Summary: Lateral compression (LC) 3 pelvic ring injuries are high energy, complex patterns that may include a "crescent fracture," which is an important consideration when determining the appropriate fixation tactic. This review discusses the reduction and fixation of a pediatric LC3 pelvic ring injury with particular focus on the open and percutaneous techniques for treatment of a crescent fracture.
Objectives: To identify patient, injury, and surgical characteristics associated with success or failure of Masquelet's induced membrane technique (IMT) for acute traumatic bone loss.
Methods: Design: Retrospective cohort study.
Setting: Four Level 1 Academic Trauma Centers.
Patients selection criteria: Patients acutely treated with IMT for AO/OTA 32, 33, and 41-43 fractures with bone loss at four Level 1 trauma centers between 2010-2020.
Outcome measure and comparisons: Primary outcome was fracture union with comparison between union after initial two stage IMT versus patients who underwent reoperation to promote union or experienced treatment failure defined as: amputation, implant dependent, or persistent nonunion. Variables of interest included demographic variables, injury characteristics, and differences in surgical management (definitive fixation construct, autograft source, use of graft adjuvants).
Results: 130 fractures with defects were treated with IMT, including 72 tibial fractures and 58 femoral fractures with an average defect length of 6.4cm. Average age of patients was 40 years (range 16 to 68 years) and 65 percent of patients were male. Demographic characteristics including age, sex, BMI, tobacco and alcohol use were not significantly different among treatment outcomes (p >.05). Initial success after two stage IMT was 57.7% (75/130) and 82% (107/130) after subsequent reoperation. Increasing defect length was associated with failure of IMT (mean 5.4 vs 8.3cm, p=.03). Deep infection after stage 2 surgery was associated with reoperation to promote union and treatment failure (p<.01).
Conclusions: In this study of acute traumatic bone loss, shorter defect length and absence of infection were significantly associated with success of IMT. Meanwhile fixation construct and autograft choice were not associated with treatment outcome.
Level of evidence: III retrospective comparative cohort series.
Objective: To examine the relationship between industry payments to surgeons and total cost of orthopaedic trauma surgery. Secondarily, to investigate the relationship between surgeon industry payments and operating room cost, length of stay, 30-day mortality, and 30-day readmission.
Methods: Design: Retrospective cross-sectional database study with minimum 30-day follow-up.
Setting: 20% sample of Medicare beneficiaries from January 2006 to December 2015 from the Medicare database.
Patient selection criteria: Medicare-insured patients undergoing orthopaedic trauma surgery identified by CPT codesOutcome Measures and Comparisons: The primary outcomes were the risk-adjusted relationship between amount of industry payments to surgeons and the total and operating costs. The secondary outcomes were the risk-adjusted relationships between amount of industry payments to surgeons and hospital length of stay, mortality, and readmission.
Results: 99.9% of orthopaedic trauma surgeons (n=9,023) received industry payments. Median patient age was 82 (IQR: 15), 73.2% female, 91.5% White, and with multiple comorbidities (CCI median [IQR] 6 [4]). After multivariable risk adjustment, for each $1,000 increase in surgeon industry payments, total and operating room cost of cases increased by $2.25 and $1.26 (0.003% and 0.008% of total cost), respectively (p<0.001). The median industry payment was $607.72 compared to the mean of $12,070.84 indicating a highly right-skewed distribution of payments. Amount of industry payments were not associated with length of stay (p=0.18), 30-day mortality (p=0.094) or readmission (p=0.59) after orthopaedic trauma surgery. Total and operating room cost was approximately $8,920 (17.8%) and $1,481 (14.2%) higher for surgeons receiving the highest 5% of industry payments (p<0.001). These surgeons generally practiced in large urban areas (51.7%; p<0.001), in hospitals with higher number of beds (median 398; p<0.001), with higher wage index (0.96; p<0.001).
Conclusions: and Relevance: While most orthopaedic trauma surgeons received industry payments, a minority of surgeons received the majority of payments. Although industry payments may lead to conflicts for some surgeons, these conflicts affect only a small proportion of the cost of fracture care.
Level of evidence: Prognostic Level III.
Objectives: To assess the clinical and radiographic outcomes of a consecutive series of patellar fractures treated utilizing an anatomically contoured variable-angle patellar plating system (PPS) (Synthes; Paoli, PA).
Methods: Design: Retrospective chart review.
Setting: Single, academic, Level-1 Trauma center.
Patient selection criteria: All adult patients who underwent fixation of a patellar fracture (AO/OTA 34) with the PPS between 2021 and 2024 with a minimum follow-up of 3 months. Post-operatively, full extension was maintained for six weeks.
