Minimally invasive technique for acute fixation and subtalar fusion of displaced intra-articular calcaneus fractures.

Displaced intra-articular calcaneus fractures (DIACFs) are difficult injuries to treat and are often encountered by orthopedic surgeons. For DIACFs treated nonoperatively or with open reduction internal fixation (ORIF), a common complication is painful subtalar arthritis and the need for a secondary subtalar fusion, which prolongs the overall recovery time. One treatment option to address this sequela involves ORIF with subtalar fusion as the primary treatment. We describe a reproducible, minimally invasive surgical technique for primary ORIF with subtalar fusion when the calcaneal tuberosity is amendable to cannulated screw fixation to treat these complex calcaneal fractures. Our technique offers advantages compared to other techniques in that it avoids screw traffic, allows easy bony compression of the subtalar joint, and minimizes soft tissue damage via percutaneous screw fixation. Fourteen fractured calcanei in 12 patients underwent our technique and all achieved bony union with a median time to fusion of 107.5 days (range, 54-530 days). Eight patients returned to work with the remaining 4 patients having an unknown work status at last follow-up, although 2 of these 4 patients resumed normal activities. Only 1 patient experienced a complication, which was an infection after achieving bony union, and was treated with successful hardware removal and our infection protocol. Overall, we conclude our surgical technique offers a successful option in the treatment of DIACFs when the calcaneal tuberosity is amendable to cannulated screw fixation.

Open Reduction and Internal Fixation of a Type IV Capitellum Fracture Through a Transolecranon Tunnel: A Case Report.

CASE: A 60-year-old woman sustained a type IV capitellum fracture from falling on an outstretched arm. Open reduction internal fixation (ORIF) was performed using an anconeus approach, and a transolecranon tunnel was created to place a trochlear screw. The patient showed good clinical outcomes with almost full range of motion at 6 months. CONCLUSION: With type IV capitellum fractures, the olecranon often obstructs the screw trajectory necessary for anterior-to-posterior fixation of trochlear fragments. Drilling a transolecranon tunnel through the proximal olecranon with the elbow flexed creates a viable pathway for screw placement from a more medial starting point than what is possible with traditional techniques.

Survivability of the Femoral Neck System for the treatment of femoral neck fractures in adults.

INTRODUCTION: Hip fractures are common injuries in the elderly, with an incidence that continues to rise. The femoral neck system (FNS) recently emerged as a novel treatment option for femoral neck fractures, but long-term survivability of the implant remains uncertain. The purpose of this study is to evaluate survivability of the FNS and assess risk factors for implant failure. METHODS: One hundred five adult patients who received the FNS (DePuy Synthes, Raynham, MA) for femoral neck fractures (AO/OTA 31B) were included. Surgeries were performed within a regional hospital system comprising 18 facilities. All patients had a minimum follow-up of 1 year. The primary outcome measures were cumulative incidence of implant failure and 1-year mortality, including risk factor analysis. RESULTS: Twelve implants failed at a follow-up ranging from 17 days to 8 months, and 7 failed within 90 days. Cumulative incidence of implant failure was 2% at 30 days, 7% at 90 days, 12% at 6 months, and 13% at 1 year. Causes of implant failure included cut-out (n = 5), non-union (n = 4), peri-implant fracture (n = 2), and avascular necrosis (n = 1). Univariate Cox regression identified Pauwels type III fractures and an increasing AP Parker ratio as significant risk factors for failure. Pauwels type III fractures showed a 5.48 times higher risk compared to Pauwels types I & II. Every 10% increase in AP Parker ratio increased risk of failure by 2.39 times. The 1-year mortality rate was 21%, and univariate logistic regression identified age as the only risk factor (odds ratio = 3.71). CONCLUSIONS: The incidence of implant failure and 1-year mortality rate in this study suggests that the FNS can provide reliable fixation compared to rates in the literature, but complications are not uncommon. Avoiding Pauwels type III fractures and optimizing implant placement appear crucial to preventing implant failure. LEVEL OF EVIDENCE: Therapeutic Level IV.

Targeted Muscle Reinnervation for Trauma-Related Amputees: A Systematic Review.

