Does the Fibula Need to be Fixed in Complex Pilon Fractures?

OBJECTIVES: To review a series of patients with complex plafond injuries with a metadiaphyseal dissociation who did not have the fibula fixed and compare with patients who had their fibula fixed using patients without a fibula fracture as a control group. DESIGN: Retrospective case-control study. SETTING: Level 1 Trauma center at a university hospital. PATIENTS/PARTICIPANTS: Skeletally mature patients with a complete metadiaphyseal plafond fracture, and adequate presentation, postreduction, and healed radiographs to measure varus and valgus alignment. INTERVENTION: Surgical treatment [external fixator or open reduction internal fixation (ORIF)] of high energy pilon fractures. MAIN OUTCOME MEASUREMENTS: Metaphyseal alignment at the time of presentation, after fixation, and at union, surgical procedures performed, and complications. METHODS: From 364 patients with plafond fractures, 111 had high energy injuries with metadiaphyseal dissociation and form the basis of the study. Radiographs and charts were reviewed for fracture characteristics, metaphyseal alignment at the time of presentation, after fixation, and at union, surgical procedures performed, and complications. RESULTS: Of the 111 study patients, 93 patients were treated definitively with ORIF of the tibia and 18 patients were treated definitively in an external fixator. Within the 93 patients treated definitively with ORIF of the tibia, we identified 3 groups of patients those with a fibula fracture that was fixed (26 patients), those with a fibula fracture that was not fixed (37 patients), and those without a fibula fracture acting as the control group (30 patients). Between the 2 groups having a fibula fracture treated with ORIF of the tibia, there was no difference in fibula fracture pattern or location. For the 26 patients who had fibular fixation, it was performed in 11 patients at an average of 17 days for inability to hold length and alignment and in 15 patients to augment fixation in poor bone stock or to aid in the reduction. Patients with initial valgus deformity were more likely to have their fibula fixed. There was no difference in the postoperative or final alignment between the patients with fibula fractures (with or without fixation) and those without fibula fractures (P = 0.92). When comparing the 3 groups, the only statistical finding between the 2 groups was that those with fibula fixation required plate removal (P < 0.0001). CONCLUSIONS: Fibular fixation is not a necessary step in the reconstruction of pilon fractures, although it may be helpful in specific cases to aid in tibial plafond reduction or augment external fixation. We found a higher rate of plate removal if the fibula was fixed. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Removal of the Symphyseal Cartilage in Symphyseal Dislocations Have Any Effect on Final Alignment and Implant Failure?

OBJECTIVES: To compare final symphyseal alignment, incidence of implant failure, and revision surgery with and without symphyseal cartilage excision in patients with symphyseal dislocations treated operatively. DESIGN: Retrospective review. SETTING: Two academic level 1 trauma centers. PATIENTS/PARTICIPANTS: We reviewed the records of 96 patients (89 men, 7 women) who had anterior posterior compression (APC) type 2 and 3 injuries requiring anterior plating. The average age was 46 years, and the average Injury Severity Score was 15.6. INTERVENTION: Fifty patients were treated with symphyseal cartilage removal, whereas a second cohort of 46 patients was treated without removal of the symphyseal cartilage at the time of symphyseal open reduction and internal fixation during the same time period in a different center. Operative indications were the same for both centers, with iliosacral screws used only for type 3 injuries. Both centers used 6-hole plates through a rectus sparing approach. MAIN OUTCOME MEASUREMENTS: Symphyseal separation was measured radiographically on preoperative and postoperative anteroposterior (AP) and outlet projections. The incidence of implant failure was recorded from the final postoperative radiograph available. Revision surgery was documented. RESULTS: The symphyseal space after cartilage excision was less than if retained, which was maintained through union. The incidence of implant failure was statistically lower when symphyseal cartilage was excised. There were 2 revisions of symphyseal fixation in the symphyseal retention group for implant failure versus none when excised. CONCLUSIONS: Symphyseal cartilage excision led to closer apposition of the symphyseal bodies, which correlated with substantially lower rates of implant failure, and revision surgery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The perfect reduction: approaches and techniques.

Anatomic reduction of femoral neck fractures is difficult to obtain in a closed fashion. Open reduction provides for direct and controlled manipulation of fracture fragments. This can be accomplished via multiple approaches. The anterolateral, or Watson-Jones, approach or Smith-Petersen, or direct anterior, approach are the two most frequently used. Percutaneous techniques have also been described, though they lack the visual confirmation of reduction of a traditional open approach. These can be performed using a fracture table or with a free leg on a radiolucent table in either supine or lateral positions. Knowledge of the hip and pelvis anatomy is crucial for the preservation of critical femoral neck vasculature. Intra-operative fluoroscopy together with direct visualization provides the framework for successful manipulation of the fracture fragments, temporary stabilization, and ultimately fracture fixation.