Outcome measures and comparisons: The primary outcome was fixation failure. Secondary outcomes included range of motion (ROM) at final follow-up, knee pain due to symptomatic implants, infection, and reoperation. Deep infection was defined as a return to the operating room for irrigation and debridement.
Results: There was a total of 61 patients with a mean age of 54 years (19-92 years). The cohort consisted of 32 females (52%) with a mean BMI of 27 kg/m2 (18-42 kg/m2). Fifteen patients (25%) had diabetes and 16 patients were smokers (26%). The average follow-up was 7 months (range 3 - 26 months).There were 2 34A1 fractures, 1 34B1 fracture, 16 34C1 fractures, 10 34C2 fractures, and 32 34C3 fractures. There were 6 open fractures (1%), 2 type II and 4 type IIIA.There were 54 (89%) patients who achieved uneventful healing. Seven patients (11%) experienced a postoperative complication. One patient developed a superficial wound infection which resolved with oral antibiotic therapy, 3 patients developed arthrofibrosis necessitating further intervention, 2 patients experienced fixation failure with one requiring revision fixation, and 1 patient developed osteomyelitis and underwent implant removal after fracture union. Of the 3 patients with arthrofibrosis one underwent manipulation under anesthesia, and two underwent arthroscopic lysis of adhesions.
Conclusions: The PPS may be utilized to stabilize challenging patellar fractures, leading to reliable union and minimal implant-related complications when associated with a post-operative protocol of full extension maintained for six weeks.
Level of evidence: Level IV.
Objective: To determine if fixation within 48 hours from injury reduces risk for transfusion in geriatric patients with acetabular fractures.
Methods: Design: Retrospective.
Setting: Single Level I Trauma Center (2010-2023).
Patient selection criteria: Patients above 65 years of age with open reduction internal fixation (ORIF) for acetabular fractures (AO/OTA 62) were identified using Current Procedural Terminology codes. Patients managed non-operatively, with closed reduction percutaneous fixation, acute total hip arthroplasty, staged ORIF and patients with operations with any blood loss prior to acetabular ORIF were excluded.
Outcome measures and comparisons: The primary outcome was differences in transfusion requirements between patients who had early fixation (within 48 hours) and those who had delayed fixation (after 48 hours). Secondary outcomes included differences in length of stay (LOS), estimated blood loss (EBL), surgical site infection (SSI), and mortality. Logistic regression for likelihood of transfusion during hospitalization and SSI were done and included surgical timing, surgical approach, hemoglobin at admission, TXA administration, preoperative transfusion, and intraoperative transfusion.
Results: Of 132 patients included in the study, 86 (65.9%) underwent early fixation and 45 (34.1%) delayed fixation. The early fixation group had an average age of 73.8 (65-89) and the delayed group of 73.4 (65-89) (p=0.797) and both had male majority (63.2% and 73.3%, respectively). Early fixation group had less injuries from high energy trauma (52.3% vs 75.0%;p=0.013) but no difference in injury severity scores (9 vs 11.1;p=0.184) or complex fracture patterns (69.0% vs 68.9%;p=0.993). Patients with early fixation had higher rates of anterior approaches (58.6% vs 35.6%;p=0.042) and shorter surgical time (136 vs 169 min;p=0.013). There was no statistically significant difference in rates of transfusion between early and delayed fixation (62.1% vs 73.3%;p=0.196). Early fixation group had more units of blood during overall hospital stay (5.1 vs 2.4; p=0.003). Early fixation was also associated with shorter LOS (7.1 days vs 13.5 days; p<0.001). There was no significant difference in EBL, SSI or mortality. Surgical timing did not independently influence SSI risk (p=0.913) or likelihood of transfusion (p=0.273) but early fixation increased the volume of units transfused (p=0.0143).
Conclusion: Early fixation was associated with shorter LOS and operative times. Although the overall transfusion rate did not differ significantly between groups, early fixation demonstrated an increased risk for a higher volume of blood transfused among patients requiring transfusions. Surgical timing did not influence risk for SSI or likelihood of transfusion during hospital stay.
Level of evidence:
Objectives: To determine whether suprapatellar or infrapatellar approach makes a difference in the rate of rotational malalignment in tibial diaphyseal fractures treated with intramedullary nailing.
Methods:
Design: Noninferiority, randomized controlled trial, with two arms (suprapatellar and infrapatellar approaches).
Setting: Single-center trial at a Level I trauma center in South India.
