Emphysematous Osteomyelitis of the Pubis Associated With Necrotizing Soft Tissue Infection of the Thigh.

Emphysematous osteomyelitis (EO) is a rare condition identified through the presence of intraosseous gas. It is frequently fatal even with prompt recognition and management. We report a case of EO presenting with a necrotizing soft tissue infection of the thigh in the setting of prior pelvic radiation. The purpose of this study was to highlight the unusual association between EO and necrotizing soft tissue infection.

Operative Traction Technique for an Intertrochanteric Femur Fracture in a Patient with Transfemoral Amputation: A Case Report.

CASE: A 53-year-old woman with a history of transfemoral amputation presented to the emergency department with an ipsilateral intertrochanteric femur fracture. Standard fracture tables that use a boot to pull traction are not helpful in these cases, which makes achieving adequate traction for reduction difficult. CONCLUSION: We describe a unique technique to manipulate an amputated extremity using 2 Schanz pins attached to a weight through a traction rope. This practical technique provided adequate skeletal traction for reduction and internal fixation in our case and can be performed on a standard radiolucent table without the need for special table attachments.

Comparison of outcomes and operative course between septic and aseptic nonunion in long bones.

PURPOSE: The treatment of nonunion of long bones is difficult particularly in the presence of infection, which often involves staged surgical management. There is limited literature to compare the post operative course and outcomes of patients treated for septic versus aseptic nonunion. Thus, the purpose of this study was to determine if a difference exists between the number of surgical procedures, time to union, and rate of successful union for these two groups. METHODS: A retrospective cohort study was performed at a single tertiary care center. Patients suffering nonunion of the humerus, tibia and femur were included. Patient demographic data and characteristics of the post operative course were collected to include number and reason for repeat operations, antibiotic course, time to union, and development of a successful union. RESULTS: About 28 of 122 patients had septic nonunion. After diagnosis of nonunion, the septic group averaged 3.9 surgeries compared to 1.5 in the aseptic group (p < 0.001). There was no difference in the rate of successful union (79.8% versus 85.7%; p = 0.220), though the septic group took 129 days longer on average for successful union. (376 versus 247; p = 0.018). CONCLUSION: Septic nonunion of long bones is associated with the need for significantly more operations as well as time to union, though union rates remain similar. The identification of infection is critical for both the appropriate treatment as well as counseling patients on the expected post operative course.

Dual Magnetically Expandable Intramedullary Nails for Treatment of a Large Bony Defect in a Patient with Sarcoma: A Case Report.

Aim: To describe the surgical technique of performing an all-internal lengthening to address a large diaphyseal femur defect in the sarcoma patient. Background: Various strategies exist to address large intercalary bone defects with various biomechanical and biological implications. Case description: A 23-year-old female with high-grade osteosarcoma of her left femur underwent wide resection and an internal reconstruction of a 12.5-cm femoral defect using dual magnetic lengthening intramedullary nails resulting in restoration of leg lengths, and pre-resection function with minimal residual disability. Conclusion: Preoperative chemotherapy, wide resection and post-operative chemotherapy for osteosarcoma are the current standard of care. Resection often leads to large bone defects requiring complex reconstruction. Following intercalary bone resection, biological reconstruction is a consideration. An all-inside technique was developed in an effort to minimise complications of long-term external fixation for distraction osteogenesis, or extensile secondary grafting procedures for induced membrane strategy. Clinical significance: This previously unreported surgical technique allows for an all-internal lengthening of large diaphyseal bone defects. While specifically used in an oncologic post-resection setting, this technique is applicable to the broader limb reconstruction and lengthening practice and overcomes some inherent limitations to previously described techniques. How to cite this article: Copp J, Magister S, Napora J, et al. Dual Magnetically Expandable Intramedullary Nails for Treatment of a Large Bony Defect in a Patient with Sarcoma: A Case Report. Strategies Trauma Limb Reconstr 2022;17(3):189-194.

Increase in gunshot wounds at a level 1 trauma center following the COVID19 pandemic.

