Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Dual Plate Fixation of Periprosthetic Distal Femur Fractures.

OBJECTIVES: Dual implants for distal femur periprosthetic fractures is a growing area of interest for these challenging fractures with dual plating (DP) emerging as a viable construct for these injuries. In the current study, an experience with DP constructs is described. DESIGN: Retrospective case series with comparison group. SETTING: Level 1 academic trauma center. PATIENT SELECTION CRITERIA: Adults >50 years old sustaining comminuted OTA/AO 33-A2 or 33-A3 DFPF treated with either DP or a single distal femur locking plating (DFLP). Patients with simple 33-A1 fractures were excluded. Prior to 2018, patients underwent DFLP after which the treatment of choice became DP. OUTCOME MEASURES AND COMPARISONS: Reoperation rate, alignment, and complications. RESULTS: 34 patients treated with DFLP and 38 with DP met inclusion and follow up criteria. Average follow up was 18.2 ± 13.8 months in the DFLP group and 19.8 ± 16.1 months in the DP group ( P = 0.339). The average patient age in the DFLP group was 74.8 ± 7.3 years compared to 75.9 ± 11.3 years in the DP group. There were no statistical differences in demographics, fracture morphology, loss of reduction, or reoperation for any cause ( P >.05). DP patients were more likely to be weight bearing in the twelve-week postoperative period ( P <0.001) and return to their baseline ambulatory status ( P = 0.004) compared to DFLP patients. CONCLUSIONS: Dual plating of distal femoral periprosthetic fractures maintained coronal alignment with a low reoperation rate even with immediate weight bearing and these patients regained baseline level of ambulation more reliably as compared to patients treated with a single distal femoral locking plate. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Lateral versus Medial Entry Femoral Traction Pin Complication Rates.

Distal femoral skeletal traction is a common procedure for the stabilization of fractures of the pelvis, acetabulum, and femur following trauma. Femoral traction pins are traditionally inserted via medial-to-lateral (MTL) entry to accurately direct the pin away from the medial neurovascular bundle. Alternatively, cadaveric studies have demonstrated low risk to the neurovascular bundle using a lateral-to-medial (LTM) approach. The purpose of this study was to compare the incidence of complications of LTM and MTL femoral traction pin placement at a single institution. This was a retrospective review of patients from the orthopaedic consult registry at a academic Level I Trauma Center. We identified 233 LTM femoral traction pin procedures in 231 patients and 29 MTL pin procedures in 29 patients. The two pin placement techniques were compared with respect to complications, specifically the incidence of neurovascular injury, cellulitis, septic arthritis, osteomyelitis, and heterotopic ossification after femoral traction pin placement. Two complications were reported. One patient developed heterotopic ossification along the pin tract after LTM traction pin placement. Another patient developed septic arthritis after LTM pin placement, likely attributable to retrograde intramedullary nailing of his open femur fracture rather than his traction pin. There were no reports of neurovascular injury, cellulitis, or osteomyelitis associated with pin placement. The complication rate was 0.9% for LTM group and 0.0% for MTL group (p = 0.616). LTM femoral traction pin placement is a safe procedure with a similarly low complication rate compared with traditional MTL placement when the limb is positioned in neutral alignment. (Journal of Surgical Orthopaedic Advances 32(4):259-262, 2023).

Rethinking the Coronal Anatomic Axis of the Distal Tibia for Intramedullary Nail Placement: A Cadaveric Study.

Background: Recent studies have reported that targeting a center-center position at the distal tibia during intramedullary nailing (IMN) may result in malalignment. Although not fully understood, this observation suggests that the coronal anatomic center of the tibia may not correspond to the center of the distal tibia articular surface. Questions/Purposes: To identify the coronal anatomic axis of the distal tibia that corresponds to an ideal start site for IMN placement utilizing intact cadaveric tibiae. Methods: IMN placement was performed in 9 fresh frozen cadaveric tibiae. A guidewire was used to identify the ideal start site in the proximal tibia and an opening reamer allowed access to the canal. Each nail was then advanced without the use of a reaming rod until exiting the distal tibia plafond. Cadaveric and radiographic measurements were performed to determine the center of the nail exit site in the coronal plane. Results: Cadaveric and radiographic measurements identified the IMN exit site to correspond with the lateral 59.5% and 60.4% of the plafond, respectively. Conclusions: Tibial nails inserted using an ideal start site have an endpoint that corresponds roughly to the junction of the lateral and middle third of the plafond. Further studies are warranted to better understand the impact of IMN endpoint placement on the functional and radiographic outcomes of tibia shaft fractures.

