Evaluation of Intraoperative Fluoroscopic Techniques to Estimate Femoral Rotation: A Cadaveric Study.

OBJECTIVES: To compare three fluoroscopic methods for determining femoral rotation. METHODS: Native femoral version was measured by computed tomography in 20 intact femurs from 10 cadaveric specimens. Two Steinmann pins were placed into each left femur above and below a planned transverse osteotomy which was completed through the diaphysis. Four surgeons utilized the true lateral (TL), neck-horizontal angle (NH), and lesser trochanter profile (LTP) techniques to correct the injured femur's rotation using the intact right femur as reference, yielding 120 measurements. Accuracy was assessed by comparing the angle subtended by the two Steinmann pins before and after manipulation and comparing against version measurements of the right femur. RESULTS: Absolute mean rotational error in the fractured femur compared to its uninjured state was 6.0° (95% CI, 4.6-7.5), 6.6° (95% CI, 5.0-8.2), and 8.5° (95% CI, 6.5-10.6) for the TL, NH, and LTP techniques, respectively, without significant difference between techniques ( p = 0.100). Compared to the right femur, absolute mean rotational error was 6.6° (95% CI, 1.0-12.2), 6.4° (95% CI, 0.1-12.6), and 8.9° (95% CI, 0.8-17.0) for the TL, NH, and LTP techniques, respectively, without significant difference ( p = 0.180). Significantly more femurs were malrotated by >15° using the LTP method compared to the TL and NH methods (20.0% vs 2.5% and 5.0%, p = 0.030). Absolute mean error in estimating femoral rotation of the intact femur using the TL and NH methods compared to CT was 6.6° (95% confidence interval [CI], 5.1-8.2) and 4.4° (95% CI, 3.4-5.4), respectively, with significant difference between the two methods ( p = 0.020). CONCLUSIONS: The true lateral (TL), neck-horizontal angle (NH), and the lesser trochanter profile (LTP) techniques performed similarly in correcting rotation of the fractured femur, but significantly more femurs were malrotated by >15° using the LTP technique. This supports preferential use of the TL or NH methods for determining femoral version intraoperatively.

Outcomes of free vascularized fibular flaps for the treatment of radiation-associated femoral nonunions.

INTRODUCTION: Nonunion is a known complication following fracture in the setting of radiotherapy. Free vascularized fibular (FVF) flaps have been used successfully in the treatment of segmental bone defects; however, their efficacy in the treatment of radiated nonunions is limited. The purpose of the study was to evaluate the outcome following FVFG for radiation-associated femoral fracture nonunions. METHODS: 23 (11 male and 12 female; mean age 60 ±â€¯12 years) patients underwent FVF for radiation-associated femoral fracture nonunions. The most common indication for radiotherapy was soft tissue sarcomas (n = 16). The mean follow-up was 5 ±â€¯4 years. Mean radiation dose was 51 ±â€¯14 Gy at a mean of 11 ±â€¯3 years prior to FVF. The mean FVF length was 17 ±â€¯4 cm and placed commonly with an intramedullary nail (n = 18). RESULTS: First time union was 52% (n = 12) following additional bone grafting, the overall union was 78% (n = 18) at a mean of 13 ±â€¯6 months. Musculoskeletal Tumor Society scores improved from 30% preoperatively to 73% at latest follow-up (p < 0.0001). Five fractures failed to unite; 3 were converted to proximal femoral replacements. CONCLUSIONS: FVF are a reasonable treatment option for radiation-associated femoral fracture nonunions, providing a union rate of 78% and an improvement in functional outcome. LEVEL OF EVIDENCE: Therapeutic Level IV.

Open Treatment of Olecranon Fractures with Plate Fixation.

