Pelvic Reduction Frame Facilitating Percutaneous Fixation to Pelvic Fractures.

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

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

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

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

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

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

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

Softer Tissue Issues in Orthopaedic Trauma.

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

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

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

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

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

Heterotopic ossification in orthopaedic trauma.

Heterotopic ossification (HO) can be defined as the pathologic formation of bone in extraskeletal tissues. There has been a substantial amount of recent research on the pathophysiology, prophylaxis, and treatment of HO and traumatic conditions associated with the development of HO. This research has advanced our understanding of this disease and helped to clarify evidence-based approaches to both the prophylaxis and treatment of HO. This article reviews the literature on these topics with a focus on their application in orthopaedic trauma.

Incisional negative pressure wound therapy after high-risk lower extremity fractures.

OBJECTIVES: To investigate negative pressure wound therapy (NPWT) to prevent wound dehiscence and infection after high-risk lower extremity trauma. DESIGN: Prospective randomized multicenter clinical trial. SETTING: Four Level I trauma centers. PATIENTS/PARTICIPANTS: Blunt trauma patients with one of three high-risk fracture types (tibial plateau, pilon, calcaneus) requiring surgical stabilization. INTERVENTION: Incisional NPWT (Group B) was applied to the closed surgical incisions of patients randomized to the study arm of this trial, whereas standard postoperative dressings (Group A) were applied to the control patients. MAIN OUTCOME MEASURES: Acute and chronic wound dehiscence and infection. RESULTS: Two hundred forty-nine patients with 263 fractures have enrolled in this study with 122 randomized to Group A (controls) and 141 to Group B (NPWT). There was no difference between the groups in the distribution of calcaneus (39%), pilon (17%), or tibial plateau (44%) fractures. There were a total of 23 infections in Group A and 14 in Group B, which represented a significant difference in favor of NPWT (P = 0.049). The relative risk of developing an infection was 1.9 times higher in control patients than in patients treated with NPWT (95% confidence interval, 1.03-3.55). CONCLUSIONS: There have been no studies evaluating incisional NPWT as a prophylactic treatment to prevent infection and wound dehiscence of high-risk surgical incisions. Our data demonstrate that there is a decreased incidence of wound dehiscence and total infections after high-risk fractures when patients have NPWT applied to their surgical incisions after closure. There is also a strong trend for decreases in acute infections after NPWT. Based on our data in this multicenter prospective randomized clinical trial, NPWT should be considered for high-risk wounds after severe skeletal trauma.

Nonunion of a pertrochanteric femur fracture due to a low-velocity gunshot.

The treatment of nonunions often can be a complex and challenging venture. This case report details the treatment of a young patient's pertrochanteric femoral nonunion due to a low-velocity gunshot. Fracture fixation and union were attempted with various implants, including a sliding hip screw, blade plate, and proximal femoral locking plate; however, all eventually failed. Successful union ultimately was obtained only after use of a cephalomedullary nail. There have been few reports in the literature on the failure of proximal femoral locking plates in the treatment of pertrochanteric femur fractures, though much has been published regarding the sliding hip screw and blade plate. Multiple options for use in nonunion surgery were used and discussed in this case, such as autogenous bone graft, bone morphogenic protein, and implantable bone stimulators.

The role of débridement in low-velocity civilian gunshot injuries resulting in pelvis fractures: a retrospective review of acute infection and inpatient mortality.

OBJECTIVES: To determine the use of surgical débridement in the management of low-velocity gunshot injuries (GSIs) resulting in pelvis fractures. DESIGN: : Retrospective chart review. SETTING: Level I trauma center in a major metropolitan area. PATIENTS: Fifty-six patients from 1991 to 2007 treated for pelvis GSIs with resulting pelvis fractures with six acute mortalities and 40 patients with at least 1-year follow-up. INTERVENTION: Patient data were reviewed for incidence of infection related to pelvis GSIs. Information regarding surgical débridement of pelvis GSI wounds, retained foreign bodies, and/or concomitant gastrointestinal (GI) injury was analyzed for relationships of such events to infection rate. MAIN OUTCOME MEASUREMENTS: Incidence of infection related to pelvis GSIs at least 1 year after GSI date. RESULTS: Three patients (6%) developed a deep infection related to their pelvis GSIs. There were no cases of osteomyelitis. The rate of concomitant GI injuries was 36% and the overall infection rate among those with GI injuries was 12% versus 3% for those without a GI injury (P = 0.34). There were infection rates of 7% and 6% among patients who underwent surgical débridement and those who did not, respectively. Of those with GI injuries, 41% underwent primary surgical débridement and none developed infection. In the group of remaining patients with GI injuries who did not undergo débridement of their GSI wounds, two (20%) developed an infection. The mortality rate of low-energy GSIs to the pelvis was six of 53 (11%). CONCLUSION: There was no increased incidence of infection in the absence of aggressive surgical débridement of pelvis GSI wounds. The study also demonstrated that retained bullets and bullet fragments did not increase the risk of infection, even after penetrating the GI tract organs. Finally, this study suggests there may be an increased risk of infection related to pelvis GSIs compared with reported infection rates related to GSIs of the extremities, likely secondary to a high rate of concomitant GI injuries associated with pelvis GSIs; however, there was no incidence of osteomyelitis.

Adult trauma: getting through the night.

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

The use of implantable bone stimulators in nonunion treatment.

Delayed or failure of bone healing in fracture, osteotomy, and arthrodesis patients continues to be a clinical dilemma. Electromagnetic stimulation is 1 modality demonstrated in many studies to aid bone healing; however, relatively few studies depict the use and complications associated with direct current implantable bone stimulators. Over a 9-year period, we studied a consecutive series of 120 adult patients who underwent implantation of a direct current bone stimulator. The goals of this study were to determine the time until healing, the presence of infection, and the need for additional nonunion surgery or salvage procedure following internal bone stimulator placement for nonunion treatment. Of the factors affecting the time until healing, tobacco smoking was a significant factor associated with increased time until healing. Tobacco smoking and duration of nonunion prior to implantable bone stimulator placement were both significant factors in the need for revision nonunion surgery or salvage procedure after implantable bone stimulator placement. Deep soft tissue infection or osteomyelitis was a significant factor predicting prolonged time to healing, subsequent infection following implantable bone stimulator placement, and the need for revision or salvage surgery. With the relative lack of complications directly attributable to electromagnetic implantable bone stimulators, their use may be an effective adjuvant to stable internal fixation and autogenous bone grafting in healing nonunions. However, the use of implantable bone stimulators in patients with nonunion prior to deep soft tissue infection or osteomyelitis exhibited an increased rate of postoperative infection in this study.

Locking plates for extremity fractures.

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

Avoiding complications in the treatment of humeral fractures.

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

Prevention of complications after treatment of proximal femoral fractures.

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

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

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

Avoiding complications in the care of fractures of the tibia.

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