Perioperative Management of the Orthopaedic Patient and Alcohol Use, Abuse, and Withdrawal.

Alcohol is one of most commonly abused substances in the United States, and it has contributed to a growing epidemic of medical ailments, including cirrhosis, neurologic and psychosocial disorders, impairment to fertility, and cancer. Moreover, acute and chronic alcohol use represent a significant risk factor for orthopaedic injury and postoperative complications. Yet, relatively little is known about the clinical implications of alcohol abuse in common orthopaedic procedures. Acute withdrawal from alcohol is potentially fatal, particularly in the orthopaedic inpatient whose abstinence is mandated by the hospital setting. The aim of this review is to address the screening, diagnostic, and therapeutic tools available to appropriately manage acute alcohol withdrawal in the orthopaedic inpatient. The influence of chronic alcohol consumption on bone metabolism, fracture healing, and surgical fixation will also be reviewed because this information may guide surgical decision making.

Fixed angle plate fixation of comminuted patellar fractures.

INTRODUCTION: Comminuted patella fractures are uncommon and difficult fractures to manage. Multiple treatment modalities have been suggested, with little clinical data to support practice. Recent biomechanical and technical investigations have described successful plate fixation of comminuted patella fractures. The purpose of this study was to evaluate radiographic, clinical and functional outcome of comminuted patella fractures treated with a fixed angle locking plates. We believe stable fixation, which results in successful fracture union and functional recovery, can be achieved with this technique. MATERIALS AND METHODS: A retrospective review was performed at a single regional academic Level 1 trauma hospital. All comminuted patella fractures treated with a fixed angle locking plate (AO/OTA 34C2 and C3) over a six-year period were evaluated. Thirty-six patients were identified. Average length of follow up was 154 weeks (range 12-297 weeks). Twenty patients were available for functional outcome scoring. Primary outcome measures were: Knee Outcome Score (KOS), Lower Extremity Functional Scale (LES) and goniometer measured knee range of motion. Secondary outcomes evaluated the need for additional screw or cerclage fixation, reoperation for any reason, bothersome hardware, infection and nonunion. RESULTS: Average KOS = 57.2 (20-74), average LES = 58.9 (15-80). Median extension = 0° (full extension), median flexion = 130°. Supplemental screws were used in 17/36 cases; cerclage used in 2/36 cases. Hardware irritation was noted in 4/20 patients, no patient requested elective hardware removal, one patient had failure of fixation and no nonunions were identified. CONCLUSION: Fixed angle plate stabilization of comminuted patella fractures is a viable technique for fracture fixation. Good to excellent return of knee function and low complication rates, including need for hardware removal, can be expected.

The Morel-Lavallée Lesion: Diagnosis and Management.

The Morel-Lavallée lesion is a closed soft-tissue degloving injury commonly associated with high-energy trauma. The thigh, hip, and pelvic region are the most commonly affected locations. Timely identification and management of a Morel-Lavallée lesion is crucial because distracting injuries in the polytraumatized patient can result in a missed or delayed diagnosis. Bacterial colonization of these closed soft-tissue injuries has resulted in their association with high rates of perioperative infection. Recently, MRI has been used to characterize and classify these lesions. Definitive management is dictated by the size, location, and age of the injury and ranges from percutaneous drainage to open débridement and irrigation. Chronic lesions may lead to the development of pseudocysts and contour deformities of the extremity.

Comparison of two-transsacral-screw fixation versus triangular osteosynthesis for transforaminal sacral fractures.

Transforaminal pelvic fractures are high-energy injuries that are translationally and rotationally unstable. This study compared the biomechanical stability of triangular osteosynthesis vs 2-transsacral-screw fixation in the repair of a transforaminal pelvic fracture model. A transforaminal fracture model was created in 10 cadaveric lumbopelvic specimens. Five of the specimens were stabilized with triangular osteosynthesis, which consisted of unilateral L5-to-ilium lumbopelvic fixation and ipsilateral iliosacral screw fixation. The remaining 5 were stabilized with a 2-transsacral-screw fixation technique that consisted of 2 transsacral screws inserted across S1. All specimens were loaded cyclically and then loaded to failure. Translation and rotation were measured using the MicroScribe 3D digitizing system (Revware Inc, Raleigh, North Carolina). The 2-transsacral-screw group showed significantly greater stiffness than the triangular osteosynthesis group (2-transsacral-screw group, 248.7 N/mm [standard deviation, 73.9]; triangular osteosynthesis group, 125.0 N/mm [standard deviation, 66.9]; P=.02); however, ultimate load and rotational stiffness were not statistically significant. Compared with triangular osteosynthesis fixation, the use of 2 transsacral screws provides a comparable biomechanical stability profile in both translation and rotation. This newly revised 2-transsacral-screw construct offers the traumatologist an alternative method of repair for vertical shear fractures that provides biplanar stability. It also offers the advantage of percutaneous placement in either the prone or supine position.

