Geriatric Intertrochanteric Fractures: What Is the Optimal Follow-Up Period?

OBJECTIVE: Evaluate patients with intertrochanteric fractures who were treated operatively to determine optimal follow-up to ensure complete fracture healing and recognize complications. DESIGN: Retrospective review. SETTING: Academic Level 1 trauma center. PATIENTS/PARTICIPANTS: Inclusion criteria included isolated intertroch fractures (not pathologic) and complete radiographic and clinical data, with at least 1-year follow-up. Four hundred ninety-seven patients were identified. Two hundred forty-nine patients met inclusion criteria with 194 patients studied. INTERVENTION: Operative fixation with either CMN or SHS. MAIN OUTCOME MEASUREMENTS: Radiographic parameters included time to union, neck-shaft angle, tip apex distance, and femoral neck screw telescoping (shortening) for both CMS and SHS combined. Postoperative complications were recorded. RESULTS: Union was achieved at a mean of 64.8 ± 30.7 days. Mortality (n = 12), infection (n = 4), and implant failure (n = 5) occurred within 3 months. Neck-shaft angle was changed before 3 months. Significant neck shortening for both CMN and SHS occurred within 6 weeks ( P =<0.001). Major complications occurred early, within 3 months. CONCLUSIONS: Most fractures healed by 3 months and the remainder by 6 months. Routine follow-up for 6 months is more than sufficient for most of these fractures. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Modified Masquelet Technique and Primary Tibial Metaphyseal Shortening for the Management of Proximal Tibial-infected Non-union in a Patient with Alcohol-induced Neuropathy: A Case Study.

Aim: To highlight the role of the Masquelet technique as a limb salvage procedure for a neuropathic patient presenting with infected non-union of proximal tibia. Background: The management of an infected non-union in neuropathic patients is most challenging; with various treatment options available, the prognosis is often guarded. Case description: A 37-year-old male with chronic polyneuropathy, also possessing a contralateral midfoot Charcot arthropathy secondary to a history of alcohol abuse, developed infection after a proximal tibial osteotomy for a preceding mal-non-union of a proximal tibia fracture. The management included hardware removal, excision of necrotic bone, interim insertion of antibiotic-loaded bone cement followed by an acute shortening and revision of the internal fixation utilising a second surgical incision. Successful bone union and eradication of infection was achieved and maintained after 13 months follow-up. Conclusion: A successful outcome was achieved for an infected non-union of a long bone in a neuropathic patient using the Masquelet technique which was then followed with a second-stage removal of the spacer and shortening. By performing the revision ORIF surgery utilising a different skin incision in the setting of complicated previous surgical scars proved to be a viable technique towards reducing risk of recurrence of infection and a good outcome. Clinical significance: Utilisation of the Masquelet technique and limb shortening in a staged manner for the management of long bone infections in neuropathic patients has not been reported before and may be valuable in such demanding clinical situations. How to cite this article: Mahmoud AN, Watson JT, Horwitz DS. Modified Masquelet Technique and Primary Tibial Metaphyseal Shortening for the Management of Proximal Tibial-infected Non-union in a Patient with Alcohol-induced Neuropathy: A Case Study. Strategies Trauma Limb Reconstr 2023;18(3):181-185.

Biologic Association Annual Summit: 2020 Report.

Interest and research in biologic approaches for tissue healing are exponentially growing for a variety of musculoskeletal conditions. The recent hype concerning musculoskeletal biological therapies (including viscosupplementation, platelet-rich plasma, and cellular therapies, or "stem cells") is driven by several factors, including demand by patients promising regenerative evidence supported by substantial basic and translational work, as well as commercial endeavors that complicate the scientific and lay understanding of biological therapy outcomes. While significant improvements have been made in the field, further basic and preclinical research and well-designed randomized clinical trials are needed to better elucidate the optimal indications, processing techniques, delivery, and outcome assessment. Furthermore, biologic treatments may have potential devastating complications when proper methods or techniques are ignored. For these reasons, an association comprising several scientific societies, named the Biologic Association (BA), was created to foster coordinated efforts and speak with a unified voice, advocating for the responsible use of biologics in the musculoskeletal environment in clinical practice, spearheading the development of standards for treatment and outcomes assessment, and reporting on the safety and efficacy of biologic interventions. This article will introduce the BA and its purpose, provide a summary of the 2020 first annual Biologic Association Summit, and outline the future strategic plan for the BA.

Splint Padding Thickness: Temperature Effects and X-ray Visualization.