No false elevation in ankle brachial index in patients with tibial plateau fractures and vascular risk factors.

Objectives: The ankle brachial index (ABI) is a useful tool in detection of lower extremity vascular injury. However, diabetes mellitus (DM), chronic kidney disease (CKD), and peripheral vascular disease (PVD) may affect extremity perfusion leading to possible false elevation of the ABI value. If true in trauma patients, this can affect initial evaluation, diagnostics, and management. We therefore explored mean ABI values in tibial plateau fractures of patients with vascular risk factors to help determine whether there is a difference. Design: This is a retrospective chart review of patients sustaining tibial plateau fractures with a specific ABI value recorded in the medical record. Patients were identified as either having vascular risk factors or not and data analysis performed to determine if their ABI differed and whether they were more likely to have a vascular injury. Results: 282 acute tibial plateau injuries with specific ABI values were identified, 46 of which carried the risk factors in question. The average risk factor group ABI was 0.95 ±â€¯0.15 versus those without risk factors 1.0 ±â€¯0.15 (p = 0.057). No patient with risk factors required a vascular intervention or four-compartment fasciotomy. Conclusions: This study shows no statistical significance between the presenting ABI of patients with risk factors such as DM, CKD, or PVD and those without those risk factors who sustained acute tibial plateau fractures. Therefore, in general the ABI still holds as a useful screening tool for evaluation of vascular insult in the setting of acute lower extremity trauma.

Contributions of Pubic Rami Fracture Morphology and Fixation to Pelvic Ring Stability in Type 1 Lateral Compression Injuries: A Biomechanical Cadaveric Study.

BACKGROUND: Treatment of lateral compression type 1 (LC-1) injuries has historically been nonoperative with immediate weight-bearing. However, management of these injuries remains controversial, with reports of displacement at follow-up for nonoperatively managed LC-1 fractures. The goal of our study was to determine the effect of superior pubic ramus fracture morphology and fixation construct on pelvic stability. METHODS: Ten fresh-frozen cadaveric were transected into hemi-pelvises. Incomplete Denis type 1 sacral fractures were made. Hemi-pelvises were randomized to receive a transverse-type or oblique-type superior pubic ramus fracture with the contralateral hemi-pelvis receiving the opposing morphology. A lateral load to 135N was applied with an Instron materials testing machine and lateral displacement of the hemi-pelvis was recorded. Deflection and stiffness were calculated. Statistical analysis was conducted using a t test assuming unequal variances with an alpha = 0.05. RESULTS: Oblique-type superior pubic ramus fractures allowed more deflection compared with transverse-type fractures in the absence of fixation (P = 0.018). The posterior-only and combined anterior and posterior fixation configurations on average reduced deflection more than no fixation or anterior fixation only. In all fixation configuration cases, the average deflection for transverse-type fractures was less than that of the oblique-type fractures. CONCLUSIONS: Our findings suggest that displacement of LC-1 pelvic injuries may be related to pubic rami fracture morphology. When looking at initial injury imaging, oblique-type pubic rami fractures may suggest an increased potential for displacement over time. In such cases, we recommend an examination under anesthesia to evaluate for underlying instability and consideration for fixation. LEVEL OF EVIDENCE: Therapeutic Level V.

Thermal Output of Oscillation Versus Forward Drilling of Bone.

This study's objective was to identify a difference in maximum temperature change during forward versus oscillating drilling of cadaveric bone. Paired femurs were dissected from the soft tissue of five cadavers. Each cadaver had one femur assigned to forward and the other to oscillation. The first drill hole was 2.5 cm distal to the lesser trochanter and the remaining 10 holes were evenly spaced 2 cm apart. A System 7 drill and 3.5 mm drill bit were attached to an Instron 5500R to provide a progressive force of 50 Newtons per minute for each drill hole. A thermal camera recorded each drilling. A new drill bit was used for each femur. Fifty bicortical drillings were analyzed in each group. The average time to complete forward drilling (45.0 seconds) was shorter compared to oscillation (55.5 s, p < 0.001). The average force required for forward drilling (27.7 N) was lower than for oscillation (44.3N, p < 0.001). The maximum change in temperature during the drilling process was similar (oscillating 100.2° F vs. forward 100.7° F, p = 0.871). The maximum change in temperature at the near cortex was lower for oscillation (78.1°F) compared to forward drilling (89.1°F, p = 0.011), while the maximum change at the far cortex was lower for forward drilling (89.3°F) compared to oscillation (95.8°F, p = 0.115) but not significantly. Overall, there is no difference in the thermal output between techniques. Oscillation may be beneficial in proximity to vital structures or to navigate narrow bony corridors, but it requires additional time and force. (Journal of Surgical Orthopaedic Advances 31(4):233-236, 2022).

