A Comparison of Three C-Arm Draping Techniques to Minimize Contamination of the Surgical Field.

The use of intraoperative fluoroscopy has become a routine and useful adjunct within orthopaedic surgery. However, the fluoroscopy machine may become an additional source of contamination in the operating room, particularly when maneuvering from the anterior-posterior position to the lateral position. Consequently, draping techniques were developed to maintain sterility of the operative field and surgeon. Despite a variety of methods, no studies exist to compare the sterility of these techniques specifically when the fluoroscopy machine is in the lateral imaging position. We evaluated the sterility of 3 c-arm draping techniques in a simulated operative environment. The 3 techniques consisted of a traditional 3-quarter sterile sheet attached to the side of the operative table, a modified clip-drape method, and a commercially available sterile pouch. Our study demonstrated that the traditional method poses a high risk for sterile field contamination, whereas the modified clip-drape method and commercially available sterile pouch kept floor contamination furthest from the surgical field. With the current data, we urge surgeons to use modified techniques rather than the traditional draping method.

Bilateral Hemiarthroplasty in a Patient with Below-Knee and Above-Knee Amputations: A Case Report.

CASE: This case involved a sixty-two-year-old male patient with bilateral femoral neck fractures that occurred six months apart in the setting of bilateral lower-extremity amputation. Hemiarthroplasty was performed at each presentation, with the use of a standard femoral stem on the right side and a short stem on the left. At the time of follow-up, the patient had returned to his preoperative ambulatory status. CONCLUSION: This case report illustrates successful bilateral hemiarthroplasty in a patient who had previously undergone bilateral lower-extremity amputation, with use of an implant with a short stem for the limb with above-knee amputation.

Acute Both Bone Fracture in a Chronic Contracted Forearm.

INTRODUCTION: There is a paucity of information on management of forearm fractures through pre-existing ischemic contractures. The prevention of a Volkmann's contracture in forearm compartment syndrome requires vigilant clinical evaluation and emergent fasciotomy, but many of the patients who develop these contractures often do so as a result of delayed presentation due to substance abuse and intoxication. This case describes the first report and management of a severely displaced both bone (BB) forearm fracture through a chronic forearm Volkmann's contracture. CASE REPORT: A 39 year old female presented with an acute both bone forearm fracture in the setting of a Volkmann's contracture. Although very limited in use, the arm was functional for holding objects and was determined to be important in her activities of daily living. The surgical management involved open reduction internal fixation with radial and ulnar shortening osteotomies to restore cortical alignment secondary to the extensive overlying soft tissue contractures. CONCLUSION: Restoration of the radial bow and other standard principles of open reduction and internal fixation of BB fractures may not be as important as obtaining fracture union in patients with these complicated injuries due to the pre-existing functional limitations of the limb. The soft tissue envelope in a contracted forearm is commonly fibrotic and provides an abnormal fracture healing environment. Careful attention to osseous and soft tissue healing in the postoperative period is recommended. This report details the first case, technical difficulties, and subsequent management of a BB fracture in the setting of subsequent management of a both bone fracture in the setting of a chronic Volkmann's contracture.

Polyethylene glycol improves elution properties of polymethyl methacrylate bone cements.

BACKGROUND: Bone cements are used as adjuncts to fracture fixation methods and can also function as a local drug delivery system. The ability to elute drugs makes bone cement a promising and powerful chemotherapy treatment modality for osseous tumors. However, because of poor elution rates, the clinical application of this drug delivery mode remains challenging. Soluble fillers, such as sugars, salts, or biocompatible polymers, offer a solution to improve elution rates. This study quantified the effect of polyethylene glycol (PEG) on the elution properties of three commercially available bone cements. METHODS: Two grams of Vertebroplastic, Palacos, and Confidence bone cement powder containing three concentrations (0%, 20%, or 50%) of PEG filler were hand mixed with 10 mg of methotrexate. This powder mixture was then polymerized with 1.0 mL of the cement specific liquid monomer. The cylindrical elution samples were placed in saline solution and methotrexate elution was recorded for 720 h. RESULTS: The cumulative and daily elution rate increased as the concentration of PEG increased for each bone cement. However, the percent of increase depended on the bone cement used. Cumulative methotrexate elution increased by 40%-54% in case of the highest PEG filler concentration when compared with controls. CONCLUSIONS: PEG soluble filler offers a promising method for improving methotrexate drug elution in bone cement. Future studies need to optimize the PEG and bone cement ratio that produces the greatest drug elution profile without sacrificing the biomechanical properties of bone cement.

