Outcomes in patients sustaining complex periarticular fracture-dislocations of the elbow [abstract]

Periarticular fracture-dislocations (dislocations associated with one or more fractures) of the elbow are difficult injuries to treat. They have historically been associated with poor treatment strategies which resulted in abysmal outcomes for patients. We aimed to review our management strategies for these complex injuries and patient outcomes

Management of aseptic nonunions and severe bone defects: let us get this thing healed!

Effective nonunion and bone defect management requires consideration of multiple potential contributing factors including biomechanics, biology, metabolic, and patient factors. This article reviews these factors as well as several potential nonunion or bone defect treatments including bone grafts, bone graft substitutes, the induced membrane technique, and distraction osteogenesis. A summary of these concepts and guidelines for an overall approach to management are also provided

Negative pressure wound therapy with instillation: International consensus guidelines update.

The use of negative pressure wound therapy with instillation and dwell time (NPWTi-d) has gained wider adoption and interest due in part to the increasing complexity of wounds and patient conditions. Best practices for the use of NPWTi-d have shifted in recent years based on a growing body of evidence and expanded worldwide experience with the technology. To better guide the use of NPWTi-d with all dressing and setting configurations, as well as solutions, there is a need to publish updated international consensus guidelines, which were last produced over 6 years ago. An international, multidisciplinary expert panel of clinicians was convened on 22 to 23 February 2019, to assist in developing current recommendations for best practices of the use of NPWTi-d. Principal aims of the meeting were to update recommendations based on panel members\u27 experience and published results regarding topics such as appropriate application settings, topical wound solution selection, and wound and patient characteristics for the use of NPWTi-d with various dressing types. The final consensus recommendations were derived based on greater than 80% agreement among the panellists. The guidelines in this publication represent further refinement of the recommended parameters originally established for the use of NPWTi-d. The authors thank Karen Beach and Ricardo Martinez for their assistance with manuscript preparation

Interobserver reliability of classification and characterization of proximal humeral fractures: a comparison of two and three-dimensional CT

Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Members of the Science of Variation Group--fully trained practicing orthopaedic and trauma surgeons from around the world--were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (κ) measure. Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from "slight" to "fair." A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (κ = 0.35 compared with 0.30, p < 0.001) and on the AO classification (κ = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that was observed for selection of the treatment for proximal humeral fractures. The lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

A Biomechanical Comparison of Locked Plate Fixation With Percutaneous Insertion Capability Versus the Angled Blade Plate in a Subtrochanteric Fracture Gap Model

Objectives: The angled blade plate has been the historical standard in fixed-angle extramedullary subtrochanteric femur fracture fixation, but it requires an extensile lateral approach to the femur. Little formal evaluation exists for specifically designed percutaneous extramedullary implants. The purpose of this study was to compare 3 locked plating constructs, all with percutaneous insertion capability, with the standard 95-degree angled blade plate to determine whether specifically designed fixed-angle extramedullary implants for subtrochanteric femur fractures were biomechanically comparable to the angled blade plate. Methods: Forty composite adult femurs were divided into 4 equal groups. The constructs evaluated included a 95-degree angled blade plate, a broad 4.5-mm combination locking plate, and a precontoured proximal femoral locking plate (PFLP) with and without an oblique, angled strut or ‘‘kickstand’’screw. A 30-degree wedge osteotomy was used to create a subtrochanteric fracture gap model. Each specimen underwent axial and torsional stiffness testing along with cyclic axial loading to failure. Results: Axial stiffness testing revealed that the PFLP with the ‘‘kickstand’’ screw was the stiffest construct (92.2 ± 17.4 Nm/m), which was 211% stiffer than the blade plate, 309% stiffer than the broad plate, and 194% stiffer than the PFLP without the kickstand screw. The blade plate had the highest torsional stiffness (2.42 6 0.08 Nm/degree), which was 151% stiffer than the broad plate, 128% stiffer than the PFLP with the kickstand, and 138% stiffer than the PFLP without the kickstand screw. The PFLP with the kickstand screw had the least irreversible deformation (6.3 mm), which was 52% less than the broad plate and 61% less than the PFLP without the kickstand screw. Conclusions: Our data reveal that the PFLP with the kickstand screw provides more axial stiffness, less torsional stiffness, and equivalent irreversible deformation to cyclic axial loading when compared with the blade plate

The Biomechanics of Varied Proximal Locking Screw Configurations in a Synthetic Model of Proximal Third Tibial Fracture Fixation

Objective: To determine if 1) angularly stable devices created by compressing (‘‘locking’’) proximal locking screws to intramedullary nails using end caps or compression screws or 2) increasing the number of proximal screws from two to three increases the stiffness of intramedullary constructs that stabilize proximal third tibia fractures in a nonosteopenic bone model. Methods: Four proximal locking screw configurations were examined in a synthetic composite tibia model with a 2-cm gap simulating a comminuted proximal third tibia fracture with no bony contact: 1) two proximal screws not compressed to the nail; 2) one of two proximal screws compressed to the nail; 3) two proximal screws compressed to the nail; and 4) three proximal screws with only the most proximal screw compressed to the nail. An 11-mm tibial nail with two distal locking screws was used. Stiffness was measured in axial and torsional loading. An analysis of variance was performed to compare results of the screw configurations for each testing mode. Results: Compressing two screws to the nail produced 22% to 39% greater (P ≤ 0.01) axial and 16% to 29% greater (P ≤ 0.03) torsional stiffness than securing neither or only one of the screws. Adding a third proximal transverse locking screw increased the axial stiffness by 28% (P = 0.005) and the torsional stiffness by 15% to 28% (P ≤ 0.04) compared with using two oblique proximal screws. Conclusions: Locking two proximal locking screws to the nail through compression or adding a third proximal screw increases the axial and torsional stiffness of intramedullary nails used to fix unstable proximal third tibia fractures

Efficacy of osteoporosis screening and treatment protocol at the Orthopedic Trauma Center

Fragility fractures occur due to decreased bone density (BMD) and are are of concern for both men and women. These fractures result from low energy mechanism and most frequently involve spine, hip, and wrist. If BMD is not addressed, patients can have subsequent fractures. We are interested in determining the effectiveness of the medical community at diagnosing and managingsteoporosis. We hypothesize that our current current protocol is efficient at osteoporosis screening and subsequent treatment 75% of the time