OBJECTIVES: To compare the number of patients with gunshot wounds presenting to our level 1 trauma center before and during the COVID-19 pandemic with a focus on volume trends after the lifting of stay-at-home directives through August 2020. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seven hundred six gunshot wound patients between 2016 and 2020 (months March to September only). INTERVENTION: COVID-19 pandemic and resultant stay at home directives. MAIN OUTCOME MEASUREMENTS: Number of patients presenting with gunshot wounds per time period. RESULTS: The number of patients with gunshot wounds presenting to our institution increased by 11.7% in March-April 2020 and by 67% in May-August 2020 when compared to previous years. Length of stay significantly decreased in 2020 compared to 2018 and 2019. In 2020, significantly fewer patients had orthopaedic procedures than in 2018. CONCLUSIONS: Patients presenting with gunshot wounds increased during the initial "stay-at-home" portion of the pandemic in March to April and increased significantly more after the restrictions were relaxed during May to August.Level of Evidence: Therapeutic Level III.

Acute Fixation of Displaced Intra-articular Calcaneus Fractures Is Safe Using the Sinus Tarsi Approach.

OBJECTIVE: To analyze the correlation between surgical timing and outcomes for calcaneus fractures treated using a sinus tarsi approach (STA). SETTING: Single Level-1 trauma center. DESIGN: Retrospective. PATIENTS/PARTICIPANTS: Seventy consecutive intra-articular calcaneus fractures (OTA/AO 82C; Sanders II-IV) treated operatively using STA with a minimum of 1-year follow-up. INTERVENTION: Open management using STA. MAIN OUTCOME MEASUREMENT: Surgery timing, wound complications, American Orthopaedic Foot and Ankle Society ankle and hindfoot and Patient-reported Outcomes Measurement System scores. RESULTS: Patients were primarily men (68.6%) averaging 46 years (range, 18-77 years). Nineteen (27%) were obese, 27 (38.6%) were smokers, and 3 (4.3%) were diabetic, and 10 (14.3%) had open fractures. Sanders III fracture patterns were most common (45.7%). Mean time to surgery was 4.9 days (range, 0-23 days). Three patients (4.2%) developed postoperative infections requiring surgical debridement and antibiotics. Forty patients (57%) underwent operative repair within 72 hours of injury, 9 (22.5%) of which had open fractures. Of this group, only one patient developed wound necrosis. Restoration of Bohler angle and angle of Gissane and reductions in calcaneal varus angle and heel width were achieved (all P < 0.001). No differences in Ankle Society ankle and hindfoot or Patient-reported Outcomes Measurement System scores were noted between patients treated within or beyond 72 hours from injury. CONCLUSION: Intra-articular calcaneus fractures can be treated acutely within 72 hours of injury using STA with minimal wound complications and without compromising short-term functional outcome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Secrets of Success in the Management of Lower Extremity Nonunions.

The key to obtaining healing of nonunions in the lower extremity is to provide a balance of biology and stability. To achieve this goal, the surgeon must understand why the bone did not heal with the initial treatment and change the strategy to improve the outcome. Patients need to be optimized before any proposed surgery. Whether the surgeon uses a certain type of internal or external fixation depends on the location on bone, the type (atrophic versus hypertrophic) of nonunion, the local soft tissue, the element of infection, and the health of the host. The mechanical stability of the fixation, especially in the lower extremity, should be robust and allow some early weight bearing. Early weight bearing stimulates healing, decreases osteoporosis, improves the patient's overall health, and allows early return to function. Diagnosis and management of infected nonunions in the lower extremity is also a major key to a successful outcome in this difficult group of patients.

Comparison of Infrapatellar and Suprapatellar Approaches for Intramedullary Nail Fixation of Tibia Fractures.