Reorientation osteotomy for the atypical clasp thumb in children with arthrogryposis.

Congenital thumb contractures are a well described but complex deformity to manage. Thumb contractures are common in patients with arthrogryposis. Many patients with arthrogryposis develop a supination, adduction, and flexion contracture at the thumb carpometacarpal join. Despite some thumb function, their thumb position and contracted first webspace precludes effective pinch or grasp, with the thumb opposing only to the palmar space. An extension, reorientation metacarpal osteotomy that places thumb in an efficient position has the potential to improve function in of these patients. This report provides a new classification system for congenital thumb deformities that can dictate management based upon thumb joint positions. We describe a previously unreported, arthrogrypotic thumb contracture that can be managed with an extension/pronation metacarpal osteotomy with simultaneous widening of the first webspace.

Stockinette application over a non-prepped foot risks proximal contamination.

This study sought to determine if there was an increased risk for surgical site contamination during stockinette application for a lower extremity surgery draping technique. Utilizing a simulated, sterile surgical field, stockinettes were applied over 10 cadaver lower extremities that were contaminated with non-pathogenic Escherichia coli on the foot. Of those, five specimens were then disinfected with Chloroprep and another 5 did not undergo any disinfection. All the specimens in which the stockinette was applied over a non-prepped foot showed proximal contamination. No contamination occurred in any of the specimens where the foot was disinfected. Stockinette can be a source of surgical site contamination when placed over a non-prepared foot.

Open perilunate injury with lunate revascularization after complete ligamentous avulsion.

Perilunate dislocations are a devastating injury to the carpus that carry a guarded long-term prognosis. Mayfield type 4 perilunate dislocations are rare, high-energy injuries that carry a risk for avascular necrosis (AVN) of the lunate. When AVN ensues and the carpus collapses, primary treatment with a proximal row carpectomy or arthrodesis has been advocated. This case reports a successful clinical result and revascularization of an extruded lunate with open reduction and internal fixation. This type 4, Gustilo grade 1 open perilunate dislocation exhibited complete avulsion of all lunate ligamentous attachments. Management included open reduction and internal fixation as well as carpal tunnel release through a combined dorsal and volar approach. Despite concerns for lunate AVN due to complete disruption of lunate vascularity, a 10-month postoperative clinical and radiographic examination demonstrated no pain with activities of daily living as well as a revascularized lunate.

Landing on your own two feet: a case report of bilateral calcaneus and open pilon fractures.

High energy fractures of the distal tibial plafond and calcaneus have been associated with high functional morbidity and wound complications. Although both of these fractures result from a similar mechanism, they have rarely been reported to occur on an ipsilateral extremity. The combination of these 2 injuries on the same extremity would increase the likelihood of an adverse surgical or functional outcome. We present the case and management strategy of a 43-year-old male with bilateral open pilon fractures and closed calcaneal fractures after falling from a height. A staged protocol was used for the bilateral pilon fractures, with external fixation until operative fixation on day 9. Nonoperative management of the calcaneal fractures resulted in a successful functional outcome at 10 months of follow-up. Treatment of this fracture pattern must incorporate the condition of the soft tissues, an understanding of the fractures, and minimize patient risk factors to optimize the functional and surgical outcomes.

The irreducible floating hip: a unique presentation of a rare injury.

A floating hip injury occurs in the setting of poly-trauma and is a rare and difficult problem to manage. Floating hip injuries require vigilant attention not only to the osseous injuries but also the surrounding compartments and soft tissue envelope. We report the case of a 35-year-old male with a lower extremity posterior wall acetabular fracture, ipsilateral femoral shaft fracture and a postero-superior hip dislocation. Closed reduction failed, necessitating an open reduction internal fixation of his hip dislocation and acetabular fracture. The patient then developed a thigh compartment syndrome requiring a fasciotomy. Despite the obvious bony injuries, orthopedic surgeons must be vigilant of the neurovascular structures and soft tissues that have absorbed a great amount of force. A treatment plan should be formulated based on the status of the overlying soft tissue, fracture pattern and the patient's physiologic stability.