI) when the index procedure was performed. Preoperative and postoperative variable were obtained from the electronic medical record. A total of 157 patients underwent hip HA or THA for an isolated fracture of the femoral neck. In those patients undergoing HA, obesity was associated with an increase in operative times (P = 0.021) and was associated with a nonsignificant increase in total operating room time (P = 0.088) and duration of anesthesia (P = 0.14). In those patients undergoing THA, obesity was associated with longer operative times (P = 0.043), total operating room time (P = 0.032), and duration of anesthesia (P = 0.045). There were no significant differences in complication rates postoperatively between obese and non-obese patients undergoing either procedure. The treatment of isolated fractures of the femoral neck with HA or THA leads to an increase in operative time without an increase in postoperative complications in obese patients.

Does the Subtalar or Tibiotalar Joint Need Fused in Primary Retrograde Tibiotalocalcaneal Nailing for Fragility Ankle Fractures?

BACKGROUND: As an alternative to traditional open reduction internal fixation of ankle fragility fractures, primary retrograde tibiotalocalcaneal (TTC) nailing has been investigated as a treatment option. These results suggest that this treatment is an acceptable alternative treatment option for these injuries. There are still questions about the need for formal joint preparation at the subtalar or tibiotalar joint when performing primary TTC nailing for fragility fractures. METHODS: In this study, we retrospectively evaluated 32 patients treated with primary retrograde TTC nail without subtalar or tibiotalar joint preparation for a mean of 2.4 years postoperatively. We specifically reviewed the charts for nail breakages at either joint, patients developing subtalar or tibiotalar joint pathology requiring additional treatment, including return to the operating room for formal joint preparation. RESULTS: Fracture union occurred in 100% of patients. There were 3 cases (10.0%) of hardware failure, and 2 of these cases were asymptomatic and did not require any treatment. One patient (3.3%) developed hardware failure with nail breakage at the subtalar joint. This patient developed progressive pain and symptoms requiring revision surgery with formal arthrodesis of the subtalar and tibiotalar joint. CONCLUSIONS: This study shows that retrograde hindfoot nailing without formal subtalar or tibiotalar joint preparation is an acceptable potential treatment option in ankle fragility fractures. Mid-term follow-up demonstrates favorable outcomes without the need for formal joint preparation in this high-risk population. Comparative studies with higher patient numbers and long-term follow-up are needed to confirm the results of this study.Levels of Evidence: Level IV.

Go with the flow: An experimental analysis with tubing alternative with irrigation.

Background and Aims: Literature regarding alternative tubing for fluid delivery in irrigation and debridement procedures is lacking. The purpose of this study was to compare three different apparatuses with varying quantities of irrigation fluid to assess efficiency of administration and evaluate overall time for fluid administration. Methods: This model was designed to compare available methods of gravity irrigation used in practice. Fluid flow time was measured for three types of tubing: single-lumen cystoscopy tubing, Y-type double-lumen cystoscopy tubing, and nonconductive suction tubing. Irrigation times were assessed for varying volumes of 3, 6, and 9 L to investigate the relationship between bag changes and irrigation time. Bag changes were not conducted for the 3 L trial, but were for 6 and 9 L trials. Dimensions of cystoscopy tubing consisted of 4.95 mm internal diameter and 2.1 m length in both single-lumen and Y-type double-lumen apparatus. Nonconduction suction tubing dimensions were 6.0 mm internal diameter and standard 3.7 m in length. Results: The mean flow time for suction tubing was significantly faster than the cystoscopy tubing for the 3 and 9 L trials (p < 0.001). At 6 L, flow time for the suction tubing and the double lumen cystoscopy tubing were similar, 264 versus 260 s, respectively. At 9 L, the mean flow time for the suction tubing was 80 s faster (410 vs. 491 s) compared with single-lumen cystoscopy and was nearly 30 s faster compared with Y-type cystoscopy tubing. Conclusion: The results of this study provide insight into a faster, widely available, and cost-efficient alternative to commonly used cystoscopy tubing.

Contrast Enhanced Computed Tomography in the Diagnosis of Acute Pyogenic Flexor Tenosynovitis.

