1222 C OPYRIGHT 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Specialty Update
What’s New in Orthopaedic Trauma William M. Ricci, MD, Michael Linn, MD, Michael Gardner, MD, and Christopher McAndrew, MD
This update presents a synopsis of the most clinically relevant high-quality studies related to orthopaedic trauma from the past twelve months. Key methods (¤), results (), and take-home points (V) for these studies are presented. Clavicle and Humerus Clavicle Plating ¤ A retrospective cohort study compared plating of diaphyseal clavicular fractures (AO/OTA [Arbeitsgemeinschaft f¨ur Osteosynthesefragen/Orthopaedic Trauma Association] type B) with either a 2.7-mm (n = 19) or a 3.5-mm (n = 18) reconstruction plate placed anteroinferior1. There were no differences in outcome scores (Constant and Disabilities of the Arm, Shoulder and Hand [DASH]), time to union, rate of union, or reoperation rate. Patients with lower profile, 2.7-mm plates had a higher rate of a cosmetically acceptable reconstruction. V Use of anteroinferior, 2.7-mm reconstruction plates appears reasonable for treatment of clavicular fractures. Application for comminuted fractures may still require caution. There were only three highly comminuted fractures, and the 2.7-mm plates applied in bridge mode may not have sufficient fatigue strength. Humeral Shaft: Nail Versus Plate ¤ A retrospective comparative cohort analysis utilized Medicare data from 1993 to 2007 to identify trends in utilization, reoperation, and mortality in patients Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
treated with nails (n = 279) compared with plates (n = 172) for humeral shaft fracture2. There was no difference in reoperation or mortality rates at one year. Anesthesia time was reduced in the nail cohort by 27.1 minutes (p < 0.0001). V Nailing and plating are associated with similar reoperation rates. The authors note that reduced operating-room time for nailing may be offset by reduced implant costs for plating. Elbow Treatment of Olecranon Fractures with Intramedullary Nailing ¤ A retrospective review evaluated the results of twenty-eight patients with unstable olecranon fractures treated with a locked ulnar intramedullary nail3. All fractures healed within eight weeks after treatment. Motion was within 10 of the contralateral side, and no pain was reported at the twelve-week follow-up. V Intramedullary nailing of olecranon fractures may be an option for treatment in addition to plate fixation. Nonoperative Management of Olecranon Fractures ¤ Forty-three patients, ages forty to ninety-eight years (mean, seventy-six years), with intra-articular, displaced (>2 mm) olecranon fractures treated nonoperatively were studied retrospectively4. No patients required secondary procedures for symptomatic nonunion. In the short term (mean, four months), 72% of patients had a good or excellent outcome. At an average follow-up of six years, 91% were satisfied with the result.
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has a patent or patents, planned, pending, or issued, that is broadly relevant to the work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:1222-30
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http://dx.doi.org/10.2106/JBJS.N.00289
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What’s New in Orthopaedic Trauma V Older patients who place lower demands on the elbow may tolerate nonoperative treatment of displaced olecranon fractures. Early Mobilization of Radial Head Fractures ¤ One hundred and eighty patients with AO/OTA B2 radial head fractures (multifragmentary without depression) were randomly allocated into immediate mobilization, two days of sling use followed by mobilization, or casting for seven days followed by mobilization. Patients were evaluated with use of multiple outcome measurements5. Both early mobilization protocols had improved outcomes compared with immobilization, with the best results achieved in patients who rested the elbow for two days prior to mobilization. V A brief period of limited immobilization followed by early motion decreased pain and improved outcomes as compared with longer periods of immobilization or immediate mobilization. Heterotopic Ossification About the Elbow ¤ One hundred and thirty elbow fractures and fracture-dislocations treated surgically were examined for the presence of heterotopic ossification and analyzed for risk factors in the development of heterotopic ossification6. Heterotopic ossification was seen in 37% of elbows, limited motion was found in 20%, and additional surgery was required in 10%. Heterotopic ossification developed in proximity to fractures, the origins of torn soft-tissue structures, and, most commonly, about the radial neck and posterior aspect of the ulna. Distal humeral fractures, terrible triad injuries (i.e., posterolateral dislocation, radial head fracture, and coronoid fracture), and fracture-dislocations involving the olecranon were risk factors. V Heterotopic ossification occurs in a high percentage of surgically treated elbow injuries and is clinically relevant in 20% of patients. Pelvis & Acetabulum Pelvic Ring Injuries ¤ Twenty-one patients (twenty-five external rotation injuries of the pelvis) underwent acute magnetic resonance imaging (MRI) to specifically evaluate several ligamentous structures about the pelvis. These patients were compared with twenty-six control patients without pelvic trauma7. Overall, visualization of all five soft-tissue structures studied was excellent. Ligament injury was common and correlated with the Young-Burgess classification system, with the notable exception of sacrospinous
V
¤
V
ligament injury in only 50% of the anteriorposterior compression type-II fractures. Pelvic ligament integrity is integral to determining pelvic ring stability, for the prognostication of outcome, and for treatment recommendations. Pelvic stability is often difficult to determine based on static standard imaging, and MRI may be a useful modality for stable patients in centers with this capability. Eighty patients with unstable pelvic fractures treated surgically were administered sexual function and global function questionnaires at a median period of three years after injury (minimum period, one year)8. There was an overall significant decrease of quality of life. Forty-four percent of women and 52% of men reported sexual dysfunction. Risk factors for sexual dysfunction included urinary tract injury and open surgical treatment. The importance of this study is related to the necessary high suspicion for these sequelae of surgically-treated pelvic fractures. Patients should be counseled appropriately early in the postoperative period, and prompt multidisciplinary engagement of urological, gynecological, and psychiatric specialists should be considered.
Acetabular Fractures ¤ Thirty-nine patients older than seventy years with protrusio-type acetabular fractures were treated with open reduction and internal fixation (ORIF) including infrapectineal plates. Clinical, radiographic, and functional outcomes were assessed in twenty-six patients at a mean follow-up time of thirty-four months (minimum follow-up time, one year)9. Eighteen patients had good or excellent radiographic outcomes. Five (19%) underwent total hip arthroplasty. Fourteen (54%) had excellent or very good functional outcomes. Of the thirty-nine original patients, ten (26%) died during the follow-up period, at an average period of twenty months. V In this challenging patient cohort, reasonable functional and radiographic outcomes were achieved with ORIF of this difficult fracture pattern. The main question remaining is with regard to the functional outcomes in patients who were treated nonoperatively with early mobilization. ¤ Eighty consecutive patients with surgically treated acetabular fractures underwent blood salvage during surgery, and an economic analysis was performed to determine the cost-effectiveness10. The mean volume of autologous blood transfused was 484 mL, and the mean volume transfused was
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What’s New in Orthopaedic Trauma significantly greater in patients who had an associated fracture type than it was in patients who had an elementary fracture type. Twenty patients (25%) required additional allogeneic blood transfusions. The mean cost of using the blood salvage system was significantly less than the predicted cost of transfusing the equivalent volume of allogeneic blood. V Blood management in acetabular fracture surgery can be challenging. This study found the use of intraoperative blood salvage systems to be costeffective. Of importance, the system used in this study did not require a technician for the blood salvage, which may affect the economics. Geriatrics Intertrochanteric Hip Fractures ¤ Two hundred and eighty-three patients with pertrochanteric hip fractures (OTA classification of 31-A1 and A2) treated with either a long (n = 183) or a short (n = 100) hip fracture nail were reviewed retrospectively. Outcomes included complications and mortality11. There were no differences between the demographics of the group, and no differences between the union or complication rates. V Nails with a longer working length may optimize stability, and they theoretically decrease the risk of peri-implant fracture. However in this study, no advantages in using a long nail were found. Longer nails also require free-hand distal interlocking, and they increase the risk of anterior cortical perforation due to femoral bow mismatch. Femoral Neck Fractures ¤ One thousand four hundred and eleven patients older than sixty years with femoral neck fractures were analyzed retrospectively. Treatment modality and displacement were specifically assessed as independent risk factors for reoperation12. For nondisplaced fractures treated with internal fixation, the reoperation rate was 15%. Displaced fractures treated with ORIF had a reoperation rate of 38%, and the rate for those treated with hemiarthroplasty was 7%. Reasons for reoperation were most often nonunion (for those treated with ORIF) and infection (for those treated with hemiarthroplasty). V This study confirmed the high failure rate of internal fixation of displaced femoral neck fractures. Interestingly, nondisplaced fractures that underwent closed reduction and percutaneous pinning still had a 15% failure rate, highlighting the difficulty of treating these fractures in older patients.