Fixation techniques for complex traumatic transverse sacral fractures: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: To identify and describe reconstruction methods for the treatment of transverse sacral fracture (TSF) and to evaluate outcomes based on treatment interventions. SUMMARY OF BACKGROUND DATA: A variety of surgical interventions for stabilization of TSFs exist, yet the optimal management remains unclear. Although there are many individual case reports and series describing techniques to stabilize TSF, prior reviews fail to provide a comprehensive summary of current and past surgical techniques and their individual outcomes. METHODS: Our systematic review searched the PubMed database using keywords identifying sacral fractures with a transverse component, requiring internal fixation for stabilization as well as a review of bibliographies and archives from meeting proceedings. RESULTS: Our search located 417 publications for abstract review, of which 27 (109 patients) with TSF were included. Average follow-up was 22 months (range, 0-82 mo). Thirty-eight patients (34%) underwent spinopelvic fixation (SPF), 53 (49%) underwent posterior pelvic ring fixation (PPRF), and 18 (17%) underwent both. PPRF included iliosacral screws (37 patients), transiliac screws (11 patients), transiliac screws with plating (3 patients), posterior plating (1 patient), and transiliac bar (1 patient). Additional injuries causing lumbosacral instability were seen in 8 patients (42%) who underwent SPF, 2 patients (18%) treated with PPRF, and 5 patients (45%) who were treated with both SPF and PPRF. Of those who presented with a neurological deficit, 5 patients (45%) with SPF, 9 (39%) with PPRF, and 3 (30%) with SPF and PPRF experienced full neurological recovery. Five patients (45%) with SPF, 7 (30%) with PPRF, and 5 (50%) with both regained partial neurological function. One patient (9%) with SPF, 7 (30%) with PPRF, and 2 (20%) with both experienced no neurological recovery. CONCLUSION: PPRF seems to be effective for stabilization of TSF. However, in the setting of further injuries causing additional lumbosacral instability, SPF should be used to ensure effective stabilization.

Limb salvage with major nerve injury: current management and future directions.

Major peripheral nerve injuries are often associated with devastating functional deficits. Current management techniques fail to achieve adequate functional neural regeneration, and the development of adjunct therapies is necessary to improve outcomes. Recent efforts at enhancing the regeneration rate of peripheral nerves and developing axonal guidance channels or conduits have had limited success. The neuromuscular junction serves as the interface between the peripheral nerves and muscle. This critical area undergoes significant changes following peripheral nerve injury and induces end-organ atrophy after denervation, which limits the chance of true functional regeneration. Stabilization of the neuromuscular junction may be an important adjunct in peripheral nerve repair and should be explored as a method of managing major nerve injuries.

Reverse achilles tendon allograft technique for anterior cruciate ligament reconstruction.

Because of the increasing popularity of allograft anterior cruciate ligament (ACL) reconstructions, the technical difficulties with posterior bone loss in revision ACL surgery, and the limited supply of bone-patellar tendon-bone donor grafts, we have developed a technique using a reversed Achilles tendon allograft to reconstruct the ACL-deficient knee. This technique allows for bony tibial fixation with an interference screw by rotating the graft 180 degrees and optimizing soft-tissue fixation at the femur with an EndoButton CL (Smith & Nephew, Andover, MA). Short-term follow-up (average, 26.4 weeks) of 10 patients undergoing the reversed Achilles technique has shown excellent results, with Lysholm scores between 91 and 100 and 84 and 90 in 8 of 10 and 2 of 10 patients, respectively. Objective stability assessments, including the Lachman test, anterior drawer, and pivot-shift tests, were also encouraging. Reverse Achilles tendon allografts can be excellent alternatives for ACL reconstruction when bone-patellar tendon-bone grafts are not indicated.