OBJECTIVE: To assess clinical, radiographic, and functional outcomes after intramedullary nail (IMN) fixation of tibia fractures with an infrapatellar approach compared to a suprapatellar approach. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred four patients with 208 tibia fractures treated with intramedullary nailing between 2008 and 2018. METHODS: A retrospective chart review of tibia fractures was conducted. The clinical and functional outcomes of tibia fractures treated with IMN were compared between groups treated with an infrapatellar approach versus a suprapatellar approach. Multivariate models were created to control for confounding demographic, comorbidity, and injury-related confounders. MAIN OUTCOME MEASUREMENTS: Outcome measures included nonunion, malunion, and infection. Subjective functional patient outcomes were assessed using pain interference and physical function Patient-Reported Outcome Measurements Systems scores. RESULTS: There were 101 patients treated with infrapatellar nailing (49%) and 107 patients treated with suprapatellar nailing (51%). On multivariate analysis, suprapatellar nailing was independently associated with decreased risk of malunion (adjusted odds ratio, 0.165; 95% confidence interval, 0.054-0.501; P = 0.001) and decreased risk of postoperative knee pain (adjusted odds ratio, 0.272; 95% confidence interval, 0.083-0.891; P = 0.032). There was no difference in the rate of nonunion (P = 0.44), infection (P = 0.45), or Patient-Reported Outcome Measurements Systems pain interference or physical function scores. CONCLUSIONS: Suprapatellar IMN fixation of tibial shaft fractures is independently associated with lower risk of malunion and postoperative knee pain compared to the infrapatellar approach. However, there are no functional differences between approaches. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes After Intramedullary Nailing of Intraarticular Distal Tibial Fractures: A Retrospective Review.

The objective of this study was to evaluate the clinical and functional outcomes of intra-articular distal tibial fractures after intramedullary nail (IMN) and independent fixation compared with extra-articular fracture controls. Methods: A retrospective chart review of distal tibial fractures treated with IMN was performed. Clinical outcomes were compared between fractures with and without intra-articular involvement. Outcomes included nonunion, malunion, ankle arthrosis, and infection. Patient-Reported Outcome Measurement System (PROMIS) scores were used to assess subjective outcomes. Results: Of the 135 distal tibial fractures, 87 extra-articular and 48 intra-articular, no significant difference was observed in the rate of ankle arthrosis between intra-articular and extra-articular fractures (2% versus 0%; P = 0.35). Similarly, no difference was observed in the postoperative rates of infection (8% versus 3%; P = 0.25), the rate of nonunion (17% versus 10%; P = 0.29), or the rate of malunion (10% versus 21%; P = 0.17). No notable difference was observed in PROMIS scores between groups. Conclusion: This study suggests that IMN is an acceptable method of fixation in select intra-articular distal tibial fractures. In the intra-articular group, low rates of ankle arthrosis were noted at intermediate follow-up, with no increase in nonunion, malunion, or infection compared with extra-articular fractures. Furthermore, PROMIS scores indicate similar functional outcomes in patients, regardless of intra-articular involvement.

Comparison of Clinical Outcomes After Intramedullary Fixation of Tibia Fractures Caused by Blunt Trauma and Civilian Gunshot Wounds: A Retrospective Review.

OBJECTIVE: To assess the outcomes of patients who sustained blunt trauma tibia fractures compared with tibia fractures from civilian gunshot injuries when treated with intramedullary fixation. DESIGN: Retrospective chart review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Two hundred and seven patients underwent intramedullary nailing for 211 tibia fractures. METHODS: A retrospective review of tibia fracture(s) treated with intramedullary fixation with comparison of closed, open, and gunshot wound (GSW) fracture outcomes. MAIN OUTCOME MEASUREMENTS: Outcomes included infection and nonunion. RESULTS: The infection rate in closed and GSW tibia fractures was significantly lower compared with the infection rate of open fractures (1% vs. 9% vs. 20%; P = 0.00005). Significantly lower rates of nonunion in closed fractures compared with open fractures and GSW fractures were appreciated (8% vs. 20% vs. 30%; P = 0.003). There was no difference in infection or nonunion between GSW fractures with small wounds, no exposed bone, and minimal comminution and closed injuries (P = 0.24, P = 0.60). Conversely, there was a significantly higher nonunion rate in GSW fractures with large wounds, exposed tibia, and comminution compared with blunt injuries (P = 0.0014). CONCLUSIONS: This study suggests that tibia fractures from civilian GSWs are heterogeneous injuries, and outcomes are dependent on the extent of soft-tissue injury, bone exposure, and bone loss. There are comparable infection rates in all fractures due to civilian GSWs and closed fractures, which are lower than high-grade open fractures. Tibia GSW fractures with exposed bone and comminution have higher complication rates and should be treated accordingly. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