While amputation techniques have improved over time, questions remain around how to best treat neuromas and severed nerves in the amputee population, specifically for trauma-related amputees. This systematic review investigates and summarizes outcomes following targeted muscle reinnervation (TMR) for the trauma-related amputee population. Studies were classified based on primary or secondary TMR and relevant outcomes, including the ability to use a prosthesis, post-TMR opioid use, Patient-Reported Outcomes Measurement Information System (PROMIS) scores for phantom limb pain and residual limb pain, and overall pain resolution/reduction. Following TMR for trauma-related amputation, most patients experienced neuroma pain resolution (86.2%, 95% confidence interval [CI]: 67.2-95.0%) and overall pain reduction/resolution (90.7%, 95% CI: 82.2-95.4%). No differences were seen between primary and secondary TMR. Preliminary evidence indicates that TMR is effective for preventing or treating pain in patients with trauma-related amputation, whether used in the acute or delayed setting.

Newer generation of proximal tibia locking plates demonstrate large variability in their ability to capture the posteromedial fragment in bicondylar tibial plateau fractures.

INTRODUCTION: The early generations of proximal tibial locking plates demonstrated inferior results when compared to dual plating in bicondylar tibial plateau fractures with posteromedial fragments (PMF). Modern plates have multiple rows of locking screws and variable angle technology -which tote the ability to capture the PMF. The purpose of this study was to determine if the modern plates could capture the PMF in a large series of bicondylar tibial plateau fractures. MATERIALS & METHODS: Axial computer topography (CT) scans of 114 bicondylar tibial plateau fractures with PMF were analyzed. Five proximal tibia locking plates-in seven total configurations-were applied to radiopaque tibiae models. All possible screws were placed. Templates of screw trajectories were created based on the model CT scans. These were superimposed onto patient CT scan images to assess for screw penetration into the PMF. Number of screws fully within the PMF were recorded. Capture of the PMF was defined as having at least two screws within the fragment. RESULTS: On average, all plates were able to capture 81.6% of PMF with an average of 3.77 [95% Confidence Interval (CI): 3.47-4.07] screws. However, their ability to capture all fragments varied greatly, from 55.7%-95.2% in fixed angle constructs. Overall, variable angle constructs had a significantly higher capture rate (98.5% vs. 74.9%; p<0.0001) and more screws in the PMF (5.88 [95% CI: 5.58-6.17] vs 2.93 [95% CI: 2.62-3.24]; p<0.0001) when compared to fixed angle constructs. CONCLUSION: Newer generation locking plates vary greatly in their ability to capture the PMF. Variable angle technology dramatically increases the ability to capture the majority of PMFs. Prior biomechanical and clinical studies may yield substantially different results if repeated with these newer implants. Use of newer generation locked plates should not replace thorough preoperative planning.

Addition of alarm pheromone components improves the effectiveness of desiccant dusts against Cimex lectularius.

We demonstrate that the addition of bed bug, Cimex lectularius, alarm pheromone to desiccant formulations greatly enhances their effectiveness during short-term exposure. Two desiccant formulations, diatomaceous earth (DE) and Dri-die (silica gel), were applied at the label rate with and without bed bug alarm pheromone components, (E)-2-hexenal, (E)-2-octenal, and a (E)-2-hexenal:(E)-2-octenal blend. First-instar nymphs and adult females were subjected to 10-min exposures, and water loss rates were used to evaluate the response. Optimal effectiveness was achieved with a pheromone concentration of 0.01 M. With Dri-die alone, the water loss was 21% higher than in untreated controls, and water loss increased nearly two times with (E)-2-hexenal and (E)-2-octenal and three times with the (E)-2-hexenal: (E)-2-octenal blend. This shortened survival of first-instar nymphs from 4 to 1 d, with a similar reduction noted in adult females. DE was effective only if supplemented with pheromone, resulting in a 50% increase in water loss over controls with the (E)-2-hexenal:(E)-2-octenal blend, and a survival decrease from 4 to 2 d in first-instar nymphs. Consistently, the addition of the pheromone blend to desiccant dust was more effective than adding either component by itself or by using Dri-die or DE alone. Based on observations in a small microhabitat, the addition of alarm pheromone components prompted bed bugs to leave their protective harborages and to move through the desiccant, improving the use of desiccants for control. We concluded that short exposure to Dri-die is a more effective treatment against bed bugs than DE and that the effectiveness of the desiccants can be further enhanced by incorporation of alarm pheromone. Presumably, the addition of alarm pheromone elevates excited crawling activity, thereby promoting cuticular changes that increase water loss.