Which Surgical Approach Provides Maximum Visualization and Access for Open Reduction and Internal Fixation of Femoral Head Fractures?

OBJECTIVES: Femoral head fracture open reduction and internal fixation (ORIF) requires adequate surgical access and visualization. The purpose of this study was to objectively characterize femoral head access associated with commonly used surgical approaches. Our hypothesis was that a surgical hip dislocation (SHD) provides the greatest visualization and access to the femoral head. METHODS: Ten fresh-frozen cadaveric whole-pelvis specimens (n = 20 hips) were used to compare 4 surgical approaches to the femoral head (n = 5 hips per approach): SHD, Smith-Petersen (with and without rectus release), and Hueter. After surgical exposure, standardized and calibrated digital images were captured and analyzed to determine the percent-area visualized. Three independent investigators assessed each specimen to determine surgical visualization and access to the following femoral head anatomic quadrants: anteromedial, anterolateral, posteromedial, and posterolateral. Data were analyzed for significant (P < 0.05) differences using analysis of variance (ANOVA) and Fisher exact tests. RESULTS: The Hueter approach provided the lowest calculated % visualization. For surgeon visualization, SHD demonstrated a significantly (P < 0.001) higher proportion of visualized anatomic landmarks compared with all other approaches. SHD provided significantly (P < 0.049) more access to the femoral head quadrants compared with all other approaches. The Hueter approach had significantly (P = 0.004) lower surgeon access compared with the Smith-Petersen with release. CONCLUSIONS: SHD provided superior visualization and access to clinically relevant femoral head anatomy compared with the Smith-Petersen with or without rectus release and Hueter approaches.

Which surgical approach provides maximum visualization and access for open reduction and internal fixation (ORIF) of femoral neck fractures?

OBJECTIVES: Appropriate visualization of the femoral neck is critical when performing open reduction and internal fixation (ORIF) of a femoral neck fracture. The purpose of this study was to objectively identify which surgical approach provided the most extensive visualization of the femoral neck during ORIF. Our hypothesis was that the Smith-Petersen approach with rectus release would provide the most extensive visualization. METHODS: Ten cadaveric hips were utilized to compare 4 different surgical approaches to the femoral neck: Smith-Petersen (SP), Smith-Petersen with rectus release (SPwR), Watson-Jones (WJ), and Hueter approach. After surgical exposure, calibrated digital images were captured and analyzed using a computer software program to determine the percent-area visualized. Three trained investigators separately assessed each specimen to determine clinical visualization and ability of the surgeon to manually outline anatomic locations of the femoral neck: subcapital, trans-cervical, and basicervical. Data were analyzed for significant (p < 0.05) differences using ANOVA and Fisher Exact tests. RESULTS: For calculated percent-visualization, SP and SPwR allowed for significantly more (p = 0.003) visualization than the Hueter and WJ approaches. For surgeon visualization, SP and SPwR were significantly higher (p < 0.029) when compared to WJ. The ability for the individual surgeon to outline the femoral neck's anatomical landmarks was significantly higher (p < 0.049) with SP and Hueter approaches compared with SPwR. CONCLUSION: The SP and SPwR provided superior visualization of femoral neck anatomy compared to Hueter and WJ approaches. Similarly, the SP approach allowed for optimal surgeon visualization of and access to clinically relevant femoral neck anatomic landmarks compared to other approaches assessed.

The Dilemma of the Racist Patient.

Encounters with racist patients can be distressing, damage the physician-patient relationship, and threaten the collegial environment of the health care setting. Although policies guiding physician interactions may exist, providers may be uncomfortable and left vulnerable in racially charged interactions. When providers deal with racially intolerant patients, a courteous address of their inappropriate behavior is crucial, after which a dialogue should ensue to identify causes of potentially misplaced anger. Unsuccessful attempts at relationship salvage should be further guided by ethics teams, and in cases of a continued impasse, physicians should absolve themselves of medical duties provided that an appropriate alternative provider is available. Although racism in the health care setting can present a reasonable window to generate productive dialogue to improve race relations, a deeply entrenched and pervasive mindset can be difficult to reverse and should not impede the primary goal of providing timely patient care.

Acute Management of Traumatic Knee Dislocations for the Generalist.

Acute knee dislocations are an uncommon injury that can result in profound consequences if not recognized and managed appropriately on presentation. Patients presenting with knee pain in the setting of high- or low-energy trauma may have sustained a knee dislocation that spontaneously reduced. Prompt reduction of the dislocated knee and serial neurovascular examinations are paramount. Damage to the popliteal artery is a common associated injury that can be diagnosed on physical examination using ankle brachial indices (ABIs), CT angiography, or standard angiography. After reduction, patients with a normal pulse examination and an ABI ≥0.9 may be observed, with serial examination performed to document vascular status and monitor for compartment syndrome. Patients with asymmetric pulses or an ABI <0.9 in the presence of pulses may be treated urgently depending on the results of additional vascular imaging, and patients with absent pulses and clear signs of vascular compromise should be treated emergently. Some knee dislocations are not reducible and should be taken emergently to the operating room for an open reduction. Persistent joint subluxation or severe soft-tissue injuries after reduction require temporary external fixation before definitive repair or reconstruction of ligaments is performed.