Advances in Geriatric Hip Fractures: Pre-Operative Considerations and Tips to Optimize Outcome.

SUMMARY: Geriatric hip fractures are complicated by increased morbidity and mortality, and their incidence continues to rise around the world. Frequent considerations in treating geriatric hip fractures include optimal time to surgery, need for preoperative cardiac clearance, risks of operating through anticoagulation, utilization of regional anesthesia, and collaborative care between treatment teams. This article aims to summarize these factors as well as to provide some tips and tricks that can be helpful in their surgical management.

Economic impact of orthopaedic care for non-fatal gunshot wounds: analysis of a public health crisis.

BACKGROUND: The purpose of this study was to perform an epidemiological evaluation and an economic analysis of 90-day costs associated with non-fatal gunshot wounds (GSWs) to the extremities, spine and pelvis requiring orthopaedic care in the United States. METHODS: A retrospective epidemiological review of the Medicare national patient record database was conducted from 2005 to 2014. Incidence, fracture location and costs associated where evaluated. Those patients identified through International Classification of Disease (ICD)-9 revision codes and Current Procedural Terminology (CPT) Codes who sustained a fracture secondary to a GSW. Any type of surgical intervention including incision and drainage, open reduction with internal fixation, closed reduction and percutaneous fixation, etc. were identified to analyze, and evaluate costs of care as seen by charges and reimbursements to the payer. The 90-day period after initial fracture care was queried. RESULTS: A total of 9,765 patients required surgical orthopaedic care for GSWs. There was a total of 2,183 fractures due to GSW treated operatively in 2,201 patients. Of these, 22% were femur fractures, 18.3% were hand/wrist fractures and 16.7% were ankle/foot fractures. A majority of patients were male (83.3%) and under 65 years of age (56.3%). Total charges for GSW requiring orthopedic care were $513,334,743 during the 10-year study period. Total reimbursement for these patients were $124,723,068. Average charges per patient were highest for fracture management of the spine $431,021.33, followed by the pelvis $392,658.45 and later by tibia/fibula fractures $342,316.92. CONCLUSIONS: The 90-day direct charges and reimbursements of orthopedic care for non-fatal GSWs are of significant amounts per patient. While the number of fatal GSWs has received much attention, non-fatal GSWs have a large economic and societal impact that warrants further research and consideration by the public and policy makers.

Technical Trick: Dual Plate Fixation of Periprosthetic Distal Femur Fractures.

SUMMARY: Treatment of periprosthetic distal femur fractures remains challenging due to assuring adequate distal fixation. Traditional treatment options include lateral locked plating and retrograde nailing, although recently dual implant constructs have been explored with promising results. Allowing immediate weight-bearing in this patient population has benefits with regards to rehabilitation and outcome. Recent literature has focused on nail-plate constructs, however plate-plate constructs are preferred at our institution as they do not require arthroplasty component compatibility, facilitate the coronal plane reduction, and allow for immediate weight-bearing.

Reconstruction of Distal Humerus Fractures with Severe Bone Loss: A Case Series and Review of the Literature.

The objective of this study was to describe examples and review the literature of distal humerus fracture reconstruction in the setting of severe bone loss. Four individuals (ages 19-59 years) were treated with either fibular strut allograft or fresh frozen osteochondral allograft in the setting of unreconstructable periarticular bone loss. The radiographs were evaluated for evidence of union. Pain and degrees of range of motion were reported when available. The follow-up period ranged from 3 to 42 months. While additional surgery was often needed, union was ultimately obtained in each case. Normal range of motion was not obtained, but two of the four patients were near normal upon union. Two of the four patients were pain free, and the other two had mild pain. All were limited in their activities, even after union. This case series describes satisfactory results with the use of allograft in this difficult clinical problem. (Journal of Surgical Orthopaedic Advances 29(2):65-72, 2020).

Comparing the Efficiency, Radiation Exposure, and Accuracy Using C-Arm versus O-Arm With 3D Navigation in Placement of Transiliac-Transsacral and Iliosacral Screws: A Cadaveric Study Evaluating an Early Career Surgeon.