Fractures of the olecranon are sometimes difficult to treat. The steps for operative plate fixation of olecranon fractures consist of (1) a dorsal incision, (2) exposure using full-thickness flaps, (3) removal of hematoma from the fracture site, (4) fracture reduction, (5) provisional fixation, (6) plate application, (7) proximal fixation, (8) distal fixation, and (9) layered wound closure. Although this is generally a straightforward procedure, several specific steps may make fixation easier and improve outcomes. Outcomes following olecranon fracture fixation are generally good. Patients should expect some loss of terminal extension and a potential for symptoms related to implant prominence, especially in slender patients. Ulnar nerve symptoms are unusual but possible.

Pediatric Pelvic Ring Injuries.

The purpose of this study was to determine whether pelvic fracture pattern is associated with transfusion requirements or concomitant injuries in pediatric patients. This was a single-institution, retrospective review from 1970 to 2000. Pelvic ring injuries were classified using the Orthopaedic Trauma Association system. Injury Severity Scores were assigned. Ninety patients were included in this study. There were 27 A-type (30.0%), 51 B-type (56.7%), and 12 C-type (13.3%) injuries. Mean Injury Severity Scores were 8.1 for 61 A-type, 12.7 for 61 B-type, and 23.6 for 61 C-type fractures (P<.0001). Transfusion was required for 14.8% of A-type, 18.4% of B-type, and 66.7% of C-type injuries (P=.0009). There was no significant association with the number of units transfused (P=.9614). Decreased pelvic ring fracture stability was associated with an increased need for blood transfusion, although not with the number of units. Pelvic ring fracture stability may be a marker of associated injuries. [Orthopedics. 2018; 41(5):e701-e704.].

Tranexamic Acid Safely Reduced Blood Loss in Hemi- and Total Hip Arthroplasty for Acute Femoral Neck Fracture: A Randomized Clinical Trial.

OBJECTIVES: We aimed to determine whether (1) tranexamic acid (TXA) reduces the incidence of transfusion (2) TXA reduces the calculated blood loss, and (3) there are any observable differences in 30- and 90-day complications with TXA administration during arthroplasty for femoral neck fracture (FNF). DESIGN: Prospective, double-blinded, randomized controlled trial. SETTING: Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS: One hundred thirty-eight patients who presented with a low-energy, isolated, FNF (AO 31B) treated with either hemi- or total hip arthroplasty within 72 hours of injury were randomized to either the TXA group (69 patients) or placebo group (69 patients). INTERVENTION: In the TXA group, patients received 2 doses of 15 mg/kg intravenous TXA dissolved in 100 mL of saline, each administered over 10 minutes; 1 dose just before incision, and the second at wound closure. In the placebo group, 100 mL of saline solution was administered in a similar fashion. Perioperative care was otherwise standardized including conservative transfusion criteria. MAIN OUTCOME MEASUREMENTS: Our primary outcome was to determine the proportion of patients who underwent blood transfusion during hospitalization. Secondary outcomes were calculated blood loss, number of units transfused during hospitalization, and incidence of adverse events at 30 and 90 days including thromboembolic event, wound complications, reoperation, hospital readmission, and all-cause mortality. RESULTS: TXA reduced mean incidence of transfusion by 305 mL (P = 0.0005). There was a trend toward decreased transfusion rate in the TXA group (17% vs. 26%, P = 0.22). TXA was safe with no differences in adverse events at 30 and 90 days. CONCLUSIONS: This randomized clinical trial found that TXA administration safely reduced blood loss with a tendency for decreased transfusion rate and total blood product consumption for patients undergoing hip arthroplasty for acute FNF. More studies are needed to further ascertain the role of TXA in the management of patients with FNF. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Open Treatment of Radial Head Fractures.

