Arnold J. Suda

Intraoperative Three-dimensional Imaging in the Treatment of Acute Unstable Syndesmotic Injuries

BACKGROUND Acute unstable syndesmotic ankle injuries are treated primarily by reduction and stabilization with a syndesmotic screw. Examination with fluoroscopy or standard radiographs may not provide reliable information about the quality of the reduction. There is evidence that intraoperative three-dimensional imaging can demonstrate a large proportion of malreductions. The aim of this study was to determine whether intraoperative three-dimensional imaging improves the detection of inadequate positioning of the distal aspect of the fibula in the tibiofibular incisura after syndesmotic screw insertion compared with the findings on standard intraoperative fluoroscopy. METHODS Of 2286 ankle fractures treated operatively from August 2001 to February 2011, 251 consecutive cases (11%) were identified in a retrospective chart review. All had an unstable syndesmosis and underwent syndesmosis stabilization on the basis of an intraoperative hook test. After fluoroscopy, an intraoperative three-dimensional scan was performed. The result of this scan was documented by the surgeon and analyzed retrospectively with regard to the incidence and nature of the need for intraoperative revisions. RESULTS The intraoperative three-dimensional scan altered the surgical outcome in eighty-two ankles (32.7%). In most ankles (seventy-seven; 30.7%), the reduction was improved, with the most common improvement being the alignment of the fibula in the tibiofibular incisura in sixty-four patients (25.5%) followed by correction of the fracture reduction in thirteen patients (5.2%). The other five alterations involved implant corrections. The most common malpositions requiring correction after insertion of a positioning screw, with or without additional fixation, were anterior displacement and internal rotation of the distal aspect of the fibula. CONCLUSIONS Following open reduction and internal fixation of an ankle fracture, the correct position of the syndesmosis cannot be evaluated reliably with use of conventional radiographs or intraoperative fluoroscopy. In view of the high proportion of positive findings in this study, we believe that any treatment of a syndesmotic injury should include intraoperative three-dimensional imaging or at least a postoperative computed tomography scan.

Intraoperative Three-Dimensional Imaging in the Treatment of Calcaneal Fractures

BACKGROUND Displaced intra-articular calcaneal fractures are frequently treated by open reduction and internal fixation. The usual intraoperative monitoring by means of fluoroscopy does not always provide complete intraoperative information for the surgeon. The aims of this study were to analyze the percentage of patients for whom intraoperative three-dimensional imaging leads to intraoperative revision and whether the avoidance of an intra-articular step or gap influences the clinical outcome. METHODS From August 2001 to June 2009, 377 consecutive, operatively treated calcaneal fractures were identified in a retrospective chart review. The results of the intraoperative three-dimensional scans were analyzed for the rate of and the reason for intraoperative revision. For the clinical evaluation, all patients with Sanders type-II and III fractures who were seen from October 2002 to January 2006 were included. When the outer shape of the calcaneus was successfully restored, the fractures were divided into two groups according to the reduction outcome for all joint surfaces (a step-off or gap of <2 mm or ≥2 mm). RESULTS The intraoperative revision rate was 40.3%. An additional fracture reduction was performed in 19.6% of the patients. Seventy-seven fractures were followed clinically. The American Orthopaedic Foot & Ankle Society (AOFAS) score indicated that postoperative joint surface congruence had a significant influence on clinical outcome, in both the bivariate and the multivariate analysis. The same relationship was shown between the joint surface congruence and the degree of osteoarthritis. CONCLUSIONS In many cases, intraoperative three-dimensional imaging identifies intra-articular incongruence and implants that are not detected by fluoroscopy. Due to the resulting options for better joint surface reconstruction, clinical outcomes may be improved, at times requiring repeat reduction, and posttraumatic osteoarthritis may be reduced.

Prosthetic infection: improvement of diagnostic procedures using 16S ribosomal deoxyribonucleic acid polymerase chain reaction

PurposeProsthetic infection is the worst complication in joint arthroplasty. The diagnostic procedure is time consuming and in many cases unrewarding. The aim of this investigation was to raise the sensitivity of the diagnostic procedure.MethodsAltogether, 229 implants were removed from 229 patients. Complete data from 157 patients could be analysed. On explantation of the respective arthroplasty, tissue was removed, puncture fluid aspirated and biofilm scratched from the implant surface with a surgical knife. Specimens were investigated with conventional culture methods and with 16S ribosomal DNA (rDNA) polymerase chain reaction (PCR) and sequencing.ResultsIn 123 cases, no pathogen could be identified by routine culture methods. In three of these culture-negative cases, bacteria could be identified with 16S rDNA sequencing of the removed biofilm. In 34 cases, bacteria could be identified with culture methods. In two of these cases, sequencing detected additional pathogens.ConclusionsThe process of 16S ribosomal deoxyribonucleic acid polymerase chain reaction (rDNA PCR) and sequencing of biofilm removed from the explanted prosthesis is an important addition to conventional culture methods in prosthetic joint infection. Polymerase chain reaction detects additional pathogens and improves diagnostic sensitivity. The examination of tissue, puncture fluid and biofilm should be performed in cases of prosthesis loosening and explantation.

Predictors of a persistent dislocation after reduction of syndesmotic injuries detected with intraoperative three-dimensional imaging.