OBJECTIVES: To compare the efficiency, radiation exposure to surgeon and patient, and accuracy of C-arm versus O-arm with navigation in the placement of transiliac-transsacral and iliosacral screws by an orthopaedic trauma fellow, for a surgeon early in practice. METHODS: Twelve fresh frozen cadavers were obtained. Preoperative computed tomography scans were reviewed to assess for safe corridors in the S1 and S2 segments. Iliosacral screws were assigned to the S1 segment in dysmorphic pelvises. Screws were randomized to modality and laterality. An orthopaedic trauma fellow placed all screws. Time of procedure and radiation exposure to the cadaver and surgeon were recorded. Three fellowship-trained orthopaedic trauma surgeons rated the safety of each screw on postoperative computed tomography scan. RESULTS: Six normal and 6 dysmorphic pelvises were identified. Eighteen transiliac-transsacral screws and 6 iliosacral screws were distributed evenly between C-arm and O-arm. Average operative duration per screw was significantly shorter using C-arm compared with O-arm (15.7 minutes ± 6.1 vs. 23.7 ± 8.5, P = 0.014). Screw placement with C-arm exposed the surgeon to a significantly greater amount of radiation (3.87 × 10 rads vs. 0.32 × 10, P < 0.001) while O-arm exposed the cadaver to a significantly greater amount of radiation (0.03 vs. 2.76 rads, P < 0.001). Two S2 transiliac-transsacral screws (1 C-arm and 1 O-arm) were categorized as unsafe based on scoring. There was no difference in screw accuracy between modalities. CONCLUSIONS: A difference in accuracy between modalities could not be elucidated, whereas efficiency was improved with utilization of C-arm, with statistical significance. A statistically significant increase in radiation exposure to the surgeon using C-arm was found, which may be clinically significant over a career. The results of this study can be extrapolated to a fellow or surgeon early in practice. The decision between use of these modalities will vary depending on surgeon preference and hospital resources.

Technical Trick: The Trochanteric Hook Plate in Treatment of B1 Periprosthetic Femur Fractures.

Vancouver B1 periprosthetic fractures undergoing operative fixation remain difficult to treat due to a short proximal segment that offers limited options for fixation. The trochanteric hook plate addresses this issue by maximizing proximal purchase and utilizing the entire lateral surface area of the greater trochanter. A surgical technique that prioritizes proximal fixation and adheres to basic principles resulted in all fractures healing in a small case series. (Journal of Surgical Orthopaedic Advances 29(4):199-201, 2020).

Negative-Pressure Wound Therapy in Foot and Ankle Surgery.

Negative Pressure Wound Therapy (NPWT) is frequently utilized to manage complex wounds, however its mechanisms of healing remain poorly understood. Changes in growth factor expression, micro- and macro-deformation, blood flow, exudate removal, and bacterial concentration within the wound bed are thought to play a role. NPWT is gaining widespread usage in foot and ankle surgery, including the management of traumatic wounds; diabetic and neuropathic ulcers; wounds left open after debridement for infection or dehiscence; high-risk, closed incisions; tissue grafts and free flaps. This article reviews the rationale for NPWT, its proposed mechanisms of action, and the evidence regarding its clinical applications within the field of foot and ankle surgery. Level of Evidence: Level V, expert opinion.

Valgus Intertrochanteric Osteotomy for Femoral Neck Nonunion.

Valgus intertrochanteric osteotomy is an effective method of treating femoral neck nonunion by reducing shear forces at the fracture and correcting the neck-shaft angle. Good outcomes have been reported in the literature. Through careful preoperative planning and a precise operative technique, reliable healing of both the osteotomy and nonunion can be achieved.

Delayed Closure Is Associated with Decreased Infection Rate in Amputations after Trauma.

Amputations associated with trauma carry significant morbidity in addition to risk of limb loss due to tissue damage, contamination, and risk of infection. The timing of formal amputation closure in this situation varies among surgeons, with some allowing the wound to remain open for some time after debridement, whereas others perform formal amputation and closure at the index operation if debridement is adequate. The presence of infection after closure of an amputation has the potential to result in a higher amputation (i.e., a below-knee amputation to an above-knee amputation). Our goal was to examine the relationship of timing of closure to stump infection and eventual level of amputation. A review was performed of all patients admitted to a Level I trauma center over a six-year period with amputations during the initial admission after trauma. Amputations of either an arm (above or below the elbow) or a leg (above or below the knee) were included. The number of days between adequate debridement as judged by the operating surgeon and closure of the amputation and whether there was an infection after closure were evaluated. Also investigated was the relationship between infection after closure and a higher level of amputation. Between January 1, 2010, and December 31, 2015, 63 patients (ages 15-81 years, mean age 45.1 ± 18.4) underwent an amputation of a leg or an arm. Fifty-four were male, nine were female, the mean injury severity score was 20.9 ± 10.4, and the mean lactate level at admission was 3.4 ± 1.7. Of the 63 patients, 53 patients had an amputation of a leg and 10 had an amputation of an arm. The overall infection rate was 32 per cent, and the mean time until closure was 6.7 ± 11.1 days. Comparing closure times in those with and without infection after closure, the mean intervals were 3.1 ± 9.7 and 8.4 ± 11.4 days, respectively (P = 0.01). The receiver operating characteristic curve c-statistic was 0.69 (P = 0.04). Sensitivity of various times to closure for avoiding infection was examined and was optimized at five days with infection rates above five days of 5.3 per cent versus at or below five days to closure of 43.2 per cent (P = 0.0029). Infection resulted in a higher level of amputation in 40 per cent of those who had an infection. Based on these data, delay in closure of an amputation even after debridement appears adequate was associated with a lower rate of infection and the presence of infection resulted in a higher amputation level in more than a third of studied patients. Delay of formal amputation closure for at least five days after adequate debridement is acheived is associated with a significantly reduced rate of infection.

