Journal of Orthopaedic Trauma最新文献

Summary: Anterior pelvic fixation is increasingly cited as a potentially important component of stable fixation for unstable anterior posterior compression (APC) and lateral compression (LC) pelvic ring injuries. Although anterior fixation constructs are frequently supplemented with the addition of percutaneous posterior fixation, this is not always possible given the degree of injury and/or coexisting sacral dysmorphism. Therefore, efforts should be made to maximize the strength of anterior fixation for these injuries. Superior pubic symphyseal plating has long been the gold standard for APC injuries because of ease of access and ability for long screws. Anterior-based plates additionally have been proposed for use in dual plating but only allow for short-caliber anterior to posterior screws in the pubic rami and ultimately have not been widely adopted. This article proposes and describes a novel technique of an anteriorly based "W-plate" with multiplanar screw trajectories that can be advanced through longer bony corridors in the pelvis as compared with existing strategies. Using a contoured, 5-hole reconstruction plate, the W-plate allows for anterior column (retrograde superior rami) screws to stabilize the anterior plating construct. This article details the W-plate technique and an associated case series of its use at multiple institutions.

Objectives: To quantify the morphology of an avascular "safe zone" within the obturator foramen to assess the risk of neurovascular injury with transobturator foramen cerclage.

Methods:

Design: Retrospective chart review.

Setting: Level 1 trauma center and tertiary academic center.

Patient selection criteria: Adults ≥18 years without prior pelvic pathology and with pelvic computed tomography angiography demonstrating complete visualization of the obturator arteries.

Outcome measures and comparisons: The minimum distance from the medial cranial border of the obturator foramen to the obturator artery (DOA) and the obturator foramen area (OFA) bounded by the obturator artery and pubis were measured on computed tomography angiography in the plane of the obturator foramen. Associations of OFA and DOA with demographic and anthropometric variables were analyzed by multivariable linear regression. The "safe zone" for passage of transobturator cerclage instrumentation was determined by the 5.0 mm outer diameter of a commercially available cable passer.

Results: The sample included 60 adults, 35 men (58.3%), with a mean age of 56.2 ± 16.4 years. The mean DOA (left 6.8 ± 1.9 mm, right 6.9 ± 1.6 mm, P = 0.724) and OFA (left 195.1 ± 63.3 mm 2 , right 190.3 ± 55.4 mm 2 , P = 0.657) did not vary by laterality. DOA was >3.2 mm for all patients but <5.0 mm in 23.3% of patients. Multivariable analysis indicated that DOA was associated with patient height (β = 0.04, P = 0.019) but not sex (β = 0.01, P = 0.987) or weight (β = 0.01, P = 0.253).

Conclusions: A "safe zone" defined by the obturator artery and cranial and medial obturator foramina exists for internal fixation of the anterior pelvic ring by transobturator foramen cerclage. Although a cerclage device ≤3.2 mm in diameter seems safe, passage of a cerclage wire through the cranial and medial obturator foramina for internal fixation anterior pelvic ring disruption with typical instrumentation may injure the obturator neurovascular bundle without additional surgical dissection.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Summary: Hexapod external fixators are a sophisticated class of devices that are commonly used in the management of complex trauma, limb deformity, limb reconstruction, and/or limb lengthening. They are distinguished using 6 length adjustable struts that typically connect a pair of ring components to one another. These rings serve as proximal and distal fixation to skeletal segments and can be very precisely manipulated with respect to one another across 6 degrees of freedom using dedicated software for planning purposes.

Objectives: To compare time, fluoroscopic utilization, and number of misses for placement of far interlocking screws in tibial and femoral nails using a targeting arm (Targeter) versus perfect circle technique (Control).

Methods: .

Design: Prospective randomized controlled trial.

Setting: Single-center, large, urban, level 1 trauma center.

Patient selection criteria: Patients ≥18 years old with a tibia or femur fracture (AO/OTA 31A, 32, or 42) treated with an intramedullary nail from November 2022 to December 2023 were included.

Outcome measures and comparisons: The main outcome measures were number of fluoroscopy images taken and average time elapsed to place each far interlocking screw. The far interlocking screws were defined as the screws farthest from the insertion handle. Comparisons were made between the Targeter and Control cohorts in terms of number of fluoroscopy images taken and average time elapsed to place each far interlocking screw, and the number of misses.