BACKGROUND: The diagnosis of infectious flexor tenosynovitis (FTS) has historically been made based on physical exam using Kanavel's signs. The specificity of these findings has come into question. We looked to evaluate the use of contrast-enhanced computed tomography (CT) in increasing the successful diagnosis of FTS. METHODS: Two adult cohorts were formed, one of patients with FTS confirmed in the operating room and the second of patients with ICD.10 identified finger cellulitis (FC), without concomitant FTS. Demographics, laboratory values, CT scans, and examination findings were evaluated. Axial CTs were evaluated in the coronal and sagittal planes and tendon sheath/tendon width were measured. The tendon sheath/tendon was recorded as a ratio in the coronal (CR) and sagittal (SR) planes. Continuous and dichotomous variables were analyzed and measures of sensitivity, specificity, and predictivity were calculated. Seventy patients were included, 35 in the FTS cohort and 35 with FC. RESULT: A higher number of Kanavel signs were present in the FTS group (2.9 vs. 0.5, P < .05), with CR and SR both being significantly larger in the FTS group (P < .05). CR and SR cutoffs ≥ 1.3 provided high sensitivity, specificity, and positive predictive value (PPV) for FTS. Likelihood of FTS increased 5.9% and 5.5% for every 0.1 increase in CR and SR, respectively, with a 14% increase for every additional Kanavel sign. CONCLUSION: In conclusion, CT ratios are useful in identifying FTS; and when used on their own or in combination with Kanavel's signs, CR and SR objectively improve the diagnosis of FTS.

Peri-implant Proximal Humerus Fracture Stabilized with Stacked Plating: A Case Report.

Introduction: A peri-implant proximal humerus fracture is a rare complication after open reduction and internal fixation (ORIF) and poses a surgical dilemma. Case Report: A 56-year-old male sustained a peri-implant proximal humerus fracture after undergoing ORIF. We present a stacked plating method for fixation of this injury. This construct allows for decreased operative time, less soft-tissue dissection, and the ability to leave previous intact hardware in place. Conclusion: We describe the rare case of a peri-implant proximal humerus treated with stacked plating.

Early Definitive Fixation of Talus Fractures Is Safe: A Retrospective Review.

BACKGROUND: Talus fractures are often result of high energy mechanisms and can lead to devastating complications. Treatment is often operative; however, the appropriate timing of this has been debated. The purpose of this study is to determine the efficacy and safety of the early treatment of talus fractures. METHODS: Patients aged 18 years or older who underwent definitive operative stabilization of their talus fracture at a single urban level 1 trauma center were retrospectively reviewed. Patients were split into 2 groups based on their time to definitive fixation: ≤ or >24 hours. Pertinent demographic, surgical, and follow-up data were collected and analyzed. RESULTS: A total of 108 fractures were treated with 65 in the ≤24 hours fixation group and 43 in the >24 hours fixation group. Fractures involving the talar neck were the most commonly treated fracture pattern followed by the body and the head. There was no difference between the 2 groups in length to full weight bearing, union, or time to union. Open fracture was found to be the only significant risk factor for nonunion in both groups. There was no significant difference in infection or arthrodesis rates between the 2 groups. CONCLUSION: Definitive treatment of talus fractures within 24 hours from presentation is both safe and effective with equal outcomes and without increased complications when compared with those injuries that undergo delayed or staged definitive fixation. LEVEL OF EVIDENCE: Level III.

Induced membrane technique for reconstruction to manage bone loss.

Multiple surgeries are often required to manage segmental bone loss because of the complex mechanics and biology involved in reconstruction. These procedures can lead to prolonged recovery times, poor patient outcomes, and even delayed amputation. A two-stage technique uses induced biologic membranes with delayed placement of bone graft to manage this clinical challenge. In the first stage, a polymethyl methacrylate spacer is placed in the defect to produce a bioactive membrane, which appears to mature biochemically and physically 4 to 8 weeks after spacer placement. In the second, cancellous autograft is placed within this membrane and, via elution of several growth factors, the membrane appears to prevent graft resorption and promote revascularization and consolidation of new bone. Excellent clinical results have been reported, with successful reconstruction of segmental bone defects >20 cm.

Outpatient Surgery for Rib Fracture Fixation: A Report of Three Cases.

Rib fractures are common injuries observed in trauma patients that will often heal without operative intervention. However, patients can infrequently have continued pain. Operative fixation of these symptomatic rib fractures has traditionally led to the patient requiring hospital admission for observation and pain control. The purpose of this study was to review three cases of outpatient rib fracture, open reduction and internal fixation (ORIF) surgery. Three patients with symptomatic rib fractures treated with ORIF at a single urban level one trauma center underwent outpatient same-day surgery. Pertinent demographic, clinical, radiographic, and surgical data were collected. All patients had decreased preoperative pain and no complications. This case series demonstrates that outpatient surgery for rib fracture ORIF can be performed safely in a select patient population. Additionally, it has similar efficacy as inpatient operative fixation with the main added benefit being decreased costs to both the patient and the healthcare system. We suggest that outpatient operative fixation of rib fractures should be considered for select patients.