Anthony Christiano

Open surgical elbow contracture release after trauma: results and recommendations

BACKGROUND Post-traumatic elbow contracture is a debilitating complication after elbow trauma. The purpose of this study was to characterize the affected patient population, operative management, and outcomes after operative elbow contracture release for treatment of post-traumatic elbow contracture. METHODS A retrospective record review was conducted to identify all patients who underwent post-traumatic elbow contracture release performed by 1 of 3 surgeons at one academic medical center. Patient demographics, injuries, operative details, outcomes, and complications were recorded. RESULTS The study included 103 patients who met inclusion criteria. At the time of contracture release, patients were a mean age of 45.2 ± 15.6 years. Contracture release resulted in a significant mean increase to elbow extension/flexion arc of motion of 52° ± 18° (P < .0005). Not including recurrence of contracture, a subsequent complication occurred in 10 patients (10%). Radiographic recurrence of heterotopic ossification (HO) occurred in 14 patients (14%) after release. Ten patients (11%) elected to undergo a secondary operation to gain more motion. CONCLUSION Soft tissue and bony elbow contracture release is effective. Patients with post-traumatic elbow contracture can make significant gains to their arc of motion after contracture release surgery and can expect to recover a functional elbow arc of motion. Patients with severe preoperative contracture may benefit from concomitant ulnar nerve decompression. HO prophylaxis did not affect the rate of HO recurrence or ultimate elbow range of motion. However, patients must be counseled that contracture may reoccur, and some patients may require or elect to have more than one procedure to achieve functional motion.

Current Practices Regarding Perioperative Management of Patients With Fracture on Antiplatelet Therapy: A Survey of Orthopedic Surgeons.

Objective: There continues to be controversy over whether operative delay is necessary for patients on antiplatelet therapy, particularly for elderly patients with hip fractures. This study sought to assess current clinical practices of orthopedic surgeons regarding perioperative management of these patients. Methods: A 12-question, Web-based survey was distributed to orthopedic surgeons via e-mail. Questions regarding timing of surgery assumed patients were on antiplatelet therapy and assessed attitudes toward emergent and nonemergent orthopedic cases as well as operative delay for specific closed fracture types. Responses were compared using unpaired, 2-tailed Student t tests for continuous variables and Pearson chi-square tests with odds ratios (ORs) and 95% confidence intervals (CIs) for categorical variables. Statistical significance was defined as a P value <.05. Results: Overall 67 orthopedic surgeons responded. Fifty-two percent (n = 35) of the respondents described their practice as academic. Thirty-nine percent (n = 25) of the surgeons indicated that no delay was acceptable for urgent but nonemergent surgery, and 78% (n = 50) reported no delay for emergent surgery was acceptable. Sixty-eight percent (n = 46) of respondents felt patients on antiplatelet therapy with closed hip fractures did not require operative delay. Surgeons who opted for surgical delay in hip fractures were more likely to delay surgery in other lower extremity fracture types (OR = 16.4, 95% CI 4.48-60.61, P < .001). Sixty-four percent (n = 41) of the surgeons indicated there was no protocol in place at their institution. Conclusions: There continues to be wide variability among orthopedic surgeons with regard to management of patients with fracture on antiplatelet therapy. Over a quarter of surgeons continue to opt for surgical delay in patients with hip fracture. This survey highlights the need to formulate and better disseminate practice management guidelines for patients with fracture on antiplatelet therapy, particularly given the aging population in the United States.