Results: Thirty-one patients were randomized to Targeter and 31 to Control. There were no significant differences between the Targeter and Control cohorts in patient sex (58.6% vs. 54.5% women, P = 0.75), age (range (20-90 vs. 18-91, mean 52.7 vs. 54.2, P = 0.81), BMI (mean 25.9 vs. 26.2, P = 0.66), AO classification (13.8% vs. 36.4% 31 A, 37.9% vs. 21.2% 32, 48.2% vs. 42.4% 42, P = 0.20), or number of open fractures (13.8% vs. 7.1%, P = 0.67) between the 2 cohorts. For the Targeter group, fewer images were used than Controls for the first (15.0 vs. 22.5, P = 0.002), second (11.5 vs. 18.0, P = 0.006), and combined first and second (25.0 vs. 39.0, P = 0.001) screws. There was no difference between the Targeter and Control cohorts in the time it took to place the first (6.3 vs. 7.3 minutes, P = 0.31), second (5.8 vs. 6.2 minutes, P = 0.63), or combined first and second (11.9 vs. 13.7 minutes, P = 0.63) screws. In the Control cohort, there was 1 missed screw (1.4%, n = 69). In the Targeter cohort, there were 3 missed screws (5.4%, n = 56), a 4-fold increase that did not reach statistical significance ( P = 0.31).

Conclusions: In this prospective randomized controlled trial, a targeting arm decreased the number of fluoroscopic images used for all far interlocking screws as compared with the perfect circle technique without a reduction in time. There was a trend toward increased misses in the Targeter cohort ( P = 0.31). Although the reduction in radiation exposure may have a cumulative beneficial effect during the course of a surgeon's career, the trend of increased misses with the Targeter should be taken into account.

Level of evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The traditional lateral window of the ilioinguinal approach for open sacroiliac joint reduction provides limited visualization of the L5 nerve root as well as the anterior aspect of the sacral ala and SI joint. Adding an anterior superior iliac spine (ASIS) osteotomy may enhance exposure and improve safety and ease of reduction. This cadaveric study evaluates whether ASIS osteotomy significantly increases SI joint visualization compared to the standard lateral window.

Methods: Four fresh-frozen cadaveric specimens (8 SI joints) underwent lateral window exposure. Kirschner wires marked visible osseous boundaries, and calibrated digital images were obtained. A digastric ASIS osteotomy was then performed, preserving external oblique insertion. The ASIS was reflected medially to enhance visualization, and the most medial Kirschner wires were repositioned to reflect the expanded view. Images were re-captured and analyzed using ImageJ software. Surface area exposure before and after osteotomy was compared using a paired t-test.

Results: The lateral window initially provided a mean SI joint exposure of 53.4 cm2 ± 17.3 cm2. Following ASIS osteotomy, mean exposure significantly increased to 88.0 cm2 ± 26.6 cm2 (P=0.04). The mean relative increase in exposure after the osteotomy was 70% ± 24%.

Conclusions: In this cadaveric study, the addition of an ASIS osteotomy to the traditional lateral window of the ilioinguinal approach resulted in a significant increase in SI joint visualization. The enhanced exposure may facilitate more accurate reduction and safer instrumentation. These findings suggest that the ASIS osteotomy may be a beneficial adjunct to the lateral window for management of complex SI joint pathology.

Summary: Complex distal tibial injuries with segmental bone loss, joint destruction, and osteomyelitis present a formidable limb salvage challenge. A novel technique using circular external fixation with trifocal balanced cable transport combined with primary ankle arthrodesis is described. This technique allowed early weightbearing, soft tissue preservation, and alignment correction, while minimizing time in external fixation. Despite the risk of complications such as docking site nonunion and pin tract infections, adjunctive staged conversion to internal fixation mitigated these concerns. This report is the first to describe automated balanced cable trifocal transport with speed multiplier pulleys to the talus for ankle arthrodesis. The approach offers a powerful option for limb salvage in patients with complex distal tibial and osteochondral defects while minimizing external fixation time.

