The effect of coronal plane angulation on patient reported outcome measures of operatively treated distal femur fractures: A multi-center prospective evaluation.

OBJECTIVES: The goal of this trial was to determine whether coronal plane angulation affects functional and clinical outcomes after the fixation of distal femur fractures. DESIGN: Multicenter, randomized controlled trial SETTING: 20 academic trauma centers PATIENTS/PARTICIPANTS: 156 patients with distal femur fractures were enrolled. 123 patients were followed 12 months. There was clinical outcome data available for 105 patients at 3 months, 95 patients at 6 months and 81 patients at one year. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing MAIN OUTCOME MEASUREMENTS: Radiographic alignment, functional scoring including SMFA, Bother Index, and EQ-5D. Clinical scoring of walking ability, need for ambulatory support and ability to manage stairs. RESULTS: At 3 months, there was no difference between groups (varus, neutral or valgus) with respect to any of the clinical functional outcome scores measured. At 6 months, compared to those with neutral alignment, patients with varus angulation had a worse Stair Climbing score (4.33 vs. 2.91, p = 0.05). At 12 months, the average patient with neutral or valgus alignment needed less ambulatory support than the average patient in varus. Walking distance ability was no different between the groups at any time point. With respect to the validated patient-based outcome scores, we found no statistical difference in in the SMFA, Bother, or EQ-5D between patients with valgus or varus mal-alignment and those with neutral alignment at any time point (p > 0.05). Regardless of coronal angulation, the SMFA trended towards lower (improved) scores over time, while EQ-5D scores for patients with varus angulation did not improve over time. CONCLUSIONS: Valgus angulation and neutral angulation may be better tolerated in terms of clinical outcomes like stair climbing and need for ambulatory support than varus angulation, though patient reported outcome measures like the SMFA, Bother Index and EQ-5D show no statistical significance. Most patients with distal femur fractures tend to improve during the first year after injury but many remain significantly affected at 12 months post injury.

Body mass index predicts perioperative complications following orthopaedic trauma surgery: an ACS-NSQIP analysis.

PURPOSE: The impact of obesity on outcomes has been documented extensively in the elective orthopaedic literature, but little is known about the impact of obesity on outcomes following orthopaedic trauma surgery. Utilizing the ACS-NSQIP database, we sought to investigate the relationship between BMI and perioperative complications in orthopaedic trauma patients. METHODS: 53,219 orthopaedic trauma patients were identified using a CPT code search between 2005 and 2013 in the NSQIP database. Patient demographics, and perioperative complications (including minor, major, and total) were collected. Multivariate regression analysis was performed to control for baseline demographics and comorbidities. RESULTS: Compared with patients of normal weight, underweight patients had significantly greater odds of minor [OR 1.12, 95 % CI (1.0, 1.26), p = 0.04], major [OR 1.20, 95 % CI (1.1, 1.3), p = 0.0009], and total complications [OR 1.18, 95 % CI (1.1, 1.3), p = 0.0003]. Morbidly obese patients had significantly greater odds of major [OR 1.22, 95 % CI (1.0, 1.5), p = 0.023] and total complications [OR 1.18, 95 % CI (1.0, 1.4), p = 0.023] compared to normal weight patients. When wound-related complications were examined independently, obesity was associated with increased odds of superficial [OR 1.67, 95 % CI (1.3, 2.1), p < 0.0001] and deep wound infection [OR 1.52, 95 % CI (1.075, 2.144), p = 0.018], and morbid obesity was associated with increased odds of wound dehiscence [OR 2.29, 95 % CI (1.1, 4.9), p = 0.034] and deep infection [OR 2.51, 95 % CI (1.6, 3.9), p < 0.0001]. CONCLUSIONS: Morbidly obese patients have significantly greater odds of wound dehiscence, deep wound infection, major complications, and total complications compared to patients of normal weight. Additionally, BMI under 18.5 is associated with increased odds of minor, major, and total perioperative complications. Interventions aimed at decreasing complication rates should be targeted at these high-risk patient populations on both ends of the BMI spectrum.

Are extreme distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked plate?

It is unclear whether there is a limit to the amount of distal bone required to support fixation of supracondylar periprosthetic femoral fractures. This retrospective multicentre study evaluated lateral locked plating of periprosthetic supracondylar femoral fractures and compared the results according to extension of the fracture distal with the proximal border of the femoral prosthetic component. Between 1999 and 2008, 89 patients underwent lateral locked plating of a supracondylar periprosthetic femoral fracture, of whom 61 patients with a mean age of 72 years (42 to 96) comprising 53 women, were available after a minimum follow-up of six months or until fracture healing. Patients were grouped into those with fractures located proximally (28) and those with fractures that extended distal to the proximal border of the femoral component (33). Delayed healing and nonunion occurred respectively in five (18%) and three (11%) of more proximal fractures, and in two (6%) and five (15%) of the fractures with distal extension (p = 0.23 for delayed healing; p = 0.72 for nonunion, Fisher's exact test). Four construct failures (14%) occurred in more proximal fractures, and three (9%) in fractures with distal extension (p = 0.51). Of the two deep infections that occurred in each group, one resolved after surgical debridement and antibiotics, and one progressed to a nonunion. Extreme distal periprosthetic supracondylar fractures of the femur are not a contra-indication to lateral locked plating. These fractures can be managed with internal fixation, with predictable results, similar to those seen in more proximal fractures.

Percutaneous plating in the lower extremity.