¤ A national (mailed) survey following treatment for femoral neck fracture (median follow-up, fourteen months; range, seven to twenty-two months) with total hip arthroplasty, hip hemiarthroplasty, or internal fixation was undertaken to evaluate patientreported perception of recovery13. Visual analog scale scores of pain and satisfaction demonstrated consistent results, with better scores for total hip arthroplasty. Higher EQ-5D (EuroQol, Rotterdam, The Netherlands) scores were also seen in the total hip arthroplasty group. Analysis of subjects who were older and younger than seventy years of age produced consistent results. V Pain, satisfaction, and quality of life following femoral neck fracture are better when treated with total hip arthroplasty. The authors concluded that total hip arthroplasty may be the primary choice for treatment of femoral neck fracture in most patients who are younger than seventy years of age and in older patients who have a long remaining life expectancy. Femur Diagnosis of Associated Femoral Neck and Shaft Fractures ¤ Blinded radiographic analysis of twenty-eight cases of associated femoral neck and shaft fractures, grouped with sixty isolated femoral shaft fractures, was completed by five orthopaedic traumatologists to evaluate the ability to diagnose the fractures through the femoral neck with use of anteroposterior radiographs of the femur and pelvis, as well as computed tomography (CT) scans of the pelvis14. Interobserver agreement was substantial for all imaging modalities. Specificity and 1 minus negative post-test probability were high (>94%) and similar across all modalities. Sensitivity was low and similar across modalities: 51% for the anteroposterior radiographs of the femur, 56% for the anteroposterior radiographs of the pelvis, and 64% for the CT scans of the pelvis. V Similar to previous reports, this study demonstrates the low sensitivity of radiographs and CT in making this diagnosis. The authors recommend vigilance when treating femoral shaft fractures, and they also recommend thorough evaluation of intraoperative and postoperative imaging to diagnose associated femoral neck fractures. Variation of Femoral Neck Version ¤ CT data from a registry of patients treated for femoral fracture were used to analyze femoral neck version in the uninjured limb of 328 subjects, with a focus on sex and ethnic differences15.
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What’s New in Orthopaedic Trauma Mean femoral neck version and standard deviation was 8.84 ± 9.66 of anteversion, with no differences between sexes and among ethnic groups. Although the femoral necks of most subjects were anteverted, there was a large proportion with retroverted femoral necks across all subgroups, with >10 of retroversion seen in 6% of African Americans. V This study presents comparative data across sex and ethnic groups regarding femoral neck version. Most notably, a wide variation was seen across the entire group, and a large proportion of subjects displayed retroverted femoral necks. This has important implications for femoral fracture treatment and implant design. Retrograde Femoral Nailing Through Traumatic Knee Arthrotomies ¤ A retrospective cohort of subjects treated with retrograde femoral nails and with matching of those with (thirty-four) and without (thirty-six) traumatic knee arthrotomies analyzed infection and nonunion outcomes16. No infections and four nonunions occurred in the study group, compared with two infections (p = 1.00) and eight nonunions (p = 0.26) in the matched retrograde group and one infection (p = 0.40) and one nonunion (p = 0.64) in a contemporary group treated with antegrade nails. V This study concludes that retrograde nailing of femoral fractures is associated with similar rates of infection and nonunion when performed through a traumatic knee arthrotomy, as compared with retrograde nailing of femoral fractures without arthrotomy and other methods. This associated injury should not be a contraindication for use of retrograde nailing. The Association of Atypical Femoral Fractures and Bisphosphonates ¤ With use of a systematic literature review and analysis of the United States Food and Drug Administration Adverse Event Reporting System, the association of atypical femoral fractures and bisphosphonate use was explored17. With use of proportional reporting ratios and empiric Bayesian geometric means, the association of bisphosphonates (over other medications) and atypical fractures was confirmed. Using Naranjo and Bradford-Hill criteria for causality, the authors reported a ‘‘probable’’ causal relationship. V Atypical femoral fractures are associated more with bisphosphonate use than with the other medications or comorbidities. Patients should be
counseled, and the duration of treatment should be limited. Aggressive and Limited Debridement of Open Distal Femoral Fractures ¤ A retrospective review of twenty-nine patients who were treated with use of two different institutional protocols (i.e., a more aggressive protocol of removing all devitalized bone and placing an antibiotic cement spacer, and a less aggressive protocol of removing only grossly contaminated bone with retention of other bone fragments and no use of antibiotic cement spacers) was performed to study relative reoperation and infection rates18. Reoperation rates for infection were similar between the more aggressive and less aggressive groups (18% versus 25%, respectively; p = 0.63). Reoperation to achieve union was significantly higher in the more aggressive than in the less aggressive group (65% versus 8%, respectively; p < 0.01). V The authors acknowledge limitations, including potential type-II error and inability to control for the ‘‘aggressiveness’’ of each debridement, but they concluded that retained marginal bone may not be associated with high infection rates and that further study into the definition for adequate debridement for open distal femoral fractures is warranted. Tibia Single Versus Dual-Incision Fasciotomy for Acute Compartment Syndrome ¤ One hundred and seventy-five patients requiring a fasciotomy for acute compartment syndrome after a tibial fracture were identified retrospectively over twelve years. Of those treated with intramedullary nails, thirty-six had a single incision and twentyfour had a dual incision procedure. In the plate group, fifty-nine had a single incision and twentytwo had dual incisions19. In comparing single versus dual incisions: in both groups, the rates of infection and nonunion were similar. The rates of skin-grafting were similar in all groups. V The decision to perform a single or dual-incision fasciotomy should be based on patient factors or surgeon experience rather than suspicion of increased rates of infection or nonunion. Infection After Tibial Plateau Fractures ¤ The rate of infection in 302 patients with bicondylar tibial plateau fractures treated with ORIF over an eight-year period was studied retrospectively20. Forty-three patients (14.2%) developed deep infections requiring reoperation, with methicillin-resistant
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What’s New in Orthopaedic Trauma Staphylococcus aureus (MRSA) identified as the bacterium in twenty (46.5%) of the infections. 81.4% of all patients had external fixation prior to definitive treatment. Open fractures, smoking, fasciotomies, external fixation, and dual-incision and/or dual-plating fracture patterns were all risk factors for deep infection. V Despite the use of a staged protocol and external fixation, deep infections were common. MRSA was common and MRSA-specific prophylaxis may be helpful. Smoking was the only modifiable risk factor noted. Bone and Ligament Injury in Parapatellar Versus Retropatellar Tibial Nailing ¤ Bone loss and soft-tissue injury was compared in thirty-six cadaver knees. A medial parapatellar (flexed-knee) approach was used on eighteen of the knees, and a retropatellar (semi-extended) approach was used on the other eighteen knees21. The amount of bone removed was similar with both approaches. All knees in which the parapatellar technique was used had some intraarticular injury, while only 33% of knees that had the retropatellar approach had injury. The intermeniscal ligament was injured in 83% of knees that had the parapatellar approach and in 56% of knees that had the retropatellar approach. V Substantial anterior tibial bone is removed with both approaches. Intra-articular damage, most often to the intermeniscal ligament, was less frequent with use of the retropatellar approach. Foot and Ankle Syndesmosis ¤ Eighteen patients with a malleolar ankle fracture and syndesmotic injury were treated operatively. Syndesmotic reduction was achieved with use of a clamp and was verified fluoroscopically with use of mortise-view and true talar-dome lateral-view radiographs, with radiographs of the contralateral ankle used for comparison. Reductions were verified intraoperatively with use of a three-dimensional CT scanning system22. Using this fluoroscopic method, seventeen of eighteen syndesmoses were accurately reduced on the basis of CT imaging. V Comparing the tibiofibular relationship on a perfect-lateral-view radiograph to the relationship on the contralateral side is a promising technique for the assessment of syndesmotic reduction intraoperatively. Of note, this study used CTevaluation of only the injured ankle and may not have accounted for subtle anatomic variances.
