Simplifying the Volar Distraction Osteotomy for Distal Radius Malunion Repair.

Background Extra-articular fractures of the distal radius are often treated with a trial of nonoperative management if radiographic parameters are within an acceptable range, especially in the elderly population. Unfortunately, some malunions become symptomatic or become grossly misaligned during nonoperative management which require corrective surgery to restore the normal osseous anatomy and restore function. Description of Technique We describe correction of a distal radius malunion utilizing a distraction-type volar osteotomy, a volar plate specific distraction device, and a novel resorbable calcium phosphate bone cement (Trabexus) designed to withstand compressive loads. Patients and Methods Twelve patients with 13 distal radius fractures were included in this study. The average patient age was 60.9 years and average time from injury to corrective osteotomy was 96.3 days. Radiographic measures (radial inclination, volar tilt, and ulnar variance) and clinical assessment (wrist/forearm range of motion and grip strength) were done pre- and postoperatively and compared. Results The average time from corrective surgical osteotomy to final clinical follow-up was 375.8 days. After surgical intervention, there was a statistically significant improvement in mean volar tilt (-19.8 vs. +0.5 degrees) and mean ulnar variance (+2.8 vs. -0.4 mm). Improvements were also seen in grip strength (1.7 vs. 43.6 lb), wrist flexion (30.5 vs. 48.3 degrees), wrist extension (33.3 vs. 53.8 degrees), forearm pronation (75.0 vs. 88.8 degrees), and forearm supination (53.8 vs. 81.3 degrees). On average, 56.0% of Trabexus bone substitute remained on final clinical radiographs. Conclusion This simplified technique of distraction corrective osteotomy after distal radius malunion results in improved clinical and radiographic outcomes for patients.

Open Ankle Fractures: What Predicts Infection? A Multicenter Study.

OBJECTIVE: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction. DESIGN: Multicenter retrospective review. SETTING: Sixteen trauma centers. PATIENTS: One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures. MAIN OUTCOME MEASURES: Fracture-related infection (FRI) in open ankle fractures. RESULTS: The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01). CONCLUSIONS: Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of the Antegrade Posterior Interosseous Artery Flap for Coverage of Complex Elbow Wounds.

SUMMARY: One of the most versatile soft-tissue flaps available for elbow coverage that is reliable, quick, and easy to perform, with minimal donor defect and without the sacrifice of a major blood vessel, is the antegrade posterior interosseous artery flap. A large amount of vascularized fascia can be dissected with the flap, and it can be useful in lining the elbow joint or any exposed implant(s). After flap harvest, the donor site is often amenable to primary closure or requires a simple skin graft for closure. This article explains the technique for harvesting an antegrade posterior interosseous artery flap and describes 10 cases in which the flap was used for complex soft-tissue defects of the elbow not amenable to local wound care or skin grafting.

Effect of Tourniquet Use on Patient Outcomes After Cementless Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Tourniquet use is common in total knee arthroplasty (TKA), but debate exists regarding its use and effect on patient outcomes. The study purpose was to compare the effect of short tourniquet (ST) time vs long tourniquet (LT) time on pain, opioid consumption, and patient outcomes. METHODS: Patients were prospectively randomized to an ST time of 10 min vs LT time. A total of 100 consecutive patients undergoing primary cementless robotic-assisted TKA underwent randomization, with 5 patients unable to complete follow-up, leaving 49 in the ST group and 46 in the LT cohort. Visual analog scale pain scores, morphine equivalent, serum creatine kinase, distance walked, range of motion, length of stay (LOS), surgical time, hemoglobin (Hgb), and Knee Society Scores (KSS) were prospectively collected. RESULTS: Visual analog scale pain was statistically equivalent at 24, 48, and 72 hours and at 2 and 6 weeks postoperatively. Morphine equivalent consumption was 36 vs 44 (P = .03), 48 vs 50 (P = .72), 31 vs 28 (P = .57), and 4.7 vs 5.5 (P = .75) in the LT vs ST cohorts at 24 hours, 48 hours, 2weeks, and 6weeks postoperatively. Change in Hgb postoperative day 1 was 2.7 in both groups (P = .975). Postoperative day 1 creatine kinase-MB was 3.7 and 3.0 (P = .30) in LT and ST cohorts. Six-week postoperative KSS Knee and Function scores were 82.4 and 70.5 in LT group vs 80.8 and 72.3 in ST group (P = .61 and P = .63). Postoperative range of motion, LOS, and surgical time were equivalent. CONCLUSION: This study demonstrates no significant advantage of ST use in primary TKA with respect to opioid consumption, patient-reported pain, KSS scores, LOS, or postoperative Hgb level.

Evaluation of Tension at Median and Ulnar Nerve Repairs at the Wrist in a Cadaveric Model.

Background: Median and ulnar nerve lacerations at the wrist are often combined with zone 5 tendon injury. The inability to provide early range of motion leads to increased adhesions. Current therapy protocols recommend the wrist be held in 30° of flexion post operatively to protect the nerve repair. However, if tension and elongation across the nerve repair stay under a critical level in less wrist flexion, postoperative splinting in more extension could allow for better tendon excursion and less adhesions. Methods: Six cadaveric specimens were used. After appropriate dissection, the median and ulnar nerves were transected and repaired with a single 10-0 nylon suture. The wrist was ranged from 30° flexion to 45° extension to see if the repair would fail. Next, an epineural repair was accomplished with 9-0 nylon suture. The percent elongation along the nerve repair was measured at set increments from 30° flexion to 45° extension. Results: In all 6 specimens, median and ulnar nerve repairs with a single 10-0 nylon suture did not fail with wrist range of motion from 30° flexion to 45° extension. Mean percent elongation stayed under critical levels in up to 30° of extension. Conclusions: Both median and ulnar nerve repairs stayed under critical levels of tension and elongation in up to 30° of wrist extension. We believe it is possible to be more aggressive with wrist positioning in wrist level median and ulnar nerve repairs.

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.

Establishing an Efficient Care Paradigm for Trigger Finger.

BACKGROUND: To identify the time course for efficacy of corticosteroid injections in the treatment of trigger finger. METHODS: A prospective single-center observational study was conducted, consisting of 38 patients with 41 trigger digits that were injected. Enrolled patients completed an initial Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire to determine the severity of their symptoms. Following the injection, patients were contacted at scheduled time points for up to 12 weeks to determine if, and when, objective resolution of symptoms occurred. Patients who received additional treatment, such as a second injection or surgery, and those who did not have objective relief of symptoms by 12 weeks were classified as failed. Upon symptom resolution or injection failure, patients were given a DASH exit questionnaire. RESULTS: 30 of 41 injected trigger digits resolved and 11 failed treatment with a single corticosteroid injection. The latest that any study participant experienced resolution of symptoms was 69 days. At 38 days, the rate of resolution of the study population slowed significantly. CONCLUSIONS: Although symptomatic resolution of trigger finger from a single corticosteroid injection can occur early on, a follow-up of 4 weeks (28 days) does not allow enough time for symptom resolution. The earliest a surgeon and patient should consider a secondary treatment is at 38 days. After 69 days without resolution, both surgeon and patient can be confident that further treatment is needed.