Since the late 1950s, open reduction and internal fixation has been advocated to restore bone anatomy and enable early mobilization. This approach often necessitated extensive dissection and tissue devitalization, creating an environment less favorable for fracture union and more prone to bone infection. As a result, other methods, such as intramedullary nailing, have become the standard treatment for most diaphyseal fractures of the femur and tibia. However, internal fixation with plates and screws remains the treatment of choice for most periarticular fractures and other complex fractures inadequately stabilized by intramedullary nailing. Recently, more "biologic" methods of reduction involving the use of indirect techniques and new plate designs have been developed in an attempt to preserve the blood supply to the injured bone, improve the rate of fracture healing, decrease the need for bone grafting, and lower the incidence of infection and other complications. Percutaneous plating appears to be the next step in the evolution of biologic plating. With these techniques, the fracture is reduced indirectly, and plates are placed into submuscular or subcutaneous tunnels through limited skin incisions. This may result in less surgical trauma to tissues and further improvements in clinical results compared with current methods of plate insertion.

Treatment of complex tibial periarticular fractures using percutaneous techniques.

Open reduction and internal fixation typically is reserved for the treatment of patients with articular or periarticular tibia fractures, or other tibial injuries that are treated inadequately with intramedullary nailing. This approach can result in extensive dissection and tissue devitalization. By modifying the method of fixation, the plating of tibial fractures has been expanded using a percutaneous technique. Using this approach, the fracture is reduced indirectly and plates are placed through subcutaneous or submuscular tunnels through limited incisions. Between 1992 and 1998, 17 patients with tibial shaft fractures and associated severe soft tissue injury, were treated using a percutaneous plating technique. Followup was available in 14 patients. Six patients required bone grafting procedures for delayed union or nonunion, although four of these patients had significant bone loss related to their injury. There were no malunions. Three patients had superficial infections related to external fixator pin sites and one patient had osteomyelitis develop. Percutaneous plating of the tibia offers an alternative method for stabilizing complex fractures with severely compromised soft tissues, especially those injuries with periarticular extension. This technique is thought to cause no increase in the risk of infection or soft tissue damage and permits rapid mobilization of the limb and patient. When using this treatment for patients with significant bone loss, bone grafting should be considered.

Mechanical properties of small fragment screws.

For many years, stainless steel small fragment screws have been produced by one manufacturer. Recently, other implant makers have begun offering similar stainless steel screws. In addition, screw geometry and material composition have been modified in an attempt to produce screws for a wide range of clinical situations. This study compared the mechanical properties of several commonly used small fragment screws. Seven sets of screws were tested mechanically, including three brands of geometrically identical standard stainless steel cortical screws and one brand each of cannulated stainless steel cortical screws, titanium cortical screws, stainless steel cancellous screws, and bioabsorbable polylactic acid screws. Screws from each group were tested for pullout strength, torque to failure, and three-point bending to failure. There were no differences in the mechanical properties of the identical 3.5-mm standard stainless steel cortical screws. No difference in pullout strength was found between the five sets of cortical screws. However, the cancellous screws had 4% to 24% less pullout strength. Torsion tests showed that cannulated stainless steel cortical, titanium cortical screws, stainless steel cancellous screws, and polylactic acid screws failed at significantly less torque than did standard stainless steel cortical screws. Standard stainless steel cortical screws had the highest mean yield point and maximal load at failure of all screws in three-point bending. Other metal screws had lower yield strength and maximal load at failure than did the standard stainless steel cortical screws, and polylactic acid screws had the least bending strength.

Pin tract infections: silver vs uncoated pins.

To test the hypothesis that coating external fixation pins with a silver-containing compound (Spi-Argent, Spire Corp, Bedford, Mass) will reduce bacterial colonization and/or pin tract infection, 36 silver-coated and 12 conventional stainless steel pins were placed in the iliac crest of six sheep and inoculated with Staphylococcus aureus. After 2 1/2 weeks the pin sites were examined for motion and inflammation, and the pin tips were quantitatively cultured and examined with scanning electron microscopy (SEM). We found that 84% of the uncoated pins were infected, while 62% of the silver-coated pins were infected. Silver-coated pins were less frequently infected than uncoated pins (confidence interval [CI] > 85%). Also, silver-coated pins were loose less frequently than uncoated pins. Pin motion was closely correlated with infection: 28 of 32 infected pins (88%) had motion, while only 9 of 16 uninfected pins (56%) had motion (CI > 80%). SEM study of the pin tips showed a decreased level of glycocalyx-protected colonization on the surface of the silver-coated pins. Clinically, these results suggest that silver-coated pins will result in less infection and motion at the pin site, the most significant problems in external fixation.

Details of the central projections of the cochlear nerve in the hamster revealed by the fluorescent tracer DiI.

A new fluorescent tracer, DiI, may be used postmortem in perfused animals making placement in small structures such as the cochlea much less difficult. We have mapped cochlear nerve terminations in the cochlear nucleus with DiI and, using three-dimensional reconstructions, have demonstrated the topography and geometry of the cochlear input. By placing DiI in two regions of the cochlea, we have demonstrated that terminations from the cochlea form stacked sheets of inputs. If enough closely situated ganglion cells were labeled in the cochlea, a well-delineated stripe of label could be found in each section of the cochlear nucleus up to the superficial granule cell region. Here a small extension of label, separate from the stripe may represent the medial olivocochlear axons. When fewer axons were labelled in the cochlear nerve, the sheets were absent and discontinuous patches of label were found. These patches apposed rostrocaudally to form bands of label that run orthogonal to the tonotopic organization.