Treatment of Peritrochanteric Femur Fractures With Proximal Femur Locked Plating.

OBJECTIVES: To report on our results using a proximal femoral locking plate for the treatment of peritrochanteric femur fractures. DESIGN: Retrospective study. SETTING: Level I Academic Medical Center. PATIENTS: Sixty-eight patients with 68 fractures. INTERVENTION: Demographics, fracture morphology, preoperative imaging, rationale against nailing, and outcomes were collected. MAIN OUTCOME MEASUREMENTS: Outcomes were grouped into no complication, minor complication, or major complication. Minor complications included healed fractures with implant failure or change in alignment from immediate postoperative radiographs, which did not require intervention or elective implant removal. Major complications included any case that required revision for nonunion or implant failure. RESULTS: Nine patients were lost to follow-up. Of the 59 fractures, 16 had complications (27%): 9 minor and 7 major. Active tobacco use (P = 0.020) and fractures with an associated intracapsular femoral neck component (P = 0.006) correlated with complications. CONCLUSIONS: Proximal femoral locking plates continue to be associated with a high complication rate. However, based on our experience, proximal femoral locking plates may be considered in highly selected cases when absolutely no other implant is deemed appropriate, based on the degree of comminution and the complexity of the fracture pattern. Patients must be informed about the possibility of revision surgery based on the inherent limitations of these devices. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical Evaluation of Interfragmentary Compression of Lag Screw Versus Positional Screw at Different Angles of Fixation.

OBJECTIVES: To compare the compressive force achieved and retained with the lag versus positional screw technique at various angles of screw application. METHODS: Sixty humeral sawbones were stratified into 6 groups based on the technique (lag or positional) and fixation angle (30, 60, or 90 degrees relative to the fracture plane). A sensor was placed between fragments to record compressive force. Absolute screw force is the final screw force. Normalized force is the final screw force minus force generated by reduction forceps. Retained force is the quotient of absolute force relative to reduction forceps force. RESULTS: Lag screws attained higher force than positional at 60 degrees (absolute force 41% higher, P = 0.041; normalized force 1300% higher, P = 0.008; retained force 60% higher, P = 0.008) and 90 degrees (absolute force 86% higher, P = 0.006; normalized force 730% higher, P = 0.005; retained force 70% higher, P = 0.011), but not at 30 degrees. For lag screws, compressive force was similar at 60 and 90 degrees (absolute force P = 0.174, normalized force P = 0.364, and retained force P = 0.496), but not 30 degrees. For positional screws, no difference was found between the 3 angles of fixation for absolute force (P = 0.059). Normalized force and retained force were similar at 60 and 90 degrees (P = 0.944 and P = 0.725, respectively), but not 30 degrees. CONCLUSIONS: Lag screw technique compressive force was superior to positional screw technique at 60 and 90 degrees. Comparison of force at angles of 60 and 90 degrees showed no significant difference for both techniques. Indicating 30 degrees deviation from perfect technique is tolerated without significant decrease in compressive force.

Reduction Techniques for Young Femoral Neck Fractures.

Young femoral neck fractures remain challenging fractures to treat. Reduction has repeatedly been shown to be the single most important determinant of patient outcome, and treating surgeons should do all they can to achieve anatomic reduction because this is an outcome variable within the surgeon's control. Whether an open or closed reduction is performed, we hope to provide the reader with reduction strategies when faced with this difficult fracture pattern. In addition, we hope to review indications and techniques for using the various treatment implants/modalities that are currently available as they pertain to reduction and fixation.