Background: In about 25% of cases, reduction of acute unstable syndesmotic injuries and stabilization with syndesmotic screws leads to an inadequate reduction. Conventional fluoroscopy does not provide reliable information about the reduction outcome. However, use of intraoperative 3D imaging can be more accurate. The purpose of this study was to identify predictors of inadequate reduction so that the need for intra- or postoperative 3D imaging could be assessed. Our hypothesis was that complex injuries of the syndesmosis present a higher risk of malreduction than simpler ankle fractures. Methods: From August 2001 to February 2011, 251 unstable syndesmotic injuries were treated from a total of 2286 ankle fractures. In 61 of these cases, malreduction of the fibula into the fibular notch was detected by intraoperative 3D imaging. The influence of all possible concomitant and combination injuries of the ankle joint, surgeon’s experience, and potential implant-related effects was analyzed. Results: Thirty-seven Weber C fractures (60.7%), 13 Maisonneuve fractures (21.3%), 10 Weber B fractures (16.4%), and 1 syndesmotic injury without fracture (1.6%) were included. In 14 cases (23%) there was involvement of the posterior malleolus, in 10 cases of the medial malleolus (16.4%), and in 12 cases both (19.7%). The Weber C fractures included 10 bimalleolar fractures with involvement of the posterior malleolus. In neither this combination nor in any other possible injury configuration was it possible to identify a statistically significant correlation with malreduction of the fibula into the fibular notch. The surgeon’s experience or an implant-related effect had no detectable influence either. Conclusion: Based on the factors studied, it is not possible to conclude whether a patient has an increased risk of malreduction. Therefore we still recommend verifying all reduction outcomes by intraoperative 3D imaging or postoperative computed tomography. Level of Evidence: Level III, retrospective comparative study.

Incidence and Cost of Intraoperative Waste of Hip and Knee Arthroplasty Implants

Many strategies have been reported for decreasing the cost of orthopedic procedures, but prosthetic waste has not been investigated. The purpose of this study was to characterize the cost of intraoperative waste of hip and knee implants. A regional prospective assessment was performed, evaluating the reasons for component waste, the cost of the wasted implants, and where the cost was absorbed (hospital or manufacturer). Implant waste occurred in 79 (2%) of 3443 procedures, with the surgeon and operating room staff bearing primary responsibility in 73% of occurrences. The annualized cost was

Anamnestic risk factor questionnaire as reliable diagnostic instrument for osteoporosis reduced bone morphogenic density

109 295.35, with 67% absorbed by hospitals. When extrapolated to the whole of the United States, the annual cost to hospitals would be

PHTLS ® (Prehospital Trauma Life Support) provider courses in Germany – who takes part and what do participants think about prehospital trauma care training?

36,019,000 and is estimated to rise to

Severe frostbite injury in a 19-year-old patient requiring amputation of both distal forearms and lower legs due to delayed rescue: a need for advanced accident collision notification systems?

112,033,000 by 2030, representing a potential target for educational programs and other cost containment measures.

Early results with the cementless Variall hip system.

BackgroundOsteoporosis is a major health problem worldwide, and is included in the WHO list of the top 10 major diseases. However, it is often undiagnosed until the first fracture occurs, due to inadequate patient education and lack of insurance coverage for screening tests. Anamnestic risk factors like positive family anamnesis or early menopause are assumed to correlate with reduced BMD.MethodsIn our study of 78 patients with metaphyseal long bone fractures, we searched for a correlation between anamnestic risk factors, bone specific laboratory values, and the bone morphogenic density (BMD). Each indicator was examined as a possible diagnostic instrument for osteoporosis. The secondary aim of this study was to demonstrate the high prevalence of osteoporosis in patients with metaphyseal fractures.Results76.9% of our fracture patients had decreased bone density and 43.6% showed manifest osteoporosis in DXA (densitometry) measurements. Our questionnaire, identifying anamnestic risk factors, correlated highly significantly (p = 0.01) with reduced BMD, whereas seven bone-specific laboratory values (p = 0.046) correlated significantly.ConclusionsAnamnestic risk factors correlate with pathological BMD. The medical questionnaire used in this study would therefore function as a cost-effective primary diagnostic instrument for identification of osteoporosis patients.

Techniques for managing anatomic variations in primary total knee arthroplasty.

BackgroundThe goal of this study was to examine PHTLS Provider courses in Germany and to proof the assumption that formation of physicians and paramedics in prehospital trauma care can be optimized.MethodsPHTLS participants were asked to fill out standardized questionnaires during their course preparation and directly after the course. There were some open questions regarding their professional background and closed questions concerning PHTLS itself. Further questions were to be answered on an analog scale in order to quantify subjective impressions of confidence, knowledge and also to describe individual levels of education and training.Results247 questionnaires could be analyzed. Physicians noted significant (p < 0.001) more deficits in their professional training than paramedics. 80% of the paramedics affirmed to have had adequate training with respect to prehospital trauma care, all physicians claimed not to have had sufficient training for prehospital trauma care situations at Medical School. Physicians were statistically most significant dissatisfied then paramedics (p < 0.001). While most participants gave positive feedback, anesthetists were less convinced of PHTLS (p = 0.005), didn’t benefit as much as the rest (p = 0.004) and stated more often, that the course was of less value for their daily work (p = 0.03). After the course confidence increased remarkably and reached higher rates than before the course (p < 0.001). After PHTLS both groups showed similar ratings concerning the course concept indicating that PHTLS could equalize some training deficits and help to gain confidence and assurance in prehospital trauma situations. 90% of the paramedics and 100% of the physicians would recommend PHTLS. Physicians and especially anesthetists revised their opinions with regard to providing PHTLS at Medical School after having taken part in a PHTLS course.ConclusionThe evaluation of PHTLS courses in Germany indicates the necessity for special prehospital trauma care training. Paramedics and physicians criticize deficits in their professional training, which can be compensated by PHTLS. With respect to relevant items like confidence and knowledge PHTLS leads to a statistically significant increase in ratings on a visual analogue scale. PHTLS should be integrated into the curriculum at Medical School.