Technical Trick: Supplemental Medial Column Screw Fixation of Distal Femur Fractures Treated With a Laterally Based Locked Plate.

SUMMARY: Given known failure rates after lateral plating of distal femur fractures, there is an increasing interest in augmenting fixation to improve outcomes. The addition of medial plates or intramedullary nails have been described with promising results, decreasing nonunion and varus collapse rates. However, the use of dual implants increases implant costs, adds surgical complexity, and requires a second surgical approach that may increase morbidity. A supplemental, percutaneously placed, medial column screw may provide a less invasive means of improving stability and achieving fracture union compared with lateral plating alone.

Postoperative radial nerve palsy in humeral shaft nonunion reconstruction: Can the lateral paratricipital approach prevent this common complication?

BACKGROUND: Postoperative radial nerve palsy (RNP) is a well-known complication of nonunion reconstruction of the humerus. The purpose of the current study is to determine if the surgical approach for nonunion reconstruction of the humerus influences the rate of postoperative radial nerve palsy. METHODS: A retrospective case-control study of all humeral shaft and extraarticular distal humerus nonunion reconstructions performed between January 1, 2004, and August 31, 2021, was conducted. Patients included were over 18 years of age, had a non-pathologic humerus fracture nonunion and had intact radial nerve function prior to nonunion reconstruction. Exclusion criteria consisted of nonunions involving the proximal humerus, intraarticular fractures, and reconstructive treatment procedures with either intramedullary nail or external fixation methods. Perioperative variables were recorded and analyzed in regard to the development of postoperative RNP. A subgroup analysis was performed to assess the interaction of significant variables on the development of postoperative RNP. RESULTS: The overall rate of postoperative RNP in this series was 6/53 (11%). However, no cases of postoperative radial nerve palsy were observed in patients who underwent nonunion reconstruction with a lateral paratricipital approach. A new RNP was seen in 4/9 (44%) of those patients who underwent a triceps splitting approach, which was significantly higher than those utilizing either an anterolateral approach (2/28, 7%) or a lateral paratricipital approach (0/16, 0%, p = 0.007). DISCUSSION AND CONCLUSION: Our data suggests that the lateral paratricipital exposure decreases the risk of radial nerve injury with nonunion reconstruction of the humerus. The lateral paratricipital exposure offers the benefit of radial nerve exploration, decompression, neurolysis and protection prior to fracture manipulation and instrumentation. This study shows conventional approaches may predispose patients to a high rate of postoperative RNP, similar to that in the literature.

The One-Bone Forearm in Children: Surgical Technique and a Retrospective Review of Outcomes.

PURPOSE: The purpose of this study was to describe a technique of end-to-end rigid fixation of the distal radius to the proximal ulna. The shortening and radioulnar overlap in this technique yield a high union rate, large corrections, and few complications. METHODS: This retrospective chart review from 2 centers was undertaken in 39 patients (40 forearms) who underwent one-bone forearm operations between 2005 and 2019. There were 25 male and 14 female patients, with a mean age at surgery of 9.7 years (range 3 to 19 years; SD, 4.5 years). The diagnoses included brachial plexus birth injury, spinal cord injury, arthrogryposis multiplex congenita, cerebral palsy, ulnar deficiency with focal indentation, multiple hereditary exostosis, acute flaccid myelitis, and tumor. RESULTS: The average follow-up was 33.5 months (1.2-110.1 months; SD, 27.1 months). The 36 forearms in supination had an average supination contracture of 93° (range, 15° to 120°; SD, 15.4°). The 4 pronated arms had an average pronation contracture of 80° (range, 50° to 120°; SD, 29.2°). The average postoperative position was 22.8° of pronation (range, -15° to 45°; SD, 12.9°). The average correction obtained with our technique was 113° (range, 20° to 145°; SD, 22.9°). Radiographic union was demonstrated in 32 (80%) of the one-bone forearms by 10 weeks, 39 (97.5%) by 16 weeks, and 40 (100%) by 24 weeks. One patient had peri-implant fractures prior to union. No forearms required reoperation for nonunion. CONCLUSIONS: One-bone forearm performed with this technique allows reliable healing and a large degree of correction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Effectiveness of a Low Fidelity Cast Removal Module in Orthopaedic Surgical Simulation.

OBJECTIVE: The purpose of this study is to determine if an educational model during a surgical skills laboratory results in a significant reduction in cast saw blade temperatures generated during cast removal. DESIGN: As part of an orthopedic resident surgical skills laboratory an Institutional Review Board-approved study was performed. A total of 17 study subjects applied a short arm cast. Everyone removed 1 short arm cast with temperatures recorded on the saw blade. Following cast removal, an educational session was conducted on proper cast removal and blade cooling techniques. Everyone then removed a second cast. Blade temperatures were recorded. To assess reproducibility, the 5 PGY-1 orthopedic residents removed a short arm cast 3 months later. SETTING: Carolinas Medical Center, Charlotte, NC, tertiary care center PARTICIPANTS: A total of 17 study subjects with minimal casting experience (5 PGY-1 orthopedic residents and 12 senior medical students) applied a short arm cast. RESULTS: Following the educational session there was a significant reduction in mean and mean maximum blade temperatures (p < 0.05). During the second round of cast removal assessment of blade temperatures and specific techniques to cool the blade were observed among all participants. At 3 months' time, the mean and mean maximum blade temperatures remained significantly lower than before the educational session (p < 0.05). CONCLUSIONS: The intervention in this study reduced the maximum blade temperatures to levels below the threshold known to cause burns. This simple, low cost, and easily reproducible model can easily be disseminated across institutions and simulation laboratories.

Biomechanical effects of steroid injections used to treat pyogenic flexor tenosynovitis.

BACKGROUND: A recent study from our laboratory has demonstrated improved range of motion in the toes of broiler chickens afflicted with pyogenic flexor tenosynovitis when treated with local antibiotic and corticosteroid injections, without surgical drainage. However, the use of corticosteroids as an adjunct treatment raised peer concern, as steroids are thought to have deleterious effects on tendon strength. The purpose of this study was to compare the tensile strength of the aforementioned steroid treated tendons, to a group of tendons administered with the current standard treatment: systemic antibiotics, surgical drainage and no corticosteroids. METHODS: Twenty-three tendons' structural and material properties were investigated (fifteen receiving the standard treatment, eight receiving the steroid treatment). The measurements from each group were interpreted via Student's unpaired t-test and a post-hoc power analysis. RESULTS: The steroid treated tendons did demonstrate a trend toward decreased mechanical properties when compared with the standard treatment group, but the results were not statistically significant. CONCLUSIONS: Treatment of septic tenosynovitis with local corticosteroid and local antibiotic injections resulted in better digital motion, without a significant loss of tendon strength, over a twenty-eight day recovery period.