Principles of Fasciotomy Closure After Compartment Syndrome Release.

Acute compartment syndrome is a surgical emergency in the extremities resulting from increased compartmental pressure, requiring immediate fasciotomy to resolve muscular compromise. As the mainstay treatment, fasciotomies involve substantial skin incisions and are thus prone to complications such as skin necrosis, wound infection, and permanent disability. Multidisciplinary care instituted at the time of fasciotomy can facilitate timely closure and minimize the complication profile. Several approaches are available to enhance outcomes of fasciotomy wounds, and a comprehensive knowledge of these options affords the treating surgeon greater flexibility and confidence in optimal management. Common techniques include early primary closure, gradual approximation, skin grafting, and negative pressure therapy. There is currently no consensus on the best method of closure. The purpose of this study was to review fasciotomy wound management from the time of initial release to final closure. Highlights include preparation for closing these wounds; the various techniques for fasciotomy closure, including adjunct options; evaluation of timing and staging; and injury-specific features, such as fracture management, limited subcutaneous tissues, and hand fasciotomies. Combining the perspectives of orthopaedic and plastic surgery, this review evaluates the benefits of multiple closure methods and highlights the importance of planning closure at the time of release.

Managing Osteopetrosis in the Complex Polytrauma Orthopedic Patient.

Osteopetrosis is a genetic illness defined by defective osteoclasts that are incapable of absorbing adequate amounts of bone. This exceedingly rare disorder has been linked to multiple genetic mutations that have a direct impact on osteoclast function. Osteopetrosis causes bones to become brittle with large amounts of cortical bone formation making patients susceptible to pathologic fractures, pancytopenia, and cranial neuropathies among other sequelae. Known as the "marble bone disease," this condition can range from as severe as causing death in newborn infants to as mild as an incidental finding of increased cortical thickening in a trauma patient. This case demonstrates an incidental finding of osteopetrosis in a trauma patient who suffered from significant injuries as a result of a high-velocity trauma. The patient was the pedestrian in a car vs pedestrian accident and suffered from a central cord syndrome in his cervical spine, a right humerus fracture, a left subtrochanteric femur fracture, a right tibia fracture, and a right fibula fracture. This case report illustrates the complexity of dealing with a polytrauma patient with osteopetrosis and reviews the literature on the approach to fracture fixation in osteopetrotic individuals. This paper will also discuss current medication recommendations and the current standard of care for optimizing patients with osteopetrosis as well as genetic counseling.

Complications Associated with Administration of Post-operative Weight-Based Enoxaparin in Orthopaedic Trauma Patients.

Background In orthopedic-specific patients, limited evidence exists in regard to prophylactic weight-based enoxaparin dosing in the obese population. We examined the clinical outcomes of administering weight-based enoxaparin to obese orthopedic trauma patients. Methods This retrospective study involved 679 patients who underwent orthopedic trauma surgery and were admitted from 1/2016 to 6/2020 at a single institution. Of those patients, 156 patients met our inclusion criteria. Inclusion criteria included BMI>35 kg/m2 and received weight-based enoxaparin post-operatively (defined as any singular dose >40 mg at any time). Blood transfusion, documented hematoma, deep vein thrombosis (DVT), and return visits to the OR after the administration of weight-based enoxaparin were the primary endpoints assessed. Age, BMI, weight, injury severity score (ISS), sex, post-operative time to the first dose of enoxaparin, the total daily dose of enoxaparin, operating room (OR) blood loss, OR time, patient co-morbidities, and pre/post-operative hemoglobin were evaluated for a potential relationship with the primary endpoints. Results One hundred and eighty-five surgeries were performed on a total of 156 patients. Thirty-six of the 185 (19%) surgeries required post-operative blood transfusion after weight-based enoxaparin was given. Higher ISS score, lower pre-operative hemoglobin, and lower post-operative hemoglobin were significant predictors of blood transfusion. Only increased post-operative time to the first dose of enoxaparin was significantly associated with DVT formation. Thirteen of the 156 patients (8.3%) had a post-operative hematoma after administration of enoxaparin, and four of the 13 patients required return to the OR for bleeding complications. ISS was the only significant predictor of post-operative hematoma formation. Conclusion Patients with a higher injury severity score are at an increased risk of adverse bleeding and may benefit from lower doses of enoxaparin administered earlier post-operatively.

Thromboelastography is predictive of mortality, blood transfusions, and blood loss in patients with traumatic pelvic fractures: a retrospective cohort study.

PURPOSE: In patients with traumatic pelvic fractures, thromboelastography (TEG) is a useful tool to rapidly evaluate and identify coagulation disturbances. The purpose of this study was to examine the coagulation kinetics of patients with traumatic pelvic fractures (pelvic ring and/or acetabulum) by analyzing the TEG results at initial presentation and its relationship with mortality and blood loss. METHODS: A retrospective review at our Level-1 trauma center was conducted to identify Full Trauma Team activations (FTTa) with traumatic pelvic and/or acetabular fractures who were evaluated with a TEG on initial presentation between 2012 and 2016. In-hospital mortality, product transfusion, and hemoglobin changes were analyzed. Subgroup analysis was performed based on pelvic fracture type. RESULTS: 141 patients with a mean age of 49.0 ± 20.8 years and mean Injury Severity Score (ISS) of 25.18 ± 12.8 met inclusion criteria. PRBC transfusion occurred in 78.0% of patients; a total of 1486 blood products were transfused. A total of 65 patients (46.1%) underwent operative treatment for the pelvic injuries, and 18 patients (12.7%) required embolization. The overall in-hospital mortality rate was 14.9%. The degree of clot lysis at 30 min (LY30) was significantly associated with blood loss (p < 0.0001), units of packed red blood cells (PRBCs) transfused (p < 0.0001), and mortality rate (p = 0.0002). CONCLUSION: Increased fibrinolysis evidenced by an elevated LY30 on initial TEG in patients with traumatic pelvic fractures is associated with increased blood loss, blood product transfusions, and mortality. Future studies should evaluate the clinical utility of reversing hyperfibrinolysis on initial TEG. LEVEL OF EVIDENCE: Prognostic level III.