Radial head fractures may commonly be treated by (1) open reduction and internal fixation (ORIF), (2) radial head excision, or (3) radial head replacement. If there is no associated elbow instability with lateral ulnar collateral ligament (LUCL) injury, the preferred approach is via a split in the extensor digitorum communis (EDC) origin. This provides a wide exposure but limits the risk of injury to the LUCL and associated instability. The radial head is fixed, excised, or replaced. Open treatment of radial head fractures begins with the following steps: (1) a laterally based incision is centered over the radiocapitellar joint, (2) the EDC is split at the midline of the radial head and elevated off the bone anteriorly and superiorly, and dissection proceeds distally, splitting the extensor origin along its fibers, and (3) the capsule is opened and the radial head fracture, identified. For ORIF, provisional fixation is then obtained with Kirschner wires and small bone reduction clamps. Headless low-profile screws are preferred if possible. If a plate is used, the dissection proceeds distally and the posterior interosseous nerve may need to be identified and protected. Definitive fixation is applied in the safe zone for implant placement (i.e., a right angle based laterally when the forearm is in a neutral position). For excision of the radial head as definitive treatment or for radial head replacement, the fragments are removed and an oscillating saw is used to remove additional radial neck or other fragments. When radial head excision is the definitive treatment, the radial neck is planed to a smooth contour that allows for placement of the prosthesis or for smooth motion without impingement at the proximal radioulnar joint. An indication for radial head replacement is suspicion of an Essex-Lopresti-type injury or demonstration of longitudinal instability of the forearm with excessive motion when a "push-pull" test is performed under fluoroscopy of the wrist while traction is applied to the radial neck. The final step of open treatment of radial head fractures, before the wound is closed in layers, consists of assessment of the range of motion and use of fluoroscopy to confirm appropriate fixation, resection, or prosthetic position. Outcomes following radial head fixation, resection, or arthroplasty for isolated radial head fractures are generally favorable. Loss of motion is particularly problematic in the pronation-supination arc in the setting of plate fixation, and patients are generally counseled that implant removal is often necessary. Loss of motion in the flexion-extension arc, particularly loss of terminal extension, may be noted. Resection of the radial head results in radiographic evidence of degenerative changes along the ulnohumeral joint, but this may be well tolerated as symptoms develop slowly, particularly in older patients. Radial head replacement results in changes in the capitellum over time, but these are usually asymptomatic.

Does Ankle Aspiration for Acute Ankle Fractures Result in Pain Relief? A Prospective Randomized Double-Blinded Placebo Controlled Trial.

OBJECTIVES: Does ankle aspiration help with pain control in patients with ankle fractures? DESIGN: Prospective, double-blind, randomized, placebo-controlled trial. SETTING: Level 1 Academic Medical Center. PATIENTS/PARTICIPANTS: Consecutive skeletally mature patients with ankle fractures. INTERVENTION: Randomized between ankle aspiration and sham procedure. MAIN OUTCOME MEASUREMENTS: Pain scores for 72 hours after injury and pain medicine usage. RESULTS: Comparison between study subjects receiving ankle aspiration and sham procedure showed no significant differences in pain scores acutely in the emergency department or within 3 days after injury. There were also no statistically significant differences in pain medicine usage within 3 days after injury. Secondary outcomes, including lower leg volume, 6-month functional outcome scores, and complication rate, also showed no significant differences between subjects receiving aspiration and the sham procedure. CONCLUSIONS: Aspiration of acute ankle fractures does not result in decreased pain scores or opioid usage after aspiration. Aspiration of acute ankle fractures does not provide measurable clinical benefit. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Fibular shaft allograft support of posterior joint depression in tibial plateau fractures.

Posterior depression of the lateral articular surface of the tibial plateau can be difficult to elevate and support with morselized bone graft and internal fixation. Progressive collapse after open reduction and internal fixation has been described and can lead to failure in treatment. A standard anterolateral approach to the tibia may not allow direct reduction and stabilization of posterolateral joint depression given the anatomic barriers of the fibular collateral ligament and the proximal tibiofibular articulation. Posterolateral approaches to the tibial plateau have been described and may allow direct reduction of the articular depression. These approaches, however, require dissection close to the common peroneal nerve, and some approaches also require a proximal fibular osteotomy. The use of an intraosseous fibular shaft allograft as an adjunct to open reduction and internal fixation in select cases of depressed posterolateral tibial plateau fractures allows both reduction of the joint and stabilization of the articular segment through a single approach familiar to many orthopaedic surgeons.

Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review.