¤ Thirty-six patients with syndesmotic injuries had intraoperative syndesmotic reduction performed with use of either standard fluoroscopy or threedimensional CT. Quality of reduction was assessed with use of postoperative CT23. With a 1-mm difference used as a threshold for malreduction, 55% in the standard group and 50% in the three-dimensional CT group had malreduction. V Without use of the contralateral side for comparison, neither standard fluoroscopic nor intraoperative three-dimensional CT provides consistent syndesmotic reduction. ¤ Syndesmosis injuries were created in fourteen cadaver legs. A variety of well-controlled clamp placements and screw insertions were performed, and CT scans assessed the effect on syndesmotic reduction24. Clamps placed at 15 and 30 relative to the neutral axis of the ankle (from posterior on the fibula to anterior on the tibia) caused significant external rotation and overcompression of the syndesmosis. A variety of screw vectors also contributed to syndesmotic malreduction. V This study highlights the sensitivity of clamp position and vector in malreducing the syndesmosis. Additionally, a substantial number of syndesmoses became overcompressed, which corroborates previous data25. The clamp force used in this study was not specified. ¤ Thirty-seven patients with syndesmotic injuries treated with sixty-four TightRopes (Arthrex, Naples, Florida) were assessed radiographically and clinically at a mean of twenty-four months. In 73% of patients, two suture buttons were used26. The mean changes in radiographic measurements were all 30), and obesity combined with preoperative leukocytosis were associated with significantly increased odds of wound infection. Notable unassociated variables included preoperative fever, leukocytosis in
isolation, other system infection, other open fractures, and transfusion. Preoperative angioembolization demonstrated a higher odds ratio for wound infection (11.14) and a high positive predictive value (66.7%), but those values failed to reach significance. V This study concluded that obesity, an ISS of >16, and preoperative angioembolization are risk factors for deep wound infection after operative treatment of pelvic and acetabular fractures. Polytrauma patients, particularly the obese, should be treated with additional concern regarding this complication and should be appropriately counseled. Mangled Limbs with Foot and Ankle Injuries ¤ A subset (n = 182) of the Lower Extremity Assessment Project (LEAP) study cohort, whose injuries included fractures of the foot and ankle (including pilon fractures), was analyzed to compare two-year outcomes between patients with standard below-the-knee amputation and limb salvage, with additional analysis of the effect of free tissue transfer and/or ankle arthrodesis30. There were no differences between salvage and amputation in overall, physical, and psychosocial Sickness Impact Profile scores between patients who underwent limb salvage and those who underwent amputation. However, regression analysis that took into consideration the additional need for free flap and/or ankle arthrodesis demonstrated clinically and significant worse overall and psychosocial outcomes in this group as compared with the group that had salvage without free flap and/or arthrodesis and below-the-knee amputation. The best overall and psychosocial scores were in the salvage without free flap and/or arthrodesis group, but this did not reach significance (p = 0.34 and p = 0.20). V Limb-salvage decision making remains a challenging case-by-case conundrum. Patients with foot and ankle fractures who require free tissue transfer or ankle arthrodesis for limb salvage should be counseled regarding worse expected outcomes compared with below-the-knee amputation. Nonunion, Infection, and Wound Management Prediction of Tibial Nonunion ¤ Clinical vignettes (including radiographic images) representing fifty-six patients treated with intramedullary nails for tibial fractures that had incomplete healing at three months were presented to three fellowship-trained trauma surgeons. Surgeons were asked to predict if the fractures would progress to union31.
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What’s New in Orthopaedic Trauma The diagnostic accuracy of all three surgeons was 74%; sensitivity, 62%; and specificity, 77%. V Experienced surgeons can accurately predict healing or nonunion in a majority of patients at three months after tibial nailing. The authors suggest that a protocol of waiting six months before considering reoperation in all such patients may be unnecessary. Lidocaine for Vacuum-Assisted Closure (VAC) Dressing Changes ¤ A randomized double-blinded placebo-controlled trial compared pain and narcotic requirement after extremity wound VAC dressing changes at the bedside (n = 21 VAC changes) with use of topical lidocaine or normal saline solution32. The lidocaine-treated patients had 2.4 points less on a 0 to 10 visual analog scale for pain and used 1.7 mg less morphine-equivalents. V Pretreatment with topical lidocaine decreased pain and narcotic requirement in patients undergoing extremity wound VAC dressing changes at the bedside. Preoperative Diagnosis of Infection in Patients with Nonunion ¤ A review of ninety-five nonunions evaluated the utility of evaluating preoperative white blood-cell count, C-reactive protein, erythrocyte sedimentation rate, and white blood cell/sulfur colloid scan to rule out infection33. 31.5% of the nonunions were ultimately infected. Excluding bone scan, the predictive probability of infection with zero, one, two, and three positive tests was 19.6%, 18.8%, 56.0%, and 100.0%, respectively. Erythrocyte sedimentation rate and C-reactive protein were independent accurate predictors of infected nonunion. V Common serologic tests can accurately stratify risk of infection for nonunion. A white blood-cell scan or sulfur-colloid bone scan is not recommended. Protocol for Presumptive Aseptic Nonunion ¤ A retrospective review of eighty-seven patients with presumed aseptic nonunion (by history and physical examination) and treated with a single-stage repair was used to compare results among those with positive intraoperative cultures and those with negative cultures34. Unexpected positive cultures were found in 28.7%. Secondary surgery was required more often in patients with positive cultures (28%) than in those without positive cultures (6.4%; p = 0.01). V Single-stage nonunion repair for presumed aseptic nonunion is supported. Patients with unexpected
positive cultures healed without need for reoperation in 72% of cases. Bone-Marrow Injection for Tibial Nonunions ¤ Eleven patients with nonunion or delayed union of the distal tibial metaphysis following ORIF were treated with 40 to 80 mL of bone marrow aspirate from the posterior iliac crest35. Nine of eleven had osseous union within six months following injection. Six of the nine had long-term follow-up (1.3 to 8.2 years) and reported substantial improvement. V With distal tibial nonunions and delayed unions with intact and stable implants, percutaneous bone-marrow injection is an effective treatment option. Basic Science Screw Biomechanics ¤ Five pairs of cadaveric humeri from three different bone mineral density groups (normal, osteopenic, osteoporotic) were drilled. Maximum torque (Tmax) was measured with 3.5-mm cortical screws, and additional screws were placed at 50%, 70%, and 90% of the Tmax. Pullout strength was then measured, and cortical thickness and bone mineral density were controlled36. In osteoporotic and normal bone, the pullout strength was greatest for screws inserted to 50% of Tmax. This strength was not significantly greater than that for screws inserted to 70% and 90% of Tmax. V This study concluded that no benefit in pullout strength is gained by approaching the maximum insertion torque and risking stripping the screw. The main caveat is that the pullout strength of a screw may not always be an appropriate surrogate for clinical fixation failure, as very rarely are plate screws subjected to axial forces leading to direct pullout. ¤ Synthetic and cadaveric bone models were predrilled, and 3.5-mm self-tapping cortical screws with washers were completely inserted between one and five times into the same hole. Pullout strength was then measured37. In all specimens, both cadaveric and synthetic, pullout strength decreased as the screws were reinserted into the same predrilled hole. V Many situations may lead to screw reinsertions intraoperatively, such as fracture realignment, plate repositioning, or screw-size changing. When performing one of these interventions, the surgeon should be aware that there may be a small price to pay regarding fixation strength.
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What’s New in Orthopaedic Trauma ¤ Twenty-five 3.5-mm locking screws were inserted into standard locking plates and a foam-bone surrogate to 1.7 N-m torque. Multiple insertion axes were used to test the effect on various degrees of cross-threading on bending strength38. As insertion angle increased, the bending strength decreased. Screws inserted at 3 or below failed by way of screw deformation; greater insertion angles failed by means of screw disengagement. V Although nonvariable angle locking screws are designed to be placed through threaded guides or physical jigs, cross-threading occurs occasionally. The surgeon should be aware that greater than 3 of deviation from the perpendicular axis substantially
diminishes the mechanical strength of the locking screw mechanism.