How Can I Get This Bone to Heal?

A nonunion is a reconstructive challenge that may have a devastating effect on a patient's quality of life. To develop an individualized treatment plan, surgeons must carefully assess several factors related to the nonunion, including the involved bone, the existing implants, the presence of infection, the soft-tissue envelope, and the function of the involved extremity, as well as the status of the patient. Essential components of an individualized treatment plan for a patient with a nonunion include management of infection (if present); optimization of the systemic and local biologic environment via management of nutritional and metabolic deficiencies, systemic disease, tobacco use, and medications that interfere with bone healing as well as via supplemental procedures, such as use of biologics or bone grafting; and achievement of mechanical stability via internal or external fixation that allows for early functional active range of motion and weight bearing. The goal in the management of nonunion is to maximize the likelihood of healing in the most expedient manner without further complications.

Hexapod Stacked Transport for Tibial Infected Nonunions With Bone Loss: Long-Term Functional Outcomes.

OBJECTIVES: To analyze long-term functional outcomes in patients with posttraumatic infected tibial nonunions having undergone bone transport with hexapod external fixator. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Thirty-eight patients with infected nonunions of the tibia. INTERVENTION: Resection of nonunion with application of stacked hexapod external fixator for bone transport. MAIN OUTCOME MEASUREMENTS: Functional outcome was measured using the short Musculoskeletal Functional Assessment (sMFA). Parameters measured included age, sex, presence of diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening. RESULTS: The mean sMFA score for the entire group was 27.1. Average patient age was 46.8 ± 12.7 years, 74% patients were male, 8% were diabetic, and 29% were smokers. Seventeen patients had soft-tissue defects that required a free flap. Smokers had higher degrees of disability compared with nonsmokers (39 ± 16 vs. 22 ± 14, P = 0.011). Patients requiring adjunctive stabilization had worse functional scores compared with those who did not receive adjunctive stabilization (33 ± 17 vs. 22 ± 15, P = 0.049). Sixteen patients returned 2 sMFA surveys at different time points after completion of bone transport. Initial average sMFA score was 26.5 at a mean of 25.3 months; subsequent sMFA scores averaged 19.4 at a mean of 98.8 months. CONCLUSIONS: Stacked hexapod external fixator bone transport is a reliable technique for infected nonunion of the tibia with bone loss. Improved sMFA scores can be expected from 2 to 8 years, suggesting full recovery takes longer than previously anticipated. Limb salvage with hexapod bone transport is justified over time. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hexapod Frame Stacked Transport for Tibial Infected Nonunions With Bone Loss: Analysis of Use of Adjunctive Stability.