Surgical site infection in high-energy peri-articular tibia fractures with intra-wound vancomycin powder: a retrospective pilot study.

BACKGROUND: Surgical site infections (SSI) continue to be a significant source of morbidity despite the introduction of perioperative intravenous antibiotics. Our objective was to assess the efficacy of local vancomycin powder on lowering deep SSI rates in high-energy tibial plateau and pilon fractures. MATERIALS AND METHODS: A retrospective review of all tibial plateau and pilon fractures treated in 2012 at our level I trauma center identified 222 patients. Of these, 107 patients sustained high-energy injuries that required staged fixation, and 93 had minimum 6 month follow-up. Ten patients received 1 gram vancomycin powder directly into the surgical wound at the time of definitive fixation, and the remaining 83 patients served as controls. SSI was defined according to criteria from the Centers for Disease Control. Demographic data, patient comorbidities, injury and treatment details, and infection details were recorded. Descriptive and comparative statistics were performed. RESULTS: Amongst the vancomycin powder group, 1 patient (10 %) developed a deep SSI; in the control group, 14 (16.7 %) developed deep SSI. The rate of deep SSI between the groups was not statistically significantly different (P = 1.0). The groups were statistically similar with regard to injuries, treatment, comorbidities, and infectious outcomes (P values range = 0.06-1.0). CONCLUSIONS: The application of local vancomycin powder into surgical wounds of high-energy tibial plateau and pilon fractures did not reduce the rate of deep SSI in this retrospective review. There is a need to find effective, cheap, and widely available methods for prevention of SSI. Basic science and larger prospective clinical studies are needed to further delineate the role of local vancomycin powder as a modality to reduce deep SSI in extremity trauma.

Single and Dual-Incision Fasciotomy of the Lower Leg.

INTRODUCTION: Compartment syndrome of the leg is an orthopaedic emergency and can be treated with single or dual-incision fasciotomy, allowing for necessary decompression of all four compartments. STEP 1 SINGLE-INCISION TECHNIQUE POSITION THE PATIENT: Place the patient supine with a bump underneath the ipsilateral buttock. STEP 2 SINGLE-INCISION TECHNIQUE MAKE THE SKIN INCISION: An incision centered over the posterolateral aspect of the leg provides access to all four compartments of the leg. STEP 3 SINGLE-INCISION TECHNIQUE DECOMPRESS THE SUPERFICIAL POSTERIOR LATERAL AND ANTERIOR COMPARTMENTS: Make longitudinal fascial incisions, approximately the length of the skin incision, in the superficial posterior, lateral, and then anterior compartments. STEP 4 SINGLE-INCISION TECHNIQUE DECOMPRESS THE DEEP POSTERIOR COMPARTMENT: Using the lateral intermuscular septum as a guide to reach the posterolateral aspect of the fibula, release the fascial attachment of the deep posterior compartment from the fibula. STEP 5 SINGLE-INCISION TECHNIQUE POSTOPERATIVE PROTOCOL: After appropriate operative fixation and/or debridement of nonviable tissue, dress the wounds with a VAC device. STEP 1 DUAL-INCISION TECHNIQUE POSITION THE PATIENT: Position the patient, administer antibiotics, and prepare and drape the limb as described in Step 1 for the single-incision technique. STEP 2 DUAL-INCISION TECHNIQUE MAKE THE ANTEROLATERAL SKIN INCISION: Make an incision centered over the anterolateral aspect of the leg to provide access to the anterior and lateral compartments of the leg. STEP 3 DUAL-INCISION TECHNIQUE DECOMPRESS THE ANTERIOR AND LATERAL COMPARTMENTS: Make a longitudinal fascial incision in the anterior compartment anterior to the intermuscular septum and a separate longitudinal incision for decompression of the lateral compartment posterior to the intermuscular septum. STEP 4 DUAL-INCISION TECHNIQUE MAKE THE POSTEROMEDIAL SKIN INCISION: Make an incision centered over the posteromedial aspect of the leg to provide access to the superficial and deep posterior compartments of the leg. STEP 5 DUAL-INCISION TECHNIQUE DECOMPRESS THE SUPERFICIAL AND DEEP POSTERIOR COMPARTMENTS: Through the posteromedial skin incision, identify both the deep and the superficial posterior compartments and incise their fascia longitudinally for adequate decompression. STEP 6 DUAL-INCISION TECHNIQUE POSTOPERATIVE PROTOCOL: Follow the same postoperative protocol as outlined in Step 5 for the single-incision technique. RESULTS: Both the single and the dual-incision techniques are effective for relieving elevated intracompartmental pressures to prevent myonecrosis.IndicationsContraindicationsPitfalls & Challenges.