Ability of modern distal tibia plates to stabilize comminuted pilon fracture fragments: Is dual plate fixation necessary?

OBJECTIVES: The purpose of this study was to examine the screw trajectory of ten commercially available distal tibia plates and compare them to common fracture patterns seen in OTA C type pilon fractures to determine their ability to stabilize the three most common fracture fragments while buttressing anterolateral zones of comminution. HYPOTHESIS: We hypothesized that a single plate for the distal tibia would fail to adequately stabilize all three main fracture fragments and zones of comminution in complex pilon fractures. METHODS: Ten synthetic distal tibia sawbones models were used in conjunction with ten different locking distal tibia plate designs from three manufacturers (Depuy Synthes, J&J Co, Paoli, PA; Smith & Nephew, Memphis, TN; and Stryker, Mawa, NJ). Both medial and anterolateral plates from each company were utilized and separately applied to an individual sawbone model. Three implants allowing variable angle screw placement were used. The location of the locking screws and buttress effect 1cm above the articular surface was noted for each implant using axial computed tomography (CT). The images were then compared to a recently published "pilon fracture map" using an overlay technique to establish the relationship between screw location and known common fracture lines and areas of comminution. Each of the three main fragments was considered "captured" by a screw if it was purchased by at least two screws thereby controlling rotational forces on each fragment. RESULTS: Three of four anterolateral plates lacked stable fixation in the medial fragment. Of the 4 anterolateral plates used, only the variable angle anterolateral plate by Depuy Synthes captured the medial fragment with two screws. All four anterolateral plates buttressed the area of highest comminution and had an average of 1.25 screws in the medial fragment and an average of 3 screws in the posterolateral fragment. All five direct medial plates had variable fixation within anterolateral and posterolateral fragments with an average of 1.8 screws in the anterolateral fragment and an average of 1.3 screws in the posterolateral fragment. The Depuy Synthes variable angle anterolateral plate allowed for fixation of the medial fragment with two screws while simultaneously buttressing the zone of highest comminution and capturing both the anterolateral and posterolateral fragments with five and three screws respectively. The variable angle anteromedial plate by Depuy Synthes captured all three main fracture fragments but it did not buttress the anterolateral zone of comminution. CONCLUSION: In OTA 43C type pilon fractures, 8 out of 10 studied commercially available implants precontoured for the distal tibia, do not adequately stabilize the three primary fracture fragments typically seen in these injuries. Anterolateral plates were superior in addressing the coronal primary fracture line across the apex of the plafond, and buttressing the zone of comminution. None of the available plates can substitute for an understanding of the fracture planes and fragments typically seen in complex intra-articular tibia fractures and the addition of a second plate is necessary for adequate stability. LEVEL OF EVIDENCE: Level IV.

Femoral Nerve Block vs Periarticular Bupivacaine Liposome Injection After Primary Total Knee Arthroplasty: Effect on Patient Outcomes.

CONTEXT: Patients receiving femoral nerve blocks for total knee arthroplasty (TKA) have been shown to have a high incidence of postoperative falls, which has been attributed to weakening of the quadriceps muscles. Local injection of analgesic medication that allows for full motor function of the quadriceps and, therefore, better progress through inpatient physical therapy and decreased hospital stay, has been suggested as an option for postoperative pain relief. OBJECTIVE: To compare the number of inpatient physical therapy sessions and hospital days needed in patients receiving periarticular injection of extended-release bupivacaine liposome vs femoral nerve block after TKA. METHODS: Data were retrospectively reviewed from the records of patients who underwent bilateral primary TKA, in which femoral nerve block was administered at the first operation and periarticular injection of an extended-release bupivacaine liposome mixture at the second operation. An average of 2.3 years had passed between the 2 procedures. The number of inpatient physical therapy sessions and hospital days needed were compared between both procedures for each patient. RESULTS: Sixteen patients (14 women) were included in the study, with a mean (SD) age of 63.8 (6.7) years. Compared with femoral nerve block, periarticular injection of analgesic medication resulted in fewer inpatient physical therapy sessions (femoral nerve block: mean [SD], 3.5 [1.3] sessions; periarticular injection: mean [SD], 2.3 [1.0] sessions; P=.002) and fewer hospital days (femoral nerve block: mean [SD], 1.9 [0.6] days; periarticular injection: mean [SD], 1.5 [0.6] days; P<.032). CONCLUSION: Compared with femoral nerve block, periarticular injection of analgesia was found to quicken postoperative recovery in patients hospitalized for TKA. The use of periarticular injections in patients undergoing TKA could yield substantial cost savings given the high frequency of this procedure.

Comparison Between Liposomal Bupivacaine and Femoral Nerve Block in Patients Undergoing Primary Total Knee Arthroplasty.

This study sought to evaluate opioid consumption, hospitalization costs, and length of stay when surgical site periarticular infiltration of liposomal bupivacaine is used after total knee arthroplasty (TKA). Sixty-six consecutive primary TKA cases performed with a single-injection femoral nerve block before this date were compared with 59 consecutive TKA cases performed with the liposomal bupivacaine cocktail after this date. The mean amount of postsurgical opioids consumed was 199 mg versus 121 mg (p = .075), the average hospitalization cost was $28,546 versus $26,472 (p < .001), and the average length of stay was 2.05 days versus 1.58 days (p < .001) in the femoral nerve block versus liposomal bupivacaine group, respectively. There were no significant demographic differences between the two groups. Liposomal bupivacaine infiltration before primary wound closure may be an effective means in lowering hospitalization costs, decreasing length of stay, and decreasing postsurgical opioid consumption after TKA.