Functional and Clinical Outcomes of Nonsurgically Managed Tibial Plateau Fractures

Introduction: This study sought to assess and compare long-term functional and clinical outcomes in patients with tibial plateau fractures that are treated nonsurgically. Methods: Over a period of 8 years, 305 consecutive tibial plateau fractures were treated by three surgeons at a single institution and followed prospectively in an Institutional Review Board–approved study. Overall, 41 patients (13%) were treated nonsurgically and 37 were available for follow-up. Indications for nonsurgical management were minimal fracture displacement or preclusion of surgery because of comorbidities. A series of univariate retrospective analyses were used to identify individual risk factors potentially predictive of Short Musculoskeletal Functional Assessment scores. Results: Thirty-seven patients were included with a mean follow-up of 21 ± 14.9 months. Overall, 59% of patients (n = 22) attained good to excellent functional outcomes. In patients for whom surgery was precluded because of comorbidities, outcome scores were significantly poorer (38.8 ± 23.0 versus 12.7 ± 14.2; P = 0.001). Surgery precluded by a factor other than minimal fracture displacement predicted poor outcome (P = 0.002). Discussion: Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically. Level of Evidence: Level III, retrospective comparative study

Femoral Nonunion With Iliac Crest Bone Graft

Purpose: Fracture nonunion is a common problem for todays orthopaedic surgeon. However, many techniques are currently available for the treatment of long-bone nonunion. This video demonstrates the use of iliac crest bone graft and plate stabilization in the setting of a hypertrophic femoral nonunion. Methods: Treatment of femoral nonunion after intramedullary nail fixation using compression plating and bone grafting is a reliable technique for reducing pain, improving function, and achieving radiographic union. Furthermore, the use of autologous bone graft, in particular iliac crest bone graft, has provided reliable clinical results. Results: In this video, we present the case of a hypertrophic femoral nonunion treated with supplemental bone grafting in addition to plate and screw fixation. Conclusions: Although femoral nonunions are a relatively rare occurrence, they can be reasonably treated using stabilization and supplemental bone grafting. Iliac crest bone graft provides for excellent results when used for treatment of a fracture nonunion.

Risk factors for complications after primary repair of Achilles tendon ruptures

Purpose To identify patient characteristics associated with adverse events in Achilles tendon rupture (ATR) surgical repair cases. Methods A high risk (HR) cohort group of ATR patients were compared to healthy controls in the ACSNSQIP database with multivariate regression analysis. Results Overall, 2% (n = 23) of the group sustained an AE postoperatively, most commonly superficial SSI (0.9%, n = 10). Multivariate analysis did not reveal any patient characteristics to be significantly associated with the occurrence of an AE or superficial SSI. Conclusions Obesity, diabetes and a history of smoking did not predispose patients to significantly more AEs in the 30 day postoperative period following ATR repair in this study.

Risk Factors for Complications after Primary Repair of Achilles Tendon Ruptures

Background: Operative treatment of Achilles tendon ruptures is associated with lower rates of rereupture compared to nonoperative treatment. However, concerns regarding adverse events (AE) in the postoperative period such as wound complications and surgical site infection (SSI) persist. The purpose of this study was to identify patient characteristics associated with the occurrence of adverse events in Achilles tendon rupture (ATR) surgical repair cases. Methods: Primary ATR repairs completed from 2005-2012 were identified in the ACS-NSQIP database. Univariate analyses were conducted to identify patient characteristics associated with 30 day postoperative complications. A high risk (HR) cohort group of patients who were either obese (Body Mass Index [BMI]>30), had a history of diabetes, or a history of smoking were compared to healthy controls. A multivariate logistic regression analysis of the overall cohort was done to assess for independent predictors of AEs. Results: In total, 1,164 patients met inclusion criteria with 615 meeting criteria for the HR cohort (53%). Overall, 2% (n=23) of the group sustained an AE postoperatively and, the most common AE was superficial SSI (0.9%, n=10). Operative time was longer in HR group compared to other ATR cases in the study (57.95 ± 28.2 minutes vs. 63.16 ± 30.2 minutes, p=0.002). Multivariate analysis did not reveal any patient characteristics to be significantly associated with the occurrence of an adverse event or superficial SSI. Conclusions: Rates of AEs in the 30 day postoperative period for surgically repaired ATR are very low. Obesity, diabetes and a history of smoking do not seem to predispose patients to AEs following repair of an ATR.