OBJECTIVES: The stacked hexapod bone transport technique is an effective treatment for infected tibial nonunions with bone loss. The purpose of this study was to evaluate the patients' risk factors and timing for requiring adjunctive stabilization. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seventy-five patients with infected posttraumatic nonunions of the tibia. INTERVENTION: Resection of nonunion with application of stacked hexapod frame for bone transport. MAIN OUTCOME MEASUREMENTS: Parameters measured included age, sex, diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening. Outcomes recorded: removal of frame, below knee amputation, or adjunctive stability. Further analysis evaluated location of nonunion, timing of adjunctive stabilization, and type of fixation. RESULTS: The average patient age was 45.7 ± 12.5 years, 76% patients were men, 11% were diabetic, and 44% were smokers. Forty two percent had soft tissue defects that required a free flap. Thirty-eight patients had removal of frame, whereas 36 patients required adjunctive stability of the hexapod frame. Patient receiving adjunctive stabilization had a longer length of time in the hexapod frame (P = 0.026) and were more likely to require a free flap (P = 0.053). Ninety-three percent docking site nonunions occurred after the removal of the frame (P = 0.032); whereas 79% regenerate nonunions occurred before the hexapod frame was removed (P = 0.029). CONCLUSIONS: The use of a hexapod frame for the infected tibial nonunions with bone loss is an effective method for achieving union and eradicating infection in a difficult orthopaedic patient population. Use of adjunctive stabilization is a reasonable technique to address delayed regenerate and docking site nonunions. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Premature Consolidation with Resultant Implant Failure Using PRECICE Femoral Nail Lengthening: A Case Report.

CASE: Posttraumatic limb-length discrepancies secondary to femoral malunion can be treated with a variety of external or internal lengthening systems. The PRECICE nail is an intramedullary device featuring an external remote control to activate a magnetically driven internal distraction mechanism. While this intramedullary system avoids the soft-tissue complications common to external lengthening, it has unique mechanisms of failure that are difficult to diagnose and that require a systematic approach. CONCLUSION: In this case report, we describe a failure to lengthen with the PRECICE femoral nail and the subsequent steps taken to determine the root cause. We believe that this failure represents the first reported case of malfunction of the PRECICE femoral nail distraction mechanism since its 2013 redesign.

Osteocutaneous pedicle flap transfer for salvage of transtibial amputation after severe lower-extremity injury.

BACKGROUND: A conventional transtibial amputation may not be possible when the zone of injury involves the proximal part of the tibia, or in cases of massive tibial bone and/or soft-tissue loss. The purpose of this study was to examine the outcomes of salvage of a transtibial amputation level with a rotational osteocutaneous pedicle flap from the ipsilateral hindfoot. METHODS: Fourteen patients who had an osteocutaneous pedicle flap from the ipsilateral foot were included in the study. Twelve patients were followed for more than twenty-four months (mean, 60.2 months) and were evaluated with use of the Sickness Impact Profile (SIP), Musculoskeletal Function Assessment (MFA), and a 100-ft (30.48-m) timed walking test. RESULTS: There were ten men and four women with mean age of 43.2 years. Thirteen patients had a type-IIIB open tibial fracture, and one had extensive soft-tissue loss secondary to a burn. Four patients were treated for infection after the index procedure. There were no nonunions of the tibia to the calcaneus. Three patients underwent late reconstructive procedures to improve prosthetic fit. No patient required subsequent revision to a more proximal amputation level. Mean knee flexion was 139°. CONCLUSIONS: A novel technique has been developed to salvage a transtibial amputation level with use of a rotational osteocutaneous flap from the hindfoot. In the absence of adequate tibial length and/or soft-tissue coverage to salvage the entire limb or to perform a conventional-length transtibial amputation, this technique is a highly functional alternative that does not require microvascular free tissue transfer.

Surgical Technique for Osteocutaneous Pedicle Flap Transfer for Salvage of Transtibial Amputation After Severe Lower-Extremity Injury.