OBJECTIVES: The purpose of this study was to determine if the thickness of splint padding could be determined on X-rays, and whether increasing layers of splint padding have an effect on temperature at the skin after placement. METHODS: Both in vitro and in vivo testing was performed. Ten cadaveric lower extremities were used. A thermocouple was placed on the posterior calf for temperature determination. Cadavers were used with short leg posterior splints with sidebars placed using various thicknesses of padding: (1) 2 layers of Webril, (2) 4 layers of Webril, (3) 2 × 2 padding (Webril followed by kerlix, then repeated), and (4) bulky cotton padding. A splint with no padding was used as a control. Lateral X-rays of the ankle were obtained. The padding thickness was measured. The change in temperature at the level of the skin was measured throughout the process. The test was then repeated in vivo to correlate the cadaver findings with a live subject. RESULTS: The mean thickness of the 5 padding types could be reliably determined on X-ray. Our cadaver temperature data shows that all padding thickness tested decreased temperature change after plaster curing, with no significant difference between wraps. Live subject testing showed similarities between the 2-layer Webril and 2 × 2 padding, and between the 4-layer Webril and bulky padding. CONCLUSIONS: Padding thickness can be consistently determined on X-ray. We determined that at least 2 layers of Webril significantly decrease temperature change at the level of the skin caused by plaster curing. Two layers of Webril can be identified on X-ray by measuring at least 1 mm of padding.

Altering spacer material affects bone regeneration in the Masquelet technique in a rat femoral defect.

The Masquelet technique depends on pre-development of a foreign-body membrane to support bone regeneration with grafts over three times larger than the traditional maximum. To date, the procedure has always used spacers made of bone cement, which is the polymer polymethyl methacrylate (PMMA), to induce the foreign-body membrane. This study sought to compare (i) morphology, factor expression, and cellularity in membranes formed by PMMA, titanium, and polyvinyl alcohol sponge (PVA) spacers in the Masquelet milieu and (ii) subsequent bone regeneration in the same groups. Ten-week-old, male Sprague-Dawley rats were given an externally stabilized, 6 mm femur defect, and a pre-made spacer of PMMA, titanium, or PVA was implanted. All animals were given 4 weeks to form a membrane, and those receiving an isograft were given 10 weeks post-implantation to union. All samples were scanned with microCT to measure phase 1 and phase 2 bone formation. Membrane samples were processed for histology to measure membrane morphology, cellularity, and expression of the factors BMP2, TGFß, VEGF, and IL6. PMMA and titanium spacers created almost identical membranes and phase 1 bone. PVA spacers were uniformly infiltrated with tissue and cells and did not form a distinct membrane. There were no quantitative differences in phase 2 bone formation. However, PMMA induced membranes supported functional union in 6 of 7 samples while a majority of titanium and PVA groups failed to achieve the same. Spacer material can alter the membrane enough to disrupt phase 2 bone formation. The membrane's role in bone regeneration is likely more than just as a physical barrier. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Management of Open Lower Extremity Wounds With Concomitant Fracture Using a Porcine Urinary Bladder Matrix.

BACKGROUND: Open wounds of the distal third of the leg and foot with exposed bone, fractures, and hardware are challenging wounds for which to achieve stable coverage. The orthopedic advances in lower extremity fracture management over the last 30 years have allowed a rethinking of the standard operative approach to close these complex wounds. MATERIALS AND METHODS: The ability of extracellular matrix (ECM) products to facilitate constructive remodeling of a wound seemed a reasonable approach for treatment, especially in patients who are often poor surgical candidates for more advanced reconstructive procedures. RESULTS: The authors reviewed 9 patients with 11 open fractures of the leg, ankle, or foot treated with a newer ECM wound healing device to total closure. The clinical course and patient management are reviewed. CONCLUSION: The authors conclude that newer ECM products can provide a reasonable method of management for patients who have wounds with exposed hardware, distal leg wounds, and open foot fractures compared to prolonged negative pressure wound therapy or complex reconstructive operative procedures.

Management of Open Distal Lower Extremity Wounds With Exposed Tendons Using Porcine Urinary Bladder Matrix.

Open wounds of the distal third of the leg and foot with an exposed tendon present a challenge in wound management and in attaining stable, durable coverage. The mobility of the tendon often leads to chronic inflammation that impedes wound closure, while the desiccation of the exposed tendon leads to progressive tendon necrosis. For the authors' cases, the ability of extracellular matrix (ECM) products to modulate wound bed inflammation and facilitate constructive remodeling of a wound seemed a reasonable approach in treating these wounds, especially in patients who are often poor surgical candidates for more advanced reconstructive procedures. METHODS: The authors reviewed 13 patients who had open wounds of the distal third of the leg and/or foot that had associated tendon involvement in the wound (Achilles, 6; tibialis anterior, 6; and peroneal, 1). Patients' wounds were treated to total closure. The clinical course and patient management is reviewed herein. RESULTS: The authors found newer ECM products can provide a more optimal method of management of patients with exposed tendons, as compared to prolonged negative pressure wound therapy. CONCLUSION: Furthermore, the authors conclude the use of newer ECM products yields a more stable, less scarred, reconstructed wound that more closely resembles normal foot and ankle appearance compared to other more complex reconstructive operative procedures.