Patient selection criteria: Adults presenting with tibial diaphyseal fractures (OTA/AO 42A, B and C, 43A) planned for intramedullary nailing between September 2021 and July 2022.
Outcome measures and comparisons: The primary outcome compared was the degree of rotational malalignment in patients undergoing tibia nailing with suprapatellar and infrapatellar approaches. This was performed using CT scan in the immediate postoperative period. Secondary outcomes assessed across the 2 groups were postoperative entry site pain, anterior knee pain (Kujala score), functional scores, and union rates.
Results: Fifty patients, 25 in each arm, were included and followed up to a period of 1 year. The mean age was 34 (16-67) years (68% male) in the suprapatellar group and 45 (16-72) years (72% male) in the infrapatellar group. The rate of rotational malalignment was 34% with 8 (32%) in the suprapatellar group and 9 (36%) in the infrapatellar group and was independent of the approach used ( P = 0.76). The rotational malalignment had no association with knee functional scores ( P = 0.24). Factors such as location of fracture ( P = 0.81), mechanism of injury ( P = 0.76), type of injury ( P = 0.24), and surgeon seniority ( P = 0.2) had no association with malrotation. Suprapatellar and infrapatellar groups were similar in knee function ( P = 0.52), knee ( P = 0.31) and ankle ( P = 0.23) range of movement, and union rates ( P = 0.84). Entry site pain was found to be significantly less ( P = 0.021) in the suprapatellar group (6/25) as compared with the infrapatellar group (14/25). This difference persisted at 1 year.
Conclusions: Rotational malalignment in tibial diaphyseal fractures treated by intramedullary nailing was independent of the approach used. Entry site pain was less common with the suprapatellar approach.
Level of evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Objectives: To report on pin-related complications in patients who underwent temporary staging external fixation using a self-drilling pin insertion technique.
Methods:
Design: Retrospective cohort study.
Setting: Single tertiary referral level 1 trauma center.
Patient selection criteria: Adult patients were included who underwent temporary spanning external fixation of the lower extremity (AO/OTA 32, 33, 41, 42, 43, 44, 81, 82, 83, 84, and 85 fractures) using self-drilling and self-tapping pins placed using the self-drilling technique (Stryker Hoffman External Fixation System, Kalamazoo, MI) between August 1, 2015, and December 31, 2022, with a minimum follow-up of 90 days. The self-drilling technique included use of a soft tissue sleeve for pin protection in the femur and tibia, release of the tourniquet if inflated, and full speed insertion with the final turns completed by hand. Irrigation of the pin-bone interface was not typically used.
Outcome measures and comparisons: Outcome measures included pin site infection, pin loosening, loss of reduction in the external fixator, and deep infection of the primary surgical site.
Results: Two hundred sixty-five patients were included with a mean follow-up of 556 days. The mean age was 50 years (range 18-86 years). One hundred fifty-five patients (59%) were male. One thousand one hundred fifty-four total pins were placed: 289 (25%) in the femur (1 metaphyseal), 527 (46%) in the tibia (12 metaphyseal), 161 (14%) transfixion pins in the calcaneus, and 171 (15%) in the midfoot/forefoot. Seven patients (2.6%) developed a pin site infection. The infection rate for the total number of pins placed was 7 of 1154 (0.6%). One patient sustained a loss of reduction in the external fixator, and 3 pins were noted to be loose at the time of definitive fixation (2 in the tibial diaphysis and 1 in the first metatarsal shaft). In total, 35 of 265 patients (13.2%) developed deep fracture-related infection or septic nonunion in the postoperative period, none of which were associated with prior pin site infection.
Conclusions: The self-drilling technique for temporary external fixator pin insertion in this study demonstrated low rates of pin site infection, pin loosening, and loss of reduction.
Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Summary: Recreating tibial torsion in patients with complex tibial fractures is an important intraoperative consideration, particularly for fractures with comminution or segmental bone loss. Failure to accurately restore tibial alignment may lead to malrotation, poor functional outcomes, and reoperation to correct rotational deformity. No consensus currently exists regarding the optimal technique for intraoperative measurement of tibial torsion in patients undergoing tibial fracture fixation. This article describes a technique using a mobile C-arm fluoroscope to intraoperatively measure torsion of the contralateral uninjured leg to guide surgical fixation of the fractured tibia. The rotational profile of the uninjured leg is produced by obtaining a perfect lateral of the knee followed by an ankle mortise view. A series of patients is also presented that demonstrates the reproducibility of the technique and demonstrates the range of tibia torsion in patients with tibia fractures.
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：