William M. Ricci, MD Michael Linn, MD Michael Gardner, MD Christopher McAndrew, MD Washington University Orthopedics, Campus Box 8233, 660 South Euclid Avenue, St. Louis, MO 63110. E-mail address for W.M. Ricci: [email protected]
References 1. Galdi B, Yoon RS, Choung EW, Reilly MC, Sirkin M, Smith WR, Liporace FA. Anteroinferior 2.7-mm versus 3.5-mm plating for AO/OTA type B clavicle fractures: a comparative cohort clinical outcomes study. J Orthop Trauma. 2013 Mar;27(3): 121-5. 2. Chen F, Wang Z, Bhattacharyya T. Outcomes of nails versus plates for humeral shaft fractures: a Medicare cohort study. J Orthop Trauma. 2013 Feb;27(2): 68-72. 3. Argintar E, Cohen M, Eglseder A, Edwards S. Clinical results of olecranon fractures treated with multiplanar locked intramedullary nailing. J Orthop Trauma. 2013 Mar;27(3):140-4. 4. Duckworth AD, Bugler KE, Clement ND, Court-Brown CM, McQueen MM. Nonoperative management of displaced olecranon fractures in low-demand elderly patients. J Bone Joint Surg Am. 2014 Jan 1;96(1):67-72. 5. Paschos NK, Mitsionis GI, Vasiliadis HS, Georgoulis AD. Comparison of early mobilization protocols in radial head fractures. J Orthop Trauma. 2013 Mar;27(3):134-9. 6. Foruria AM, Augustin S, Morrey BF, Sa´ nchez-Sotelo J. Heterotopic ossification after surgery for fractures and fracture-dislocations involving the proximal aspect of the radius or ulna. J Bone Joint Surg Am. 2013 May 15;95(10):e66. 7. Gary JL, Mulligan M, Banagan K, Sciadini MF, Nascone JW, O’toole RV. Magnetic resonance imaging for the evaluation of ligamentous injury in the pelvis: a prospective case-controlled study. J Orthop Trauma. 2014 Jan;28(1):41-7. 8. Harvey-Kelly KF, Kanakaris NK, Obakponovwe O, West RM, Giannoudis PV. Quality of life and sexual function after traumatic pelvic fracture. J Orthop Trauma. 2014 Jan;28(1):28-35. 9. Archdeacon MT, Kazemi N, Collinge C, Budde B, Schnell S. Treatment of protrusio fractures of the acetabulum in patients 70 years and older. J Orthop Trauma. 2013 May;27(5):256-61. 10. Bigsby E, Acharya MR, Ward AJ, Chesser TJ. The use of blood cell salvage in acetabular fracture internal fixation surgery. J Orthop Trauma. 2013 Oct;27(10):e230-3. 11. Hou Z, Bowen TR, Irgit KS, Matzko ME, Andreychik CM, Horwitz DS, Smith WR. Treatment of pertrochanteric fractures (OTA 31-A1 and A2): long versus short cephalomedullary nailing. J Orthop Trauma. 2013 Jun;27(6):318-24. 12. Murphy DK, Randell T, Brennan KL, Probe RA, Brennan ML. Treatment and displacement affect the reoperation rate for femoral neck fracture. Clin Orthop Relat Res. 2013 Aug;471(8):2691-702. Epub 2013 May 3. ˚ 13. Leonardsson O, Rolfson O, Hommel A, Garellick G, Akesson K, Rogmark C. Patient-reported outcome after displaced femoral neck fracture: a national survey of 4467 patients. J Bone Joint Surg Am. 2013 Sep 18;95(18):1693-9. 14. O’toole RV, Dancy L, Dietz AR, Pollak AN, Johnson AJ, Osgood G, Nascone JW, Sciadini MF, Castillo RC. Diagnosis of femoral neck fracture associated with femoral shaft fracture: blinded comparison of computed tomography and plain radiography. J Orthop Trauma. 2013 Jun;27(6):325-30. 15. Koerner JD, Patel NM, Yoon RS, Sirkin MS, Reilly MC, Liporace FA. Femoral version of the general population: does ‘‘normal’’ vary by gender or ethnicity? J Orthop Trauma. 2013 Jun;27(6):308-11. 16. Bible JE, Kadakia RJ, Choxi AA, Bauer JM, Mir HR. Analysis of retrograde femoral intramedullary nail placement through traumatic knee arthrotomies. J Orthop Trauma. 2013 Apr;27(4):217-20.
17. Edwards BJ, Bunta AD, Lane J, Odvina C, Rao DS, Raisch DW, McKoy JM, Omar I, Belknap SM, Garg V, Hahr AJ, Samaras AT, Fisher MJ, West DP, Langman CB, Stern PH. Bisphosphonates and nonhealing femoral fractures: analysis of the FDA Adverse Event Reporting System (FAERS) and international safety efforts: a systematic review from the Research on Adverse Drug Events And Reports (RADAR) project. J Bone Joint Surg Am. 2013 Feb 20;95(4): 297-307. 18. Ricci WM, Collinge C, Streubel PN, McAndrew CM, Gardner MJ. A comparison of more and less aggressive bone debridement protocols for the treatment of open supracondylar femur fractures. J Orthop Trauma. 2013 Dec;27(12):722-5. 19. Bible JE, McClure DJ, Mir HR. Analysis of single-incision versus dual-incision fasciotomy for tibial fractures with acute compartment syndrome. J Orthop Trauma. 2013 Nov;27(11):607-11. 20. Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM, Obremskey WT. Risk factors of infection after ORIF of bicondylar tibial plateau fractures. J Orthop Trauma. 2013 Sep;27(9):e196-200. 21. Bible JE, Choxi AA, Dhulipala S, Evans JM, Mir HR. Quantification of anterior cortical bone removal and intermeniscal ligament damage at the tibial nail entry zone using parapatellar and retropatellar approaches. J Orthop Trauma. 2013 Aug;27(8): 437-41. 22. Summers HD, Sinclair MK, Stover MD. A reliable method for intraoperative evaluation of syndesmotic reduction. J Orthop Trauma. 2013 Apr;27(4): 196-200. 23. Davidovitch RI, Weil Y, Karia R, Forman J, Looze C, Liebergall M, Egol K. Intraoperative syndesmotic reduction: three-dimensional versus standard fluoroscopic imaging. J Bone Joint Surg Am. 2013 Oct 16;95(20):1838-43. 24. Miller AN, Barei DP, Iaquinto JM, Ledoux WR, Beingessner DM. Iatrogenic syndesmosis malreduction via clamp and screw placement. J Orthop Trauma. 2013 Feb;27(2):100-6. 25. Phisitkul P, Ebinger T, Goetz J, Vaseenon T, Marsh JL. Forceps reduction of the syndesmosis in rotational ankle fractures: a cadaveric study. J Bone Joint Surg Am. 2012 Dec 19;94(24):2256-61. 26. Rigby RB, Cottom JM. Does the Arthrex TightRope provide maintenance of the distal tibiofibular syndesmosis? A 2-year follow-up of 64 TightRopes in 37 patients. J Foot Ankle Surg. 2013 Sep-Oct;52(5):563-7. Epub 2013 Jun 14. 27. Vallier HA, Super DM, Moore TA, Wilber JH. Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course. J Orthop Trauma. 2013 Jul;27(7): 405-12. 28. Matityahu A, Marmor M, Elson JK, Lieber C, Rogalski G, Lin C, Belaye T, Miclau T 3rd, Kandemir U. Acute complications of patients with pelvic fractures after pelvic angiographic embolization. Clin Orthop Relat Res. 2013 Sep;471(9): 2906-11. 29. Sagi HC, Dziadosz D, Mir H, Virani N, Olson C. Obesity, leukocytosis, embolization, and injury severity increase the risk for deep postoperative wound infection after pelvic and acetabular surgery. J Orthop Trauma. 2013 Jan;27(1): 6-10. 30. Ellington JK, Bosse MJ, Castillo RC, MacKenzie EJ, Group LS; LEAP Study Group. The mangled foot and ankle: results from a 2-year prospective study. J Orthop Trauma. 2013 Jan;27(1):43-8.
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What’s New in Orthopaedic Trauma 31. Yang JS, Otero J, McAndrew CM, Ricci WM, Gardner MJ. Can tibial nonunion be predicted at 3 months after intramedullary nailing? J Orthop Trauma. 2013 Nov; 27(11):599-603. 32. Christensen TJ, Thorum T, Kubiak EN. Lidocaine analgesia for removal of wound vacuum-assisted closure dressings: a randomized double-blinded placebocontrolled trial. J Orthop Trauma. 2013 Feb;27(2):107-12. 33. Stucken C, Olszewski DC, Creevy WR, Murakami AM, Tornetta P. Preoperative diagnosis of infection in patients with nonunions. J Bone Joint Surg Am. 2013 Aug 7;95(15):1409-12. 34. Amorosa LF, Buirs LD, Bexkens R, Wellman DS, Kloen P, Lorich DG, Helfet DL. A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions: a review of outcomes. J Orthop Trauma. 2013 Oct;27(10):582-6.
35. Braly HL, O’Connor DP, Brinker MR. Percutaneous autologous bone marrow injection in the treatment of distal meta-diaphyseal tibial nonunions and delayed unions. J Orthop Trauma. 2013 Sep;27(9):527-33. 36. Tankard SE, Mears SC, Marsland D, Langdale ER, Belkoff SM. Does maximum torque mean optimal pullout strength of screws? J Orthop Trauma. 2013 Apr;27(4):232-5. 37. Matityahu A, Hurschler C, Badenhop M, Stukenborg-Colsman C, Waizy H, Wentz B, Marmor M, Krettek C. Reduction of pullout strength caused by reinsertion of 3.5-mm cortical screws. J Orthop Trauma. 2013 Mar;27(3):170-6. 38. Cartner JL, Petteys T, Tornetta P 3rd. Mechanical effects of off-axis insertion of locking screws: should we do it? J Orthop Trauma. 2014 Apr; 28(Suppl 1):S2-5.