BACKGROUND: Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice. METHODS: Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence. RESULTS: Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing? CONCLUSIONS: Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

Elevated body mass index increases early complications of surgical treatment of pelvic ring injuries.

OBJECTIVES: The purposes of this study were to evaluate the relationship between body mass index (BMI) and postoperative complications and to determine the incidence of reoperation after surgical treatment of pelvic ring injuries. SETTING: Three Level I trauma centers. PATIENTS/PARTICIPANTS: A retrospective review of 184 consecutive surgically treated pelvic ring injuries (Orthopaedic Trauma Association 61) was performed. Two patients died in the initial postoperative period, and the remaining 182 patients were followed for a minimum of 3 months. MAIN OUTCOME MEASUREMENTS: Complications that were evaluated included wound infection and dehiscence, loss of reduction, iatrogenic nerve injury, deep venous thrombosis, pneumonia, and the development of decubitus ulcers. Body mass index was calculated for each patient, and a BMI greater than 30 kg/m considered to be obese as defined by the National Institutes of Health. RESULTS: There were 132 males and 50 females with an average age of 36.4 years (range, 14-83 years). There were 48 (26%) patients with a BMI over 30 kg/m. Complications occurred in 46 of 182 patients (25.3%) with 26 occurring in the 48 patients with BMI greater than 30 kg/m (54.2% complication rate) and 20 occurring in the 134 patients with BMI less than 30 kg/m (14.9% complication rate). Complications included 20 infections (four superficial wound dehiscence and 16 deep), 23 losses of reduction, five deep vein thromboses, three pulmonary embolus, three pneumonia, two decubitus ulcers, and three iatrogenic nerve injuries. Reoperation was required in 29 of 182 (15.9%) patients with 16 (8.8%) irrigation and débridement, and 17 (9.3%) refixation procedures. All wound complications occurred after open exposures. Open exposures were performed for the anterior pelvic ring in 143 of 182 (78.6%) patients, the posterior pelvic ring in 64 of 182 (35.2%) patients, and percutaneous treatment of the posterior pelvic ring was performed in 80 of 182 (44.0%) patients. Logistic regression modeling analyzing BMI as a continuous variable found a relationship between increasing BMI and complication rate (P < 0.0001) and need for reoperation (P = 0.0013). Odds ratios analysis revealed that obese patients (BMI greater than 30 kg/m) were 6.87 (95% confidence interval, 3.25-14.49) times more likely to have a complication and 4.68 (95% confidence interval, 2.03-10.76) times more likely to undergo reoperation than patients with BMI less than 30 kg/m. CONCLUSIONS: Body mass index correlates with an increased rate of complications and reoperation after operative treatment of pelvic ring injuries.

Operative versus nonoperative management of distal femur fracture in myelopathic, nonambulatory patients.

Treatment of supracondylar femur fractures in myelopathic, nonambulatory patients has traditionally been nonoperative, emphasizing careful skin protection, limited mobilization, and acceptance of malunion. This study compares the results of surgical treatment with nonsurgical treatment in this patient population. The records of all myelopathic, nonambulatory patients treated for supracondylar femur fractures (OTA code 33) between 2001 and 2006 were reviewed: 25 patients (29 fractures) were discovered (11 women, 14 men; average age, 51 years). Surgical treatment was performed in 17 fractures (13 retrograde intramedullary rods and 4 plates) and nonsurgical treatment in 12 fractures. Union was obtained in all operatively treated fractures and in 90% of nonsurgically treated fractures. Average follow-up was 16 months. One patient treated with a retrograde nail sustained a nondisplaced intertrochanteric hip fracture treated nonoperatively. One patient treated operatively developed a late deep infection. There were no other surgical-related complications. Skin or wound complications developed in no patients treated surgically and in 4 patients treated nonsurgically (P=.0208). Three patients with nonoperatively treated fractures required eventual surgery (3 above-knee amputations). Operative treatment of femoral fractures in nonambulatory patients with myelopathy is safe and effective. There were fewer skin and wound complications in the surgically treated supracondylar femur fractures.