INTRODUCTION: Osteocutaneous pedicle flap transfer from the foot can be used to "salvage" a transtibial amputation level when the severity of an injury precludes a transtibial amputation. STEP 1 PREOPERATIVE ASSESSMENT: If the posterior tibial artery is not palpable, obtain an angiogram to determine the vascular supply distal to the traumatic zone and to prepare for conversion to a composite free microvascular transfer. STEP 2 REMOVE PROVISIONAL IMPLANTS: Remove provisional stabilization implants and minimize surgery about the knee. STEP 3 DEVELOP THE FLAP: The dissection about the tarsal tunnel is the critical portion of the operative technique. STEP 4 CONTOUR THE CALCANEUS: Any deviation from perpendicular will translate to an axial deformity in the reconstructed limb. STEP 5 PREPARE THE PROXIMAL PART OF THE TIBIA AND SURROUNDING TISSUES: Retain viable soft tissues and bone, but resect the fibula obliquely. STEP 6 SECURE THE CALCANEUS TO THE TIBIA: Avoid varus and recurvatum malalignment. STEP 7 REPAIR AND RECONSTRUCT THE SOFT TISSUES: The injured limb is routinely very swollen, and in some cases complete coverage requires split-thickness skin-grafting. STEP 8 POSTOPERATIVE CARE AND REHABILITATION: As the initial reconstruction is sometimes extremely bulbous, continually advise the patient that the shape will improve dramatically over time with shrinkage of the limb. RESULTS: In our original study, ten men and four women with a mean age of 43.2 years (range, twenty-four to sixty-four years) underwent an osteocutaneous pedicle flap transfer with use of the ipsilateral foot for salvage to achieve a transtibial amputation level. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Free tissue transfer with distraction osteogenesis is effective for limb salvage of the infected traumatized lower extremity.

BACKGROUND: Salvage of acute and chronic tibial osseocutaneous defects in the lower extremity poses a formidable problem. Although local, distant, and free tissue transfer or bone grafting alone may be adequate for repair of small wounds or osseous defects, large or complicated defects necessitate a different approach. The authors describe their experience with free tissue transfer in combination with distraction osteogenesis for complex composite osteocutaneous defects. METHODS: The authors reviewed a consecutive series of 28 patients who underwent treatment over an 8-year period, with follow-up ranging from 1 to 8.5 years. Mean time to flap after injury was 1082 days (range, 6 days to 30 years). Indications for treatment included infected nonunion of the tibia (n = 18), acute traumatic bone loss (n = 5), skin and soft-tissue breakdown that occurred during distraction osteogenesis (n = 4), and exposed bone following previous failed free flap (n = 1). RESULTS: Free flaps used included the rectus abdominis (n = 17), latissimus dorsi (n = 5), gracilis (n = 5), and radial forearm (n = 1). Mean length of bone gap was 63 mm (range, 30 to 140 mm), and mean area of wound requiring flap coverage was 219 cm (range, 35 to 400 cm). Twenty-five patients (89.3 percent) had successful flap coverage and went on to ambulate independently and return to work. The minor complication rate was 42.9 percent. CONCLUSIONS: Distraction osteogenesis in combination with free tissue transfer is a powerful technique that allows limb salvage, particularly when local and regional flaps are unavailable or inadequate. For infected nonunion of the tibia, it permits a staged approach that allows underlying osteomyelitis to declare itself and provides vascularized healthy soft-tissue coverage that facilitates repeated operations for the purpose of distraction.

Tibiotalar arthrodesis using a custom blade plate.

BACKGROUND: The purpose of this study was to evaluate the clinical and radiographic outcomes of patients who underwent tibiotalar arthrodesis between 1997 and 2003 for tibiotalar arthritis. The cause was predominantly posttraumatic arthritis secondary to tibial plafond fracture (n = 15) or talar body fracture (n = 2). METHODS: We retrospectively evaluated a consecutive series of 20 patients with 21 arthritic tibiotalar joints. Radiographs, clinical notes, scheduled visits, and telephone interviews were used to obtain outcome data after tibiotalar arthrodesis using a custom blade plate. The American Orthopedic Foot and Ankle Society Ankle Hindfoot Score quantified clinical outcomes in this study. RESULTS: Sixteen patients with 17 ankle arthrodeses were available after a mean follow-up period of 37.3 months. There were no postoperative wound complications or infections. There were no nonunions identified within the study. The mean American Orthopedic Foot and Ankle Society Ankle Hindfoot Score was 78.25 (range, 65-92). The average time to fusion was 3.9 months. CONCLUSIONS: Tibiotalar arthrodesis using a custom blade plate and a lateral approach is a reliable therapy for aseptic posttraumatic arthritis.