Risk factors for fracture mobility six weeks after initiation of brace treatment of mid-diaphyseal humeral fractures.

BACKGROUND: Recent studies have identified specific subsets of diaphyseal humeral fractures for which functional bracing is less effective. The present study tested the hypothesis that a gap between fracture fragments may be a risk factor (after accounting for other potential risk factors) for fracture instability six weeks after functional bracing of humeral shaft fractures. METHODS: We retrospectively identified seventy-nine adult patients (forty-six men, thirty-three women; forty-two fractures on the right side, thirty-seven fractures on the left), each with an acute, closed, AO type-A2 (oblique, ≥30°) or type-A3 (transverse, <30°) mid-diaphyseal humeral shaft fracture treated nonoperatively at three different level-I trauma centers from June 2004 to August 2011. The gap between the fracture fragments was measured on the first radiographs made after the affected upper extremity was placed in a brace. RESULTS: Sixty-three patients (80%) had documented healing of the fracture. Sixteen patients (20%) had motion at the fracture site and a persistent fracture line shown on radiographs six weeks or more after injury. In multivariable analysis, each millimeter of gap between the main fragments with the patient wearing the brace (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.1 to 1.7), smoking (OR = 5.8, 95% CI = 1.4 to 25), and female sex (OR = 5.3, 95% CI = 1.2 to 23) increased the risk of fracture instability six weeks after injury (R2 = 0.38, area under the receiver operating characteristic [ROC] curve = 0.81). CONCLUSIONS: The magnitude of the gap between the fracture fragments is an independent risk factor for fracture instability and the lack of a bridging callus six weeks after a diaphyseal humeral fracture.

Extra-articular proximal tibial fractures: nail or plate?

The surgical goals for treating proximal tibial fractures are to restore articular congruity, the mechanical axis, and knee motion while avoiding soft-tissue complications. The fracture pattern should be correctly identified and understood. For fractures with minimal intra-articular extension, fracture fixation with an intramedullary nail can decrease the risk of infection because it uses a small incision that is not placed directly over the injured soft tissue, and it provides better axial load sharing than a plate. Using the semi-extended technique, choosing the correct starting portal, incorporating blocking screws or stability screws into the fixation construct, and using mini-open reduction and internal fixation of the fracture will help achieve the goals of fracture fixation with an intramedullary nail. All proximal tibial fractures can be treated successfully with a plate or multiple plates. When a plate is used, the surgical approach and technique should minimize soft-tissue damage and account for future surgical procedures that may be needed. Fractures with intra-articular involvement and/or comminution of the medial metaphyseal region are appropriately treated with dual plating. Extra-articular fractures without major medial comminution may be treated with a locked lateral plate. Final union rates for patients treated with either intramedullary nail or plate fixation are reported at 96% and 97%, respectively. A prospective, randomized, multicenter study is currently in progress to further clarify and advance the treatment of proximal tibial fractures.

Initial management and classification of pelvic fractures.

Pelvic fractures represent a significant transfer of kinetic energy to the body, and more than 80% of patients with unstable pelvic fractures have additional musculoskeletal injuries. A systematic approach with prompt intervention is critical in the initial management of patients with pelvic fractures. If intra-abdominal bleeding is suspected, diagnostic peritoneal lavage, focused assessment with sonography for trauma, or a CT examination is usually performed. CT angiography and interventional radiographic angiography are useful tools for determining the location of bleeding and the amount of blood loss. Patients presenting in extremis should undergo immediate pelvic stabilization and laparotomy with pelvic packing if indicated. Stable patients can undergo CT angiography. If a large pelvic hematoma or contrast blush is present, extraperitoneal packing or angiography can be performed based on the availability of the needed subspecialists. The orthopaedic surgeon provides prompt stabilization using external immobilizers, external fixation, or traction. The bladder, urethra, and nerve roots have an intimate location within the pelvis and are predisposed to injury in patients with pelvic fractures. Appropriately identifying associated abdominal, urologic, or neurologic injuries will provide important opportunities to reduce patient morbidity and improve long-term outcomes.

Open fractures of the distal radius: the effects of delayed debridement and immediate internal fixation on infection rates and the need for secondary procedures.

PURPOSE: There are few clinical data evaluating the outcome of surgery for open distal radius fractures based on treatment method. Specifically, the major contributing factors to infection are largely unknown. The purpose of this study is to determine the effect of early versus delayed debridement and the choice of initial external versus internal fixation on infection rates and the need for secondary procedures. METHODS: Thirty-two patients with open distal radius fractures were identified from a database. Ten debridements were early (<6 h after hospital admission), and 22 debridements were delayed (>6 h after hospital admission). There were 10 treating surgeons for the 32 patients in this study. Based on the attending surgeon's preference and experience, 20 fractures were treated with external fixation, 7 with plating, and 5 with planned staged conversion from external fixation to plating. The cohort included 19 grade I, 11 grade II, and 3 grade IIIA open injuries. RESULTS: There were no infections, regardless of the time to debridement or the use of immediate plating. Other complications requiring secondary procedures occurred more frequently in patients treated with a planned staged conversion from external fixation to plating than in the patients treated with either external fixation or plating. CONCLUSIONS: We did not encounter infections for grade I and grade II open distal radius fractures, and infections do not appear to be related to either the time to debridement or the initial type of fracture fixation. Plating might be safe at the initial debridement, but temporary external fixation with a staged conversion to plating increases the risk of complications, which necessitates corrective secondary procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Film dosimetry in the peripheral region using multiple sensitometric curves.

We present a method for applying film dosimetry to the peripheral region utilizing multiple sensitometric curves. There are many instances when the dose to the peripheral region outside the field edges is of clinical and/or research interest. Published peripheral dose data may be insufficient if detailed dose modeling is required, and in those cases measurements must be performed. Film dosimetry is an attractive approach for dose measurement in the peripheral region because it integrates dose, overcoming the low-dose-rate problem, and is time efficient, as it acquires an entire plan of data in a single exposure. However, film response increases at energies below approximately 300 keV. As the scattered photon spectrum changes with distance from the field edge, this increased film sensitivity causes changes in the film response along profiles perpendicular to the field edge. A single sensitometric curve is therefore no longer sufficient for accurate conversion of the optical density to dose. Our new method uses multiple sensitometric curves defined at increasing distances from the field edge. To convert an optical density profile, the dose at each point in the profile is defined as a linear combination of the doses calculated using the two sensitometric curves that bracket the point of interest. A single set of sensitometric curves derived at one field size and source-to-surface distance (SSD) can be applied to density profiles for other field sizes and SSDs. We verified our new method by comparison to ion chamber measurements using three different types of film. Agreement with chamber measurements was within 7%, or less than 2 mm in regions of high gradient, over a wide range of field sizes and SSDs.

A novel herpes simplex virus type 1 transcript (AL-RNA) antisense to the 5' end of the latency-associated transcript produces a protein in infected rabbits.

Following primary ocular infection, herpes simplex virus type 1 (HSV-1) establishes a lifelong latent infection in sensory neurons of the trigeminal ganglia. Latency-associated transcript (LAT), the only known viral gene abundantly transcribed during HSV-1 neuronal latency, is required for high levels of reactivation. Recently we showed that three different mutants that do not alter the LAT promoter but contain deletions within the 5' end of the primary LAT transcript affect viral virulence (G. C. Perng et al., J. Virol. 75:9018-9028, 2001). In contrast, in LAT-null mutants viral virulence appears unaltered (T. M. Block et al., Virology 192:618-630, 1993; D. C. Bloom et al., J. Virol. 68:1283-1292, 1994; J. M. Hill et al., Virology 174:117-125, 1990; G. C. Perng et al., J. Virol. 68:8045-8055, 1994; F. Sedarati, K. M. Izumi, E. K. Wagner, and J. G. Stevens, J. Virol. 63:4455-4458, 1989). We therefore hypothesized that the 5' end of LAT and/or an as yet unidentified gene that overlaps part of this region is involved in viral virulence. We report here on the discovery and initial characterization of a novel HSV-1 RNA consistent with such a putative gene. The novel RNA was antisense to the 5' end of LAT and was designated AL-RNA (anti-LAT sense RNA). The AL-RNA overlapped the core LAT promoter and the first 158 nucleotides of the 5' end of the primary LAT transcript. AL-RNA was detected in extracts from neuron-like cells (PC-12) infected with wild-type HSV-1 but not in cells infected with a mutant with the AL region deleted. The deletions in each of the above three mutants with altered virulence encompass the 5' end of the AL-RNA, and these mutants cannot transcribe AL. This supports the hypothesis that the AL gene may play a role in viral virulence. Based on comparison to the corresponding genomic sequence, the AL-RNA did not appear to be spliced. The AL-RNA was polyadenylated and contained an open reading frame capable of encoding a protein 56 amino acids in length with a predicted molecular mass of 6.8 kDa. Sera from three of three rabbits infected with wild-type HSV-1 but not sera from any of three rabbits infected with a mutant with the AL-RNA region deleted recognized the Escherichia coli recombinantly expressed AL open reading frame on Western blots. In addition, four of six rabbits infected with wild-type virus developed enzyme-linked immunosorbent assay titers against one or more AL synthetic peptides. These results suggest that an AL protein is produced in vivo.