Objectives: To examine the impact of frailty on 30-day outcomes of ORIF alone or ORIF+THA (fix-and-replace) for the treatment of acetabular fractures.

Methods: Design: Retrospective Cohort.

Setting: 700 hospitals in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

Patient selection criteria: Included were patients aged 60 years or older undergoing ORIF+/-THA for OTA/AO type 62 A-C fractures from 2015-2020.

Outcome measures and comparisons: Preoperative frailty was assessed by the revised Risk Analysis Index (Not frail: <21, pre-frail: 21-30, frail: 31-40, severely frail: >40) and the 5-Item Modified Frailty Index (mFI-5) factor. All outcome measures were in-hospital or within 30 days postoperatively, including the 'favorable outcome', defined as: no readmission, length of stay

Results: There were 585 patients included [ORIF (88%): mean age - 70.5 ± 14.2, sex - 41.4% female; ORIF+THA (12%): mean age - 77.0 ± 13.4; sex - 65.7% female]. Frail patients (n=353, 65.5%) were more likely to experience a complication (OR: 3.31, CI: [1.83-5.96]) and mortality (3.7% vs. 0.0%). ORIF+THA had higher association with postoperative transfusion (OR: 2.70, CI: [1.63-4.48]) but lower association with length of stay >3 days (OR: 0.41, CI: [0.24-0.72]) and non-home discharge (OR: 0.52, CI: [0.27-0.98]) than ORIF. Pre-Frail and Frail patients undergoing ORIF+THA were more likely to achieve favorable outcomes than those non-frail or severely frail (OR: 9.69, [3.40-27.57]).

Conclusions: Surgical intervention for acetabular fractures carried a 30-day complication risk of 12-19% for frail patients. Frailty had similar predictability to age for early morbidity following surgery to treat acetabular fractures. Open reduction and internal fixation with the addition of an acute total hip arthroplasty was associated with a higher rate of blood transfusion and shorter hospital length of stay in frail patients with acetabular fractures.

Level of evidence: III.

Objectives: To determine the rate of successful humeral shaft nonunion repair in patients with no prior surgery on the humerus (failed nonoperative management), compared with patients with a history of surgery on the humerus (initial operative treatment complicated by nonunion, or prior attempted nonunion repair after failed nonoperative management).

Methods:

Design: Retrospective.

Setting: Two academic trauma centers (1 level 1 and 1 level 2).

Patient selection criteria: All skeletally mature patients undergoing nonunion repair of a presumed aseptic humeral shaft nonunion (AO/OTA 11A, 11B, 11C, 12A, 12B, 12C) were eligible for inclusion.

Outcome measures and comparisons: The primary outcome was osseous union. Univariate analysis was used to examine patient, injury, and treatment factors associated with recalcitrant nonunion between those with and without prior surgery.

Results: One hundred fifty-nine patients were included. Eighty-two patients had a history of operative treatment. The group with prior operative treatment was significantly younger (47 vs. 52, P = 0.047) and had fewer comorbidities (average Charlson comorbidity score 1.3 vs. 1.9, P = 0.015). There were 34 men in the group with prior operative treatment, compared with 37 in the group without prior operative treatment ( P = 0.493). For patients with prior operative treatment, 17 of 82 (21%) patients developed a recalcitrant nonunion, versus 2 of 79 (3%) patients with no prior operative treatment ( P < 0.001). The number of prior operations on the arm was significantly associated with increased risk of recalcitrant nonunion (3% risk if no prior surgeries, 19% risk with 1 prior surgery, 25% risk with 2 prior surgeries, 33% risk with 3 prior surgeries, P = 0.004). No demographic factors were associated with development of a recalcitrant nonunion ( P > 0.05 for all). Nine patients had unexpected positive cultures, but this was not associated with increased risk of recalcitrant nonunion (22% in patients with infection vs. 26% in those without infection, P = 0.907).

Conclusions: Patients undergoing nonunion repair after prior operative treatment of a humeral shaft fracture had a 1 in 5 rate of recalcitrant nonunion, while patients undergoing initial nonunion repair after failed nonoperative management had a 3 in 100 rate of recalcitrant nonunion. Increased risk of persistent nonunion stemmed not from initial treatment strategy for the acute fracture, but rather from the presence of any prior surgery.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.