Postoperative chest radiograph after open reduction internal fixation of clavicle fractures: a necessary practice?

HYPOTHESIS/BACKGROUND: Iatrogenic pneumothorax is a rare but serious complication of open reduction and internal fixation (ORIF) of clavicular fractures. Many institutions use postoperative chest radiographs to evaluate for this complication despite a lack of data to support this routine practice. Due to concerns of radiation exposure and health care costs, this practice may not be necessary. This study determined the rate of iatrogenic pneumothorax after clavicular ORIF with plate fixation at a single institution over 8 years. We hypothesized that postoperative chest radiographs would identify a very low rate of pneumothorax in patients with isolated clavicular fractures with no serious preoperative pulmonary injury. METHODS: A retrospective review was performed identifying all patients undergoing clavicular ORIF with plate fixation at a single Level I trauma center by 3 board-certified orthopedic surgeons from 2009 to 2017. Patients without at least 1 postoperative chest radiograph were excluded. We determined patient demographics and rate of preoperative and postoperative pneumothorax. RESULTS: We identified 89 patients without preoperative pneumothorax who underwent clavicular ORIF with at least 1 postoperative chest radiograph. Within this group, no patients (0%) had a new postoperative iatrogenic pneumothorax. DISCUSSION/CONCLUSION: Within this series of 89 patients with isolated clavicular fractures without preoperative pneumothorax, no iatrogenic pneumothoraces occurred after plate fixation. Therefore, for patients undergoing ORIF of isolated clavicular fractures obtaining a postoperative chest radiograph may be an unnecessary practice, especially given their low sensitivity. Future high-powered studies are needed to validate this finding.

Tangential Bicortical Locked Fixation Improves Stability in Vancouver B1 Periprosthetic Femur Fractures: A Biomechanical Study.

OBJECTIVES: The biomechanical difficulty in fixation of a Vancouver B1 periprosthetic fracture is purchase of the proximal femoral segment in the presence of the hip stem. Several newer technologies provide the ability to place bicortical locking screws tangential to the hip stem with much longer lengths of screw purchase compared with unicortical screws. This biomechanical study compares the stability of 2 of these newer constructs to previous methods. METHODS: Thirty composite synthetic femurs were prepared with cemented hip stems. The distal femur segment was osteotomized, and plates were fixed proximally with either (1) cerclage cables, (2) locked unicortical screws, (3) a composite of locked screws and cables, or tangentially directed bicortical locking screws using either (4) a stainless steel locking compression plate system with a Locking Attachment Plate (Synthes) or (5) a titanium alloy Non-Contact Bridging system (Zimmer). Specimens were tested to failure in either axial or torsional quasistatic loading modes (n = 3) after 20 moderate load preconditioning cycles. Stiffness, maximum force, and failure mechanism were determined. RESULTS: Bicortical constructs resisted higher (by an average of at least 27%) maximum forces than the other 3 constructs in torsional loading (P < 0.05). Cables constructs exhibited lower maximum force than all other constructs, in both axial and torsional loading. The bicortical titanium construct was stiffer than the bicortical stainless steel construct in axial loading. CONCLUSIONS: Proximal fixation stability is likely improved with the use of bicortical locking screws as compared with traditional unicortical screws and cable techniques. In this study with a limited sample size, we found the addition of cerclage cables to unicortical screws may not offer much improvement in biomechanical stability of unstable B1 fractures.

Economic impact of syndesmosis hardware removal.

Ankle syndesmosis injuries are commonly seen with 5-10% of sprains and 10% of ankle fractures involving injury to the ankle syndesmosis. Anatomic reduction has been shown to be the most important predictor of clinical outcomes. Optimal surgical management has been a subject of debate in the literature. The method of fixation, number of screws, screw size, and number of cortices are all controversial. Postoperative hardware removal has also been widely debated in the literature. Some surgeons advocate for elective hardware removal prior to resuming full weightbearing. Returning to the operating room for elective hardware removal results in increased cost to the patient, potential for infection or complication(s), and missed work days for the patient. Suture button devices and bioabsorbable screw fixation present other options, but cortical screw fixation remains the gold standard. This retrospective review was designed to evaluate the economic impact of a second operative procedure for elective removal of 3.5mm cortical syndesmosis screws. Two hundred and two patients with ICD-9 code for "open treatment of distal tibiofibular joint (syndesmosis) disruption" were identified. The medical records were reviewed for those who underwent elective syndesmosis hardware removal. The primary outcome measurements included total hospital billing charges and total hospital billing collection. Secondary outcome measurements included average individual patient operative costs and average operating room time. Fifty-six patients were included in the study. Our institution billed a total of $188,271 (USD) and collected $106,284 (55%). The average individual patient operating room cost was $3579. The average operating room time was 67.9 min. To the best of our knowledge, no study has previously provided cost associated with syndesmosis hardware removal. Our study shows elective syndesmosis hardware removal places substantial economic burden on both the patient and the healthcare system.