Benjamin C. Taylor

Medial Malleolar Fractures: A Biomechanical Study of Fixation Techniques

Fracture fixation of the medial malleolus in rotationally unstable ankle fractures typically results in healing with current fixation methods. However, when failure occurs, pullout of the screws from tension, compression, and rotational forces is predictable. We sought to biomechanically test a relatively new technique of bicortical screw fixation for medial malleoli fractures. Also, the AO group recommends tension-band fixation of small avulsion type fractures of the medial malleolus that are unacceptable for screw fixation. A well-documented complication of this technique is prominent symptomatic implants and secondary surgery for implant removal. Replacing stainless steel 18-gauge wire with FiberWire suture could theoretically decrease symptomatic implants. Therefore, a second goal was to biomechanically compare these 2 tension-band constructs. Using a tibial Sawbones model, 2 bicortical screws were compared with 2 unicortical cancellous screws on a servohydraulic test frame in offset axial, transverse, and tension loading. Second, tension-band fixation using stainless steel wire was compared with FiberWire under tensile loads. Bicortical screw fixation was statistically the stiffest construct under tension loading conditions compared to unicortical screw fixation and tension-band techniques with FiberWire or stainless steel wire. In fact, unicortical screw fixation had only 10% of the stiffness as demonstrated in the bicortical technique. In a direct comparison, tension-band fixation using stainless steel wire was statistically stiffer than the FiberWire construct.

Treatment of acetabulum fractures through the modified Stoppa approach: strategies and outcomes.

BackgroundSince the original description by Letournel in 1961, the ilioinguinal approach has remained the predominant approach for anterior acetabular fixation. However, modifications of the original abdominal approach described by Stoppa have made another option available for reduction and fixation of pelvic and acetabular fractures.Questions/purposesWe evaluated our results in patients with acetabulum fractures with the modified Stoppa approach in terms of (1) hip function as measured by the Merle d’Aubigne hip score; (2) complications; and (3) quality of fracture reduction and percentage of fractures that united.MethodsBetween September 2008 and August 2012, 289 patients with acetabular fractures were treated at our Level I trauma center. Twelve percent (36 of 289) of patients were treated operatively using the modified Stoppa approach. Ninety-seven percent (35 of 36) of our patients had fracture patterns involving displacement of the posterior column. Six (17%) were converted early to a total hip arthroplasty, and 14 (39%) were lost to final followup, leaving 22 of 36 for subjective clinical outcome analysis at a mean of 32 months (range, 9–59 months). Our general indications for this approach during the period in question were fractures of the anterior column and anterior wall, anterior column with posterior hemitransverse fractures, both column fractures, transverse fractures, and T-type fractures. Followup included regularly scheduled office visits with radiographs (AP pelvis, Judet views) that were graded by the treating surgeon and by the authors of this study (MJI, BCT) and patient outcome surveys.ResultsMerle d’Aubigne hip scores were very good in 55% (12 of 22), good in 9% (two of 22), medium in 18% (four of 22), fair in 5% (one of 22), and poor in 14% (three of 22), and 70% (23 of 33) of patients were able to ambulate without any assistive devices. Complications included one superficial infection and three deep infections, two patients with temporary lateral thigh numbness, no obturator nerve palsies, and one inguinal hernia. Three deaths in the cohort were seen in followup as a result of unrelated causes. Radiographic grading of fracture reductions after surgery revealed that 27 (75%) were anatomic, six (17%) were satisfactory, and three (8%) were unsatisfactory. A total of 94% of the fractures united.ConclusionsIn agreement with prior published data, our results show good functional outcomes with minimal complications using the modified Stoppa approach for a variety of acetabular fractures. Our results highlight the difficulty but feasibility in treating posterior column displacement through an anterior approach. Consideration for dual approaches with posterior column involvement may be warranted to optimize fracture reduction and functional outcomes.Level of EvidenceLevel IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Osteomyoplastic and Traditional Transtibial Amputations in the Trauma Patient: Perioperative Comparisons and Outcomes

We hypothesized that patients undergoing transtibial amputation osteomyoplasty would have better functional outcomes than patients undergoing traditional transtibial amputation. We conducted a retrospective review of the medical and radiographic records to evaluate and compare 26 patients who underwent transtibial amputation osteomyoplasty and 10 patients who underwent traditional transtibial amputation, with specific attention to perioperative complications and functional outcomes. At >1 year follow-up, patients who underwent amputation osteomyoplasty had significantly improved rates of return to work and decreased rates of revision than patients who underwent traditional transtibial amputation. Sickness Impact Profile questionnaire results completed at a mean of 28 months postoperