Use of the Hybrid Operating Room for Pelvic and Acetabular Fracture Surgery.

The hybrid operating room (HOR) utilizes advanced imaging technology to improve intra-operative visualization and facilitate efficient care in procedures that are relatively image dependent. The robotic C-arm provides improved 2D image quality and is capable of large volume three-dimensional fluoroscopy (3DF) that can rapidly create multiplanar CT like images. Here we discuss on the technique, utility, potential benefits, pitfalls, and complications of using the hybrid suite with and without intra-arterial balloon occlusion for pelvic and acetabular fracture surgery. We also present a case series of patient who underwent pelvic fixation using the HOR. While not advocated for routine use in all pelvic and acetabular fractures; the hybrid suite can be an effective tool in the treatment of complex cases and may facilitate efficient care of the hemodynamically unstable patient. It should be considered when resuscitative stabilization, angioembolization, intra-arterial balloon occlusion, or life-threatening bleeding is anticipated. Additionally, use of the hybrid room allows access to 3D fluoroscopy, and the associated benefits, if a mobile 3D unit is otherwise unavailable. These benefits must be weighed against the cumbersome table, the potential pitfalls with patient size and positioning, and the increased cost to the hospital.

Outcomes and Cost Comparison Between Generic and Conventional Cephalomedullary Nails in the Treatment of Peritrochanteric Femur Fractures.

INTRODUCTION: Although generic orthopaedic implants have been available for several years, there has been slow adoption of this cost-saving option. We hypothesize equivalent outcomes between generic and conventional cephalomedullary nails (CMN) in the treatment of peritrochanteric femur fractures. METHODS: We evaluated 419 patients undergoing CMN for peritrochanteric femur fracture with a minimum 6-month follow-up. Demographic data, radiographic assessment, and clinical outcomes were compared. RESULTS: Ninety patients were treated with generic implants and 329 patients with conventional implants. The overall complication rate was 7.0%, with a revision surgery rate of 5.4%. No significant differences were seen in demographic variables or surgical factors. Although there was an increased incidence of postoperative infections with conventional nails (P = 0.045), no significant differences were seen in other complications. CONCLUSION: At our institution, generic nails cost approximately 38% less than their conventional counterparts. There seems to be no increased rate of implant-associated complications with the use of generic CMNs, although allowing for notable cost savings.

Bilateral Internal Iliac Artery Embolization Results in an Unacceptably High Rate of Complications in Patients Requiring Pelvic/Acetabular Surgery.

OBJECTIVES: To assess complication rates in patients undergoing open reduction internal fixation (ORIF) of pelvic/acetabular fractures with and without pelvic angiography embolization (PAE). DESIGN: Retrospective case series. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: One hundred eleven patients with pelvic or acetabular fractures that required orthopaedic fixation. INTERVENTION: Retrospective analysis of outcomes in patients who underwent ORIF of pelvic/acetabular fractures with and without PAE. MAIN OUTCOME MEASUREMENTS: Comparison of surgical wound infections, necrosis, and/or fracture nonunions between the PAE group and a control group (no PAE). RESULTS: Final study groups consisted of 50 patients in the PAE group and 61 patients in the control group. Ninety-six percent of patients underwent nonselective PAE. Significantly higher complications were noted in the PAE group than in the control group (20% compared with 4.9%; P = 0.020). In addition, posterior surgical approaches combined with internal iliac artery embolization represented the highest complication rate. CONCLUSIONS: Patients requiring PAE and pelvic/acetabular ORIF should undergo a multidisciplinary treatment approach with the trauma surgeon, interventional radiologist, and orthopaedic surgeon before PAE being performed to decrease complications and avoid nonselective bilateral internal iliac artery embolization. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Dogs and Orthopaedic Injuries: Is There a Correlation With Breed?

OBJECTIVES: To identify the incidence of orthopaedic injuries secondary to dog bites, determine the responsible breeds, and assess the severity of injury by dog breed. DESIGN: Retrospective. SETTING: Single Level I trauma center. PATIENTS: Ninety-five patients treated for a dog bite that resulted in an orthopaedic injury between January 2010 and July 2016. INTERVENTION: Patients were treated according to their specific orthopaedic injury. MAIN OUTCOME MEASUREMENTS: Dog breed and type of orthopaedic injury. RESULTS: Thirty-nine percent of all dog bite-related emergency department visits resulted in an orthopaedic injury requiring specialist treatment. Of the 95 patients, 50% were the result of a pit bull terrier bite and 22% by a law enforcement dog. A total of 32% were attacked by multiple dogs. There was a 51% incidence of severe injury (amputation or fracture) with a significant association with breed. CONCLUSIONS: Thirty-nine percent of all dog bite-related emergency department visits at our facility resulted in an injury requiring orthopaedic treatment. Pit bull terrier bites were responsible for a significantly higher number of orthopaedic injuries and resulted in an amputation and/or bony injury in 66% of patients treated, whereas bites from law enforcement dogs and other breeds were less associated with severe injuries. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Short Versus Long Intramedullary Nails in the Treatment of Pertrochanteric Hip Fractures: Incidence of Ipsilateral Fractures and Costs Associated With Each Implant.

OBJECTIVES: Both short intramedullary nails (SIMNs) and long intramedullary nails (LIMNs) are routinely used in the surgical treatment of pertrochanteric hip fractures. The purpose of this study was to assess the incidence of ipsilateral femur fractures after the surgical treatment of hip fractures and the overall costs associated with each implant. DESIGN: Retrospective cohort study. SETTING: Level I trauma center and 2 community hospitals. PATIENTS/PARTICIPANTS: A total of 609 patients with pertrochanteric hip fractures treated with an SIMN or LIMN from 2005 to 2011. INTERVENTION: Review of patient demographics and clinical outcomes over a 5-year follow-up period. MAIN OUTCOME MEASUREMENTS: Ipsilateral femur refracture rates were recorded for both groups, and a cost analysis was then performed to compare SIMNs and LIMNs while accounting for their observed refracture rates and surgical/hospital costs to determine the overall cost of each implant. RESULTS: Union rates were equivalent between groups and averaged over 97%. The incidence of ipsilateral femur fractures in both groups steadily increased with greater follow-up time to reach nearly 10% at 5 years. Although only 47% of all nails were locked distally, 15 of the 16 refractures occurred in nails that were not distally locked. Cost analysis revealed no significant difference in the use of short versus LIMNs over a 5-year period (P = 0.76). CONCLUSIONS: The incidence of ipsilateral femur refractures steadily rose with greater follow-up in both SIMN and LIMNs. Distally locking the initial fixation seems to protect against future femur fractures and may also affect the refracture location when using LIMNs. No differences in overall costs were seen at 1, 2, or 5 years between SIMNs and LIMNs. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Autosterilization of Contaminated and Devascularized Bone Fragments Through a Subcutaneous Bone Pouch.

OBJECTIVES: The purpose of this article was to present results of cases using a subcutaneous bone pouch technique and to assess the potential "autosterilization" effect that occurs when these contaminated free bone fragments are placed in nontraumatized tissue. DESIGN: Retrospective review of prospectively collected data. SETTING: Community-Based Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Eight patients were consented for the described technique, and data were collected over an 8-year period. INTERVENTION: Placement of fragments into a surgically created subcutaneous pouch in a nontraumatized tissue zone, followed by delayed, cultured, and attempted reimplantation at the initial injury site. MAIN OUTCOME MEASUREMENTS: Culture results after extraction of bone fragments from subcutaneous bone pouch and clinical outcomes after reimplantation into initial open fracture site. RESULTS: All 8 cases undergoing this technique resulted in healing of the subcutaneous bone pouch without signs or symptoms of infection at the time of attempted reimplantation or fragment removal. Four of the 8 cases had successful reimplantation and union at the open fracture site. CONCLUSIONS: Preserving devascularized bone fragments in a subcutaneous pouch in a region of nontraumatized tissue appears to be a safe procedure that allows for an "autosterilization" type of process to occur. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Contemporary management of subtrochanteric fractures.

Cephalomedullary interlocking nails that allow for trochanteric entry and minimally invasive fixation have revolutionized the contemporary management of subtrochanteric fractures with improved union rates and decreased incidence of fixation failure. The most successful alternative to intramedullary fixation remains the angled blade plate. Despite biomechanical superiority of contemporary intramedullary implants to previous intramedullary devices, the importance of achieving and maintaining satisfactory fracture reduction prior to and during hardware insertion cannot be overemphasized. In comminuted and more challenging fractures, additional techniques, such as limited open reduction with clamps and/or cables, can allow for canal restoration and more anatomic reductions prior to and/or during nail insertion.

Clamp-assisted reduction of high subtrochanteric fractures of the femur: surgical technique.

BACKGROUND: Subtrochanteric fractures can be a treatment challenge. The substantial forces that this region experiences and the fact that the proximal fragment is frequently displaced make accurate reduction and internal fixation difficult. The purpose of this study was to evaluate a series of patients who had undergone clamp-assisted reduction and intramedullary nail fixation to determine the impact of this technique on fracture union rates and reduction quality. METHODS: Between December 2003 and January 2007, fifty-five consecutive patients with a displaced high subtrochanteric femoral fracture were treated with clamp-assisted reduction and intramedullary nail fixation at two level-I trauma centers. Two patients died, and nine were lost to follow-up. The remaining forty-four patients were followed until union or a minimum of six months. There were twenty-seven male and seventeen female patients with a mean age of fifty-five years. All were treated with an antegrade statically locked nail implanted with a reaming technique as well as the assistance of a reduction clamp placed through a small lateral incision. Nine patients were treated with a single supplemental cerclage cable. Radiographs were evaluated for the quality of the reduction and fracture union. RESULTS: Forty-three of the forty-four fractures united. All reductions were within 5° of the anatomic position in both the frontal and the sagittal plane. Thirty-eight (86%) of the forty-four reductions were anatomic. Six fractures had a minor varus deformity of the proximal fragment (between 2° and 5°). There were no complications. DISCUSSION: Surgical treatment of subtrochanteric femoral fractures with clamp-assisted reduction and intramedullary nail fixation techniques with judicious use of a cerclage cable can result in excellent reductions and a high union rate. Careful attention to detail is important to perform these maneuvers with minimal additional soft-tissue disruption.

The combined hip procedure: open reduction internal fixation combined with total hip arthroplasty for the management of acetabular fractures in the elderly.

OBJECTIVE: The objective of this study was to evaluate acetabular fractures in elderly patients treated with open reduction internal fixation combined with acute total hip arthroplasty during the same anesthetic. DESIGN: The authors conducted a retrospective analysis of a treatment. SETTING: Level I and Level II trauma centers. PATIENTS: Between September 1995 through January 2005, 22 elderly patients were treated using the combined hip procedure. There were nine transverse/posterior wall patterns, seven anterior column/posterior hemitransverse patterns, and six presented as a both column injury. Six patients had hip dislocations and 14 patients demonstrated some impaction. Patients underwent medical evaluations and clearance before surgical intervention. INTERVENTION: Standard open reduction internal fixation techniques followed by immediate total hip arthroplasty during the same anesthesia. Ilioinguinal patients were repositioned and redraped for total hip placement. MAIN OUTCOME MEASUREMENTS: Complications, physical examinations, and Harris hip scores assessed outcomes. Radiographs evaluated union and stability of the femoral and acetabular components, osteolysis, or the development of any heterotopic bone. RESULTS: Follow up averaged 29.4 months. Surgeries averaged 232 minutes with 1163 mL average blood loss. Hospital stays approximated 8 days with full weightbearing occurring at 3 months. Hip motion averaged 102 degrees of flexion, 32 degrees of abduction, and 16 degrees of adduction. Harris hip scores averaged 74. Four patients developed heterotopic ossification, and five underwent revisions as result of osteolysis or multiple hip dislocations. CONCLUSIONS: The combined hip procedure is an option for acetabular fractures in elderly patients. Complications, surgical times, and hospitalizations are consistent with open reductions or belated total hip arthroplasties. Aggressive medical workups may be needed, but a single posterior surgical procedure will avoid the "wait-and-see" approach often used for these patients.

Clamp-assisted reduction of high subtrochanteric fractures of the femur.

BACKGROUND: Subtrochanteric fractures can be a treatment challenge. The substantial forces that this region experiences and the fact that the proximal fragment is frequently displaced make accurate reduction and internal fixation difficult. The purpose of this study was to evaluate a series of patients who had undergone clamp-assisted reduction and intramedullary nail fixation to determine the impact of this technique on fracture union rates and reduction quality. METHODS: Between December 2003 and January 2007, fifty-five consecutive patients with a displaced high subtrochanteric femoral fracture were treated with clamp-assisted reduction and intramedullary nail fixation at two level-I trauma centers. Two patients died, and nine were lost to follow-up. The remaining forty-four patients were followed until union or a minimum of six months. There were twenty-seven male and seventeen female patients with a mean age of fifty-five years. All were treated with an antegrade statically locked nail implanted with a reaming technique as well as the assistance of a reduction clamp placed through a small lateral incision. Nine patients were treated with a single supplemental cerclage cable. Radiographs were evaluated for the quality of the reduction and fracture union. RESULTS: Forty-three of the forty-four fractures united. All reductions were within 5 degrees of the anatomic position in both the frontal and the sagittal plane. Thirty-eight (86%) of the forty-four reductions were anatomic. Six fractures had a minor varus deformity of the proximal fragment (between 2 degrees and 5 degrees ). There were no complications. DISCUSSION: Surgical treatment of subtrochanteric femoral fractures with clamp-assisted reduction and intramedullary nail fixation techniques with judicious use of a cerclage cable can result in excellent reductions and a high union rate. Careful attention to detail is important to perform these maneuvers with minimal additional soft-tissue disruption.

Intramedullary nailing versus percutaneous locked plating of extra-articular proximal tibial fractures: comparison of 56 cases.

OBJECTIVE: To compare extra-articular proximal tibial fractures treated with intramedullary nailing (IMN) or percutaneous locked plating (PLP) and assess the ability of each technique to obtain and maintain fracture reduction. DESIGN: Retrospective clinical study. SETTING: : Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Beginning with the first use of PLP of the proximal tibia at our institution, all skeletally mature patients with surgically treated proximal extra-articular tibial fractures were reviewed. Between August 1999 and June 2004, 29 patients treated with intramedullary nails and 43 patients treated with percutaneous locked plates were identified. Patients with at least 1-year follow-up included 22 IMN and 34 PLP cases, which formed the final study group. MAIN OUTCOME MEASUREMENTS: Final outcomes were assessed for the IMN and the PLP groups by comparing rates of union, malunion, malreduction (defined as >5 degrees angulation in any plane), infection, and removal of implants. RESULTS: The IMN and PLP groups showed similar age and gender demographics. Average length of follow-up was 3.4 years in the IMN group (15-67 months) and 2.7 years in the PLP group (12-66 months). Open fractures made up 55% of the IMN group and 35% of the PLP group. Final union rates (after additional procedures for nonunions after the index procedure) were similar between groups (IMN = 96% and PLP = 97%). Implant removal in the PLP group was 3 times greater than in the IMN group, (P = 0.390), whereas an apex anterior (procurvatum) malreduction deformity occurred twice as frequently in the IMN group (P = 0.103). Additional surgical techniques (eg, blocking screws) were frequently used during reduction within the IMN group and infrequently used within the PLP group (P = 0.0002). Neither technique resulted in a statistically significant loss of final reduction confirming the stability of each construct. CONCLUSIONS: Neither IMN or PLP showed a distinct advantage in the treatment of proximal extra-articular tibial fractures. Apex anterior malreduction however was the most prevalent form of malreduction in both groups. Additional surgical reduction techniques were frequently needed with IMN, whereas removal of implants seems to be more commonly needed with PLP.

A comprehensive analysis with minimum 1-year follow-up of vertically unstable transforaminal sacral fractures treated with triangular osteosynthesis.

PURPOSE: To analyze the radiographic, clinical, and functional results of triangular osteosynthesis constructs for the treatment of vertically unstable comminuted transforaminal sacral fractures. SETTING: Level I trauma center. METHODS: During a 3-year period (July 1, 2003 to June 30, 2006), 58 patients with vertically unstable pelvic injuries were treated with triangular osteosynthesis fixation by a single surgeon at a single institution. Patients were followed-up prospectively as a single cohort, with institutional review board approval. Inclusion criteria for this study were skeletally mature patients with a vertically unstable pelvic ring injury associated with a comminuted transforaminal sacral fracture. Minimum follow-up, both clinically and radiographically, was 1 year. Computed tomography scan was performed on all patients at 6 months to assess healing of the fracture. If the fracture healed, the fixation was removed. Functional outcome was assessed using the Short Form 36, version 2, and short version of Musculoskeletal Functional Assessment questionnaires at 6 months (before fixation removal) and 12 months. RESULTS: Forty of 58 patients with an average age of 39 years were available for a minimum of 1-year follow-up. Wound complications requiring surgical debridement occurred in 5 patients (13%), all of whom had severe soft tissue wounds with internal degloving. Two patients required removal of infected fixation. Iatrogenic L5 nerve injury occurred in 5 patients (13%). Ten patients (25%) had a delayed union on computed tomography scans, and 3 patients had a nonunion as a result of residual fracture gap and incomplete reduction. Six patients (15%) were found to have pronounced tilting of the L5 vertebral body (scoliosis) and distraction of the L5/S1 facet joint ipsilateral to the fixation. This did not correct with removal of the fixation. Failure of the triangular osteosynthesis construct resulting in malunion occurred in 2 patients (5%). All but 2 patients (95%) complained of painful and prominent implants. Functional outcome scoring showed that patients continued to function below the population mean at 1 year but continued to improve, particularly with function and daily activity. Ninety-seven percent of patients returned to some form of work or schooling. CONCLUSIONS: Triangular osteosynthesis fixation is a reliable form of fixation that allows early full weight-bearing at 6 weeks while preventing loss of reduction in comminuted vertical shear transforaminal sacral fractures. For this study group, operative reduction was maintained until healing in 95% of patients. However, the 1-year follow-up shows a substantial rate of potential technical problems and complications. Of primary concern were the asymmetric L5 tilting with L5-S1 facet joint distraction and the need for a second surgery in all patients to remove painful fixation. Iatrogenic nerve injury occurred in 5 patients (13%) and is thought to arise secondary to fracture manipulation and reduction. We recommend selective use of this technique for comminuted transforaminal sacral fractures in situations only where reliable iliosacral or trans-sacral screw fixation is not obtainable.

Selective screw placement in forearm compression plating: results of 75 consecutive fractures stabilized with 4 cortices of screw fixation on either side of the fracture.

OBJECTIVES: To (1) assess the effectiveness of an alternative plate and screw construct for all diaphyseal forearm fracture patterns and (2) test the hypothesis that as the working length (WL) to plate length (PL) ratio increases, so does the construct instability and therefore likelihood of failure. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Sixty-three patients were operatively treated and 53 were available for follow-up, totaling 75 diaphyseal fractures (19 ulna, 12 radius, and 22 radius/ulna). Average follow-up was 14.6 months (8-26). MAIN OUTCOME MEASUREMENTS: Patients were followed postoperatively at 1 to 2 weeks, 6 weeks, 10 weeks, 4 months, and then at 3 month intervals. Radiographs were analyzed for changes in fracture alignment, loose or broken hardware, and fracture-healing characteristics. Fracture union was defined when a fracture was radiographically healed and clinically asymptomatic, and the patient was able to return to all activities without restrictions. RESULTS: No fractures showed radiographic evidence of changes in alignment after fixation. There were no refractures, no infections, and one nonunion. The overall union rate after the index procedure was 97.1% for the radius and 97.6% for the ulna. WL:PL ratio averaged 0.17 (range 0-0.57) and the most frequently used PL was 7 holes (n=43). Patients with closed fractures did have a significantly reduced time to union when compared to those with open fractures (P=0.002). Overall union rate averaged 9.8 weeks (range 6-32 weeks). CONCLUSIONS: Fixation with a standard length compression plate and four cortices of screw fixation on either side of the fracture seems to be a stable construct for diaphyseal forearm fractures and may result in union rates equivalent to those cited in the literature.

Open reduction and stable fixation of isolated, displaced talar neck and body fractures.

BACKGROUND: The purpose of this retrospective review was to evaluate the long-term results of surgical treatment of isolated, displaced talar neck and/or body fractures with stable internal fixation. METHODS: The study included twenty-five patients with a total of twenty-six displaced fractures isolated to the talus that had been treated with open reduction and stable internal fixation and followed for a minimum of forty-eight months after the injury. The final follow-up examination included standard radiographs, computed tomography, and a clinical evaluation. Variables that were analyzed included wound type, fracture type, Hawkins type, comminution, timing of the surgical intervention, surgical approach, quality of fracture reduction, Hawkins sign, osteonecrosis, union, time to union, posttraumatic arthritis, and the AOFAS scores including subscores (pain, function, and alignment). RESULTS: The average duration of follow-up was seventy-four months. Surgical intervention resulted in sixteen fractures with an anatomic reduction, five with a nearly anatomic reduction, and five with a poor reduction. All eight noncomminuted fractures were anatomically reduced. The overall union rate was 88%. All closed, displaced talar neck fractures healed, regardless of the time delay until surgical intervention. Posttraumatic arthritis of the subtalar joint was the most common finding and was seen in all patients, sixteen of whom had involvement of more than one joint. Osteonecrosis was a common finding, seen after thirteen of the twenty-six fractures overall and after six of the seven open fractures. CONCLUSIONS: Open reduction and internal fixation is recommended for the treatment of displaced talar neck and/or body fractures. A delay in surgical fixation does not appear to affect the outcome, union, or prevalence of osteonecrosis. Posttraumatic arthritis is a more common complication than osteonecrosis following operative treatment. Patients with a displaced fracture of the talus should be counseled that posttraumatic arthritis and chronic pain are expected outcomes even after anatomic reduction and stable fixation. This is especially true following open fractures.