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Specialty Update
What’s New in Orthopaedic Trauma William M. Ricci, MD, Michael Linn, MD, Michael Gardner, MD, and Christopher McAndrew, MD
This update presents a synopsis of the most clinically relevant high-quality studies related to orthopaedic trauma from the past twelve months. Key methods (¤), results (), and take-home points (V) for these studies are presented. Clavicle and Humerus Clavicle Plating ¤ A retrospective cohort study compared plating of diaphyseal clavicular fractures (AO/OTA [Arbeitsgemeinschaft f¨ur Osteosynthesefragen/Orthopaedic Trauma Association] type B) with either a 2.7-mm (n = 19) or a 3.5-mm (n = 18) reconstruction plate placed anteroinferior1. There were no differences in outcome scores (Constant and Disabilities of the Arm, Shoulder and Hand [DASH]), time to union, rate of union, or reoperation rate. Patients with lower profile, 2.7-mm plates had a higher rate of a cosmetically acceptable reconstruction. V Use of anteroinferior, 2.7-mm reconstruction plates appears reasonable for treatment of clavicular fractures. Application for comminuted fractures may still require caution. There were only three highly comminuted fractures, and the 2.7-mm plates applied in bridge mode may not have sufficient fatigue strength. Humeral Shaft: Nail Versus Plate ¤ A retrospective comparative cohort analysis utilized Medicare data from 1993 to 2007 to identify trends in utilization, reoperation, and mortality in patients Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
treated with nails (n = 279) compared with plates (n = 172) for humeral shaft fracture2. There was no difference in reoperation or mortality rates at one year. Anesthesia time was reduced in the nail cohort by 27.1 minutes (p < 0.0001). V Nailing and plating are associated with similar reoperation rates. The authors note that reduced operating-room time for nailing may be offset by reduced implant costs for plating. Elbow Treatment of Olecranon Fractures with Intramedullary Nailing ¤ A retrospective review evaluated the results of twenty-eight patients with unstable olecranon fractures treated with a locked ulnar intramedullary nail3. All fractures healed within eight weeks after treatment. Motion was within 10 of the contralateral side, and no pain was reported at the twelve-week follow-up. V Intramedullary nailing of olecranon fractures may be an option for treatment in addition to plate fixation. Nonoperative Management of Olecranon Fractures ¤ Forty-three patients, ages forty to ninety-eight years (mean, seventy-six years), with intra-articular, displaced (>2 mm) olecranon fractures treated nonoperatively were studied retrospectively4. No patients required secondary procedures for symptomatic nonunion. In the short term (mean, four months), 72% of patients had a good or excellent outcome. At an average follow-up of six years, 91% were satisfied with the result.
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has a patent or patents, planned, pending, or issued, that is broadly relevant to the work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:1222-30
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http://dx.doi.org/10.2106/JBJS.N.00289
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What’s New in Orthopaedic Trauma V Older patients who place lower demands on the elbow may tolerate nonoperative treatment of displaced olecranon fractures. Early Mobilization of Radial Head Fractures ¤ One hundred and eighty patients with AO/OTA B2 radial head fractures (multifragmentary without depression) were randomly allocated into immediate mobilization, two days of sling use followed by mobilization, or casting for seven days followed by mobilization. Patients were evaluated with use of multiple outcome measurements5. Both early mobilization protocols had improved outcomes compared with immobilization, with the best results achieved in patients who rested the elbow for two days prior to mobilization. V A brief period of limited immobilization followed by early motion decreased pain and improved outcomes as compared with longer periods of immobilization or immediate mobilization. Heterotopic Ossification About the Elbow ¤ One hundred and thirty elbow fractures and fracture-dislocations treated surgically were examined for the presence of heterotopic ossification and analyzed for risk factors in the development of heterotopic ossification6. Heterotopic ossification was seen in 37% of elbows, limited motion was found in 20%, and additional surgery was required in 10%. Heterotopic ossification developed in proximity to fractures, the origins of torn soft-tissue structures, and, most commonly, about the radial neck and posterior aspect of the ulna. Distal humeral fractures, terrible triad injuries (i.e., posterolateral dislocation, radial head fracture, and coronoid fracture), and fracture-dislocations involving the olecranon were risk factors. V Heterotopic ossification occurs in a high percentage of surgically treated elbow injuries and is clinically relevant in 20% of patients. Pelvis & Acetabulum Pelvic Ring Injuries ¤ Twenty-one patients (twenty-five external rotation injuries of the pelvis) underwent acute magnetic resonance imaging (MRI) to specifically evaluate several ligamentous structures about the pelvis. These patients were compared with twenty-six control patients without pelvic trauma7. Overall, visualization of all five soft-tissue structures studied was excellent. Ligament injury was common and correlated with the Young-Burgess classification system, with the notable exception of sacrospinous
V
¤
V
ligament injury in only 50% of the anteriorposterior compression type-II fractures. Pelvic ligament integrity is integral to determining pelvic ring stability, for the prognostication of outcome, and for treatment recommendations. Pelvic stability is often difficult to determine based on static standard imaging, and MRI may be a useful modality for stable patients in centers with this capability. Eighty patients with unstable pelvic fractures treated surgically were administered sexual function and global function questionnaires at a median period of three years after injury (minimum period, one year)8. There was an overall significant decrease of quality of life. Forty-four percent of women and 52% of men reported sexual dysfunction. Risk factors for sexual dysfunction included urinary tract injury and open surgical treatment. The importance of this study is related to the necessary high suspicion for these sequelae of surgically-treated pelvic fractures. Patients should be counseled appropriately early in the postoperative period, and prompt multidisciplinary engagement of urological, gynecological, and psychiatric specialists should be considered.
Acetabular Fractures ¤ Thirty-nine patients older than seventy years with protrusio-type acetabular fractures were treated with open reduction and internal fixation (ORIF) including infrapectineal plates. Clinical, radiographic, and functional outcomes were assessed in twenty-six patients at a mean follow-up time of thirty-four months (minimum follow-up time, one year)9. Eighteen patients had good or excellent radiographic outcomes. Five (19%) underwent total hip arthroplasty. Fourteen (54%) had excellent or very good functional outcomes. Of the thirty-nine original patients, ten (26%) died during the follow-up period, at an average period of twenty months. V In this challenging patient cohort, reasonable functional and radiographic outcomes were achieved with ORIF of this difficult fracture pattern. The main question remaining is with regard to the functional outcomes in patients who were treated nonoperatively with early mobilization. ¤ Eighty consecutive patients with surgically treated acetabular fractures underwent blood salvage during surgery, and an economic analysis was performed to determine the cost-effectiveness10. The mean volume of autologous blood transfused was 484 mL, and the mean volume transfused was
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What’s New in Orthopaedic Trauma significantly greater in patients who had an associated fracture type than it was in patients who had an elementary fracture type. Twenty patients (25%) required additional allogeneic blood transfusions. The mean cost of using the blood salvage system was significantly less than the predicted cost of transfusing the equivalent volume of allogeneic blood. V Blood management in acetabular fracture surgery can be challenging. This study found the use of intraoperative blood salvage systems to be costeffective. Of importance, the system used in this study did not require a technician for the blood salvage, which may affect the economics. Geriatrics Intertrochanteric Hip Fractures ¤ Two hundred and eighty-three patients with pertrochanteric hip fractures (OTA classification of 31-A1 and A2) treated with either a long (n = 183) or a short (n = 100) hip fracture nail were reviewed retrospectively. Outcomes included complications and mortality11. There were no differences between the demographics of the group, and no differences between the union or complication rates. V Nails with a longer working length may optimize stability, and they theoretically decrease the risk of peri-implant fracture. However in this study, no advantages in using a long nail were found. Longer nails also require free-hand distal interlocking, and they increase the risk of anterior cortical perforation due to femoral bow mismatch. Femoral Neck Fractures ¤ One thousand four hundred and eleven patients older than sixty years with femoral neck fractures were analyzed retrospectively. Treatment modality and displacement were specifically assessed as independent risk factors for reoperation12. For nondisplaced fractures treated with internal fixation, the reoperation rate was 15%. Displaced fractures treated with ORIF had a reoperation rate of 38%, and the rate for those treated with hemiarthroplasty was 7%. Reasons for reoperation were most often nonunion (for those treated with ORIF) and infection (for those treated with hemiarthroplasty). V This study confirmed the high failure rate of internal fixation of displaced femoral neck fractures. Interestingly, nondisplaced fractures that underwent closed reduction and percutaneous pinning still had a 15% failure rate, highlighting the difficulty of treating these fractures in older patients.
¤ A national (mailed) survey following treatment for femoral neck fracture (median follow-up, fourteen months; range, seven to twenty-two months) with total hip arthroplasty, hip hemiarthroplasty, or internal fixation was undertaken to evaluate patientreported perception of recovery13. Visual analog scale scores of pain and satisfaction demonstrated consistent results, with better scores for total hip arthroplasty. Higher EQ-5D (EuroQol, Rotterdam, The Netherlands) scores were also seen in the total hip arthroplasty group. Analysis of subjects who were older and younger than seventy years of age produced consistent results. V Pain, satisfaction, and quality of life following femoral neck fracture are better when treated with total hip arthroplasty. The authors concluded that total hip arthroplasty may be the primary choice for treatment of femoral neck fracture in most patients who are younger than seventy years of age and in older patients who have a long remaining life expectancy. Femur Diagnosis of Associated Femoral Neck and Shaft Fractures ¤ Blinded radiographic analysis of twenty-eight cases of associated femoral neck and shaft fractures, grouped with sixty isolated femoral shaft fractures, was completed by five orthopaedic traumatologists to evaluate the ability to diagnose the fractures through the femoral neck with use of anteroposterior radiographs of the femur and pelvis, as well as computed tomography (CT) scans of the pelvis14. Interobserver agreement was substantial for all imaging modalities. Specificity and 1 minus negative post-test probability were high (>94%) and similar across all modalities. Sensitivity was low and similar across modalities: 51% for the anteroposterior radiographs of the femur, 56% for the anteroposterior radiographs of the pelvis, and 64% for the CT scans of the pelvis. V Similar to previous reports, this study demonstrates the low sensitivity of radiographs and CT in making this diagnosis. The authors recommend vigilance when treating femoral shaft fractures, and they also recommend thorough evaluation of intraoperative and postoperative imaging to diagnose associated femoral neck fractures. Variation of Femoral Neck Version ¤ CT data from a registry of patients treated for femoral fracture were used to analyze femoral neck version in the uninjured limb of 328 subjects, with a focus on sex and ethnic differences15.
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What’s New in Orthopaedic Trauma Mean femoral neck version and standard deviation was 8.84 ± 9.66 of anteversion, with no differences between sexes and among ethnic groups. Although the femoral necks of most subjects were anteverted, there was a large proportion with retroverted femoral necks across all subgroups, with >10 of retroversion seen in 6% of African Americans. V This study presents comparative data across sex and ethnic groups regarding femoral neck version. Most notably, a wide variation was seen across the entire group, and a large proportion of subjects displayed retroverted femoral necks. This has important implications for femoral fracture treatment and implant design. Retrograde Femoral Nailing Through Traumatic Knee Arthrotomies ¤ A retrospective cohort of subjects treated with retrograde femoral nails and with matching of those with (thirty-four) and without (thirty-six) traumatic knee arthrotomies analyzed infection and nonunion outcomes16. No infections and four nonunions occurred in the study group, compared with two infections (p = 1.00) and eight nonunions (p = 0.26) in the matched retrograde group and one infection (p = 0.40) and one nonunion (p = 0.64) in a contemporary group treated with antegrade nails. V This study concludes that retrograde nailing of femoral fractures is associated with similar rates of infection and nonunion when performed through a traumatic knee arthrotomy, as compared with retrograde nailing of femoral fractures without arthrotomy and other methods. This associated injury should not be a contraindication for use of retrograde nailing. The Association of Atypical Femoral Fractures and Bisphosphonates ¤ With use of a systematic literature review and analysis of the United States Food and Drug Administration Adverse Event Reporting System, the association of atypical femoral fractures and bisphosphonate use was explored17. With use of proportional reporting ratios and empiric Bayesian geometric means, the association of bisphosphonates (over other medications) and atypical fractures was confirmed. Using Naranjo and Bradford-Hill criteria for causality, the authors reported a ‘‘probable’’ causal relationship. V Atypical femoral fractures are associated more with bisphosphonate use than with the other medications or comorbidities. Patients should be
counseled, and the duration of treatment should be limited. Aggressive and Limited Debridement of Open Distal Femoral Fractures ¤ A retrospective review of twenty-nine patients who were treated with use of two different institutional protocols (i.e., a more aggressive protocol of removing all devitalized bone and placing an antibiotic cement spacer, and a less aggressive protocol of removing only grossly contaminated bone with retention of other bone fragments and no use of antibiotic cement spacers) was performed to study relative reoperation and infection rates18. Reoperation rates for infection were similar between the more aggressive and less aggressive groups (18% versus 25%, respectively; p = 0.63). Reoperation to achieve union was significantly higher in the more aggressive than in the less aggressive group (65% versus 8%, respectively; p < 0.01). V The authors acknowledge limitations, including potential type-II error and inability to control for the ‘‘aggressiveness’’ of each debridement, but they concluded that retained marginal bone may not be associated with high infection rates and that further study into the definition for adequate debridement for open distal femoral fractures is warranted. Tibia Single Versus Dual-Incision Fasciotomy for Acute Compartment Syndrome ¤ One hundred and seventy-five patients requiring a fasciotomy for acute compartment syndrome after a tibial fracture were identified retrospectively over twelve years. Of those treated with intramedullary nails, thirty-six had a single incision and twentyfour had a dual incision procedure. In the plate group, fifty-nine had a single incision and twentytwo had dual incisions19. In comparing single versus dual incisions: in both groups, the rates of infection and nonunion were similar. The rates of skin-grafting were similar in all groups. V The decision to perform a single or dual-incision fasciotomy should be based on patient factors or surgeon experience rather than suspicion of increased rates of infection or nonunion. Infection After Tibial Plateau Fractures ¤ The rate of infection in 302 patients with bicondylar tibial plateau fractures treated with ORIF over an eight-year period was studied retrospectively20. Forty-three patients (14.2%) developed deep infections requiring reoperation, with methicillin-resistant
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What’s New in Orthopaedic Trauma Staphylococcus aureus (MRSA) identified as the bacterium in twenty (46.5%) of the infections. 81.4% of all patients had external fixation prior to definitive treatment. Open fractures, smoking, fasciotomies, external fixation, and dual-incision and/or dual-plating fracture patterns were all risk factors for deep infection. V Despite the use of a staged protocol and external fixation, deep infections were common. MRSA was common and MRSA-specific prophylaxis may be helpful. Smoking was the only modifiable risk factor noted. Bone and Ligament Injury in Parapatellar Versus Retropatellar Tibial Nailing ¤ Bone loss and soft-tissue injury was compared in thirty-six cadaver knees. A medial parapatellar (flexed-knee) approach was used on eighteen of the knees, and a retropatellar (semi-extended) approach was used on the other eighteen knees21. The amount of bone removed was similar with both approaches. All knees in which the parapatellar technique was used had some intraarticular injury, while only 33% of knees that had the retropatellar approach had injury. The intermeniscal ligament was injured in 83% of knees that had the parapatellar approach and in 56% of knees that had the retropatellar approach. V Substantial anterior tibial bone is removed with both approaches. Intra-articular damage, most often to the intermeniscal ligament, was less frequent with use of the retropatellar approach. Foot and Ankle Syndesmosis ¤ Eighteen patients with a malleolar ankle fracture and syndesmotic injury were treated operatively. Syndesmotic reduction was achieved with use of a clamp and was verified fluoroscopically with use of mortise-view and true talar-dome lateral-view radiographs, with radiographs of the contralateral ankle used for comparison. Reductions were verified intraoperatively with use of a three-dimensional CT scanning system22. Using this fluoroscopic method, seventeen of eighteen syndesmoses were accurately reduced on the basis of CT imaging. V Comparing the tibiofibular relationship on a perfect-lateral-view radiograph to the relationship on the contralateral side is a promising technique for the assessment of syndesmotic reduction intraoperatively. Of note, this study used CTevaluation of only the injured ankle and may not have accounted for subtle anatomic variances.
¤ Thirty-six patients with syndesmotic injuries had intraoperative syndesmotic reduction performed with use of either standard fluoroscopy or threedimensional CT. Quality of reduction was assessed with use of postoperative CT23. With a 1-mm difference used as a threshold for malreduction, 55% in the standard group and 50% in the three-dimensional CT group had malreduction. V Without use of the contralateral side for comparison, neither standard fluoroscopic nor intraoperative three-dimensional CT provides consistent syndesmotic reduction. ¤ Syndesmosis injuries were created in fourteen cadaver legs. A variety of well-controlled clamp placements and screw insertions were performed, and CT scans assessed the effect on syndesmotic reduction24. Clamps placed at 15 and 30 relative to the neutral axis of the ankle (from posterior on the fibula to anterior on the tibia) caused significant external rotation and overcompression of the syndesmosis. A variety of screw vectors also contributed to syndesmotic malreduction. V This study highlights the sensitivity of clamp position and vector in malreducing the syndesmosis. Additionally, a substantial number of syndesmoses became overcompressed, which corroborates previous data25. The clamp force used in this study was not specified. ¤ Thirty-seven patients with syndesmotic injuries treated with sixty-four TightRopes (Arthrex, Naples, Florida) were assessed radiographically and clinically at a mean of twenty-four months. In 73% of patients, two suture buttons were used26. The mean changes in radiographic measurements were all 30), and obesity combined with preoperative leukocytosis were associated with significantly increased odds of wound infection. Notable unassociated variables included preoperative fever, leukocytosis in
isolation, other system infection, other open fractures, and transfusion. Preoperative angioembolization demonstrated a higher odds ratio for wound infection (11.14) and a high positive predictive value (66.7%), but those values failed to reach significance. V This study concluded that obesity, an ISS of >16, and preoperative angioembolization are risk factors for deep wound infection after operative treatment of pelvic and acetabular fractures. Polytrauma patients, particularly the obese, should be treated with additional concern regarding this complication and should be appropriately counseled. Mangled Limbs with Foot and Ankle Injuries ¤ A subset (n = 182) of the Lower Extremity Assessment Project (LEAP) study cohort, whose injuries included fractures of the foot and ankle (including pilon fractures), was analyzed to compare two-year outcomes between patients with standard below-the-knee amputation and limb salvage, with additional analysis of the effect of free tissue transfer and/or ankle arthrodesis30. There were no differences between salvage and amputation in overall, physical, and psychosocial Sickness Impact Profile scores between patients who underwent limb salvage and those who underwent amputation. However, regression analysis that took into consideration the additional need for free flap and/or ankle arthrodesis demonstrated clinically and significant worse overall and psychosocial outcomes in this group as compared with the group that had salvage without free flap and/or arthrodesis and below-the-knee amputation. The best overall and psychosocial scores were in the salvage without free flap and/or arthrodesis group, but this did not reach significance (p = 0.34 and p = 0.20). V Limb-salvage decision making remains a challenging case-by-case conundrum. Patients with foot and ankle fractures who require free tissue transfer or ankle arthrodesis for limb salvage should be counseled regarding worse expected outcomes compared with below-the-knee amputation. Nonunion, Infection, and Wound Management Prediction of Tibial Nonunion ¤ Clinical vignettes (including radiographic images) representing fifty-six patients treated with intramedullary nails for tibial fractures that had incomplete healing at three months were presented to three fellowship-trained trauma surgeons. Surgeons were asked to predict if the fractures would progress to union31.
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What’s New in Orthopaedic Trauma The diagnostic accuracy of all three surgeons was 74%; sensitivity, 62%; and specificity, 77%. V Experienced surgeons can accurately predict healing or nonunion in a majority of patients at three months after tibial nailing. The authors suggest that a protocol of waiting six months before considering reoperation in all such patients may be unnecessary. Lidocaine for Vacuum-Assisted Closure (VAC) Dressing Changes ¤ A randomized double-blinded placebo-controlled trial compared pain and narcotic requirement after extremity wound VAC dressing changes at the bedside (n = 21 VAC changes) with use of topical lidocaine or normal saline solution32. The lidocaine-treated patients had 2.4 points less on a 0 to 10 visual analog scale for pain and used 1.7 mg less morphine-equivalents. V Pretreatment with topical lidocaine decreased pain and narcotic requirement in patients undergoing extremity wound VAC dressing changes at the bedside. Preoperative Diagnosis of Infection in Patients with Nonunion ¤ A review of ninety-five nonunions evaluated the utility of evaluating preoperative white blood-cell count, C-reactive protein, erythrocyte sedimentation rate, and white blood cell/sulfur colloid scan to rule out infection33. 31.5% of the nonunions were ultimately infected. Excluding bone scan, the predictive probability of infection with zero, one, two, and three positive tests was 19.6%, 18.8%, 56.0%, and 100.0%, respectively. Erythrocyte sedimentation rate and C-reactive protein were independent accurate predictors of infected nonunion. V Common serologic tests can accurately stratify risk of infection for nonunion. A white blood-cell scan or sulfur-colloid bone scan is not recommended. Protocol for Presumptive Aseptic Nonunion ¤ A retrospective review of eighty-seven patients with presumed aseptic nonunion (by history and physical examination) and treated with a single-stage repair was used to compare results among those with positive intraoperative cultures and those with negative cultures34. Unexpected positive cultures were found in 28.7%. Secondary surgery was required more often in patients with positive cultures (28%) than in those without positive cultures (6.4%; p = 0.01). V Single-stage nonunion repair for presumed aseptic nonunion is supported. Patients with unexpected
positive cultures healed without need for reoperation in 72% of cases. Bone-Marrow Injection for Tibial Nonunions ¤ Eleven patients with nonunion or delayed union of the distal tibial metaphysis following ORIF were treated with 40 to 80 mL of bone marrow aspirate from the posterior iliac crest35. Nine of eleven had osseous union within six months following injection. Six of the nine had long-term follow-up (1.3 to 8.2 years) and reported substantial improvement. V With distal tibial nonunions and delayed unions with intact and stable implants, percutaneous bone-marrow injection is an effective treatment option. Basic Science Screw Biomechanics ¤ Five pairs of cadaveric humeri from three different bone mineral density groups (normal, osteopenic, osteoporotic) were drilled. Maximum torque (Tmax) was measured with 3.5-mm cortical screws, and additional screws were placed at 50%, 70%, and 90% of the Tmax. Pullout strength was then measured, and cortical thickness and bone mineral density were controlled36. In osteoporotic and normal bone, the pullout strength was greatest for screws inserted to 50% of Tmax. This strength was not significantly greater than that for screws inserted to 70% and 90% of Tmax. V This study concluded that no benefit in pullout strength is gained by approaching the maximum insertion torque and risking stripping the screw. The main caveat is that the pullout strength of a screw may not always be an appropriate surrogate for clinical fixation failure, as very rarely are plate screws subjected to axial forces leading to direct pullout. ¤ Synthetic and cadaveric bone models were predrilled, and 3.5-mm self-tapping cortical screws with washers were completely inserted between one and five times into the same hole. Pullout strength was then measured37. In all specimens, both cadaveric and synthetic, pullout strength decreased as the screws were reinserted into the same predrilled hole. V Many situations may lead to screw reinsertions intraoperatively, such as fracture realignment, plate repositioning, or screw-size changing. When performing one of these interventions, the surgeon should be aware that there may be a small price to pay regarding fixation strength.
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What’s New in Orthopaedic Trauma ¤ Twenty-five 3.5-mm locking screws were inserted into standard locking plates and a foam-bone surrogate to 1.7 N-m torque. Multiple insertion axes were used to test the effect on various degrees of cross-threading on bending strength38. As insertion angle increased, the bending strength decreased. Screws inserted at 3 or below failed by way of screw deformation; greater insertion angles failed by means of screw disengagement. V Although nonvariable angle locking screws are designed to be placed through threaded guides or physical jigs, cross-threading occurs occasionally. The surgeon should be aware that greater than 3 of deviation from the perpendicular axis substantially
diminishes the mechanical strength of the locking screw mechanism.
William M. Ricci, MD Michael Linn, MD Michael Gardner, MD Christopher McAndrew, MD Washington University Orthopedics, Campus Box 8233, 660 South Euclid Avenue, St. Louis, MO 63110. E-mail address for W.M. Ricci: [email protected]
References 1. Galdi B, Yoon RS, Choung EW, Reilly MC, Sirkin M, Smith WR, Liporace FA. Anteroinferior 2.7-mm versus 3.5-mm plating for AO/OTA type B clavicle fractures: a comparative cohort clinical outcomes study. J Orthop Trauma. 2013 Mar;27(3): 121-5. 2. Chen F, Wang Z, Bhattacharyya T. Outcomes of nails versus plates for humeral shaft fractures: a Medicare cohort study. J Orthop Trauma. 2013 Feb;27(2): 68-72. 3. Argintar E, Cohen M, Eglseder A, Edwards S. Clinical results of olecranon fractures treated with multiplanar locked intramedullary nailing. J Orthop Trauma. 2013 Mar;27(3):140-4. 4. Duckworth AD, Bugler KE, Clement ND, Court-Brown CM, McQueen MM. Nonoperative management of displaced olecranon fractures in low-demand elderly patients. J Bone Joint Surg Am. 2014 Jan 1;96(1):67-72. 5. Paschos NK, Mitsionis GI, Vasiliadis HS, Georgoulis AD. Comparison of early mobilization protocols in radial head fractures. J Orthop Trauma. 2013 Mar;27(3):134-9. 6. Foruria AM, Augustin S, Morrey BF, Sa´ nchez-Sotelo J. Heterotopic ossification after surgery for fractures and fracture-dislocations involving the proximal aspect of the radius or ulna. J Bone Joint Surg Am. 2013 May 15;95(10):e66. 7. Gary JL, Mulligan M, Banagan K, Sciadini MF, Nascone JW, O’toole RV. Magnetic resonance imaging for the evaluation of ligamentous injury in the pelvis: a prospective case-controlled study. J Orthop Trauma. 2014 Jan;28(1):41-7. 8. Harvey-Kelly KF, Kanakaris NK, Obakponovwe O, West RM, Giannoudis PV. Quality of life and sexual function after traumatic pelvic fracture. J Orthop Trauma. 2014 Jan;28(1):28-35. 9. Archdeacon MT, Kazemi N, Collinge C, Budde B, Schnell S. Treatment of protrusio fractures of the acetabulum in patients 70 years and older. J Orthop Trauma. 2013 May;27(5):256-61. 10. Bigsby E, Acharya MR, Ward AJ, Chesser TJ. The use of blood cell salvage in acetabular fracture internal fixation surgery. J Orthop Trauma. 2013 Oct;27(10):e230-3. 11. Hou Z, Bowen TR, Irgit KS, Matzko ME, Andreychik CM, Horwitz DS, Smith WR. Treatment of pertrochanteric fractures (OTA 31-A1 and A2): long versus short cephalomedullary nailing. J Orthop Trauma. 2013 Jun;27(6):318-24. 12. Murphy DK, Randell T, Brennan KL, Probe RA, Brennan ML. Treatment and displacement affect the reoperation rate for femoral neck fracture. Clin Orthop Relat Res. 2013 Aug;471(8):2691-702. Epub 2013 May 3. ˚ 13. Leonardsson O, Rolfson O, Hommel A, Garellick G, Akesson K, Rogmark C. Patient-reported outcome after displaced femoral neck fracture: a national survey of 4467 patients. J Bone Joint Surg Am. 2013 Sep 18;95(18):1693-9. 14. O’toole RV, Dancy L, Dietz AR, Pollak AN, Johnson AJ, Osgood G, Nascone JW, Sciadini MF, Castillo RC. Diagnosis of femoral neck fracture associated with femoral shaft fracture: blinded comparison of computed tomography and plain radiography. J Orthop Trauma. 2013 Jun;27(6):325-30. 15. Koerner JD, Patel NM, Yoon RS, Sirkin MS, Reilly MC, Liporace FA. Femoral version of the general population: does ‘‘normal’’ vary by gender or ethnicity? J Orthop Trauma. 2013 Jun;27(6):308-11. 16. Bible JE, Kadakia RJ, Choxi AA, Bauer JM, Mir HR. Analysis of retrograde femoral intramedullary nail placement through traumatic knee arthrotomies. J Orthop Trauma. 2013 Apr;27(4):217-20.
17. Edwards BJ, Bunta AD, Lane J, Odvina C, Rao DS, Raisch DW, McKoy JM, Omar I, Belknap SM, Garg V, Hahr AJ, Samaras AT, Fisher MJ, West DP, Langman CB, Stern PH. Bisphosphonates and nonhealing femoral fractures: analysis of the FDA Adverse Event Reporting System (FAERS) and international safety efforts: a systematic review from the Research on Adverse Drug Events And Reports (RADAR) project. J Bone Joint Surg Am. 2013 Feb 20;95(4): 297-307. 18. Ricci WM, Collinge C, Streubel PN, McAndrew CM, Gardner MJ. A comparison of more and less aggressive bone debridement protocols for the treatment of open supracondylar femur fractures. J Orthop Trauma. 2013 Dec;27(12):722-5. 19. Bible JE, McClure DJ, Mir HR. Analysis of single-incision versus dual-incision fasciotomy for tibial fractures with acute compartment syndrome. J Orthop Trauma. 2013 Nov;27(11):607-11. 20. Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM, Obremskey WT. Risk factors of infection after ORIF of bicondylar tibial plateau fractures. J Orthop Trauma. 2013 Sep;27(9):e196-200. 21. Bible JE, Choxi AA, Dhulipala S, Evans JM, Mir HR. Quantification of anterior cortical bone removal and intermeniscal ligament damage at the tibial nail entry zone using parapatellar and retropatellar approaches. J Orthop Trauma. 2013 Aug;27(8): 437-41. 22. Summers HD, Sinclair MK, Stover MD. A reliable method for intraoperative evaluation of syndesmotic reduction. J Orthop Trauma. 2013 Apr;27(4): 196-200. 23. Davidovitch RI, Weil Y, Karia R, Forman J, Looze C, Liebergall M, Egol K. Intraoperative syndesmotic reduction: three-dimensional versus standard fluoroscopic imaging. J Bone Joint Surg Am. 2013 Oct 16;95(20):1838-43. 24. Miller AN, Barei DP, Iaquinto JM, Ledoux WR, Beingessner DM. Iatrogenic syndesmosis malreduction via clamp and screw placement. J Orthop Trauma. 2013 Feb;27(2):100-6. 25. Phisitkul P, Ebinger T, Goetz J, Vaseenon T, Marsh JL. Forceps reduction of the syndesmosis in rotational ankle fractures: a cadaveric study. J Bone Joint Surg Am. 2012 Dec 19;94(24):2256-61. 26. Rigby RB, Cottom JM. Does the Arthrex TightRope provide maintenance of the distal tibiofibular syndesmosis? A 2-year follow-up of 64 TightRopes in 37 patients. J Foot Ankle Surg. 2013 Sep-Oct;52(5):563-7. Epub 2013 Jun 14. 27. Vallier HA, Super DM, Moore TA, Wilber JH. Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course. J Orthop Trauma. 2013 Jul;27(7): 405-12. 28. Matityahu A, Marmor M, Elson JK, Lieber C, Rogalski G, Lin C, Belaye T, Miclau T 3rd, Kandemir U. Acute complications of patients with pelvic fractures after pelvic angiographic embolization. Clin Orthop Relat Res. 2013 Sep;471(9): 2906-11. 29. Sagi HC, Dziadosz D, Mir H, Virani N, Olson C. Obesity, leukocytosis, embolization, and injury severity increase the risk for deep postoperative wound infection after pelvic and acetabular surgery. J Orthop Trauma. 2013 Jan;27(1): 6-10. 30. Ellington JK, Bosse MJ, Castillo RC, MacKenzie EJ, Group LS; LEAP Study Group. The mangled foot and ankle: results from a 2-year prospective study. J Orthop Trauma. 2013 Jan;27(1):43-8.
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What’s New in Orthopaedic Trauma 31. Yang JS, Otero J, McAndrew CM, Ricci WM, Gardner MJ. Can tibial nonunion be predicted at 3 months after intramedullary nailing? J Orthop Trauma. 2013 Nov; 27(11):599-603. 32. Christensen TJ, Thorum T, Kubiak EN. Lidocaine analgesia for removal of wound vacuum-assisted closure dressings: a randomized double-blinded placebocontrolled trial. J Orthop Trauma. 2013 Feb;27(2):107-12. 33. Stucken C, Olszewski DC, Creevy WR, Murakami AM, Tornetta P. Preoperative diagnosis of infection in patients with nonunions. J Bone Joint Surg Am. 2013 Aug 7;95(15):1409-12. 34. Amorosa LF, Buirs LD, Bexkens R, Wellman DS, Kloen P, Lorich DG, Helfet DL. A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions: a review of outcomes. J Orthop Trauma. 2013 Oct;27(10):582-6.
35. Braly HL, O’Connor DP, Brinker MR. Percutaneous autologous bone marrow injection in the treatment of distal meta-diaphyseal tibial nonunions and delayed unions. J Orthop Trauma. 2013 Sep;27(9):527-33. 36. Tankard SE, Mears SC, Marsland D, Langdale ER, Belkoff SM. Does maximum torque mean optimal pullout strength of screws? J Orthop Trauma. 2013 Apr;27(4):232-5. 37. Matityahu A, Hurschler C, Badenhop M, Stukenborg-Colsman C, Waizy H, Wentz B, Marmor M, Krettek C. Reduction of pullout strength caused by reinsertion of 3.5-mm cortical screws. J Orthop Trauma. 2013 Mar;27(3):170-6. 38. Cartner JL, Petteys T, Tornetta P 3rd. Mechanical effects of off-axis insertion of locking screws: should we do it? J Orthop Trauma. 2014 Apr; 28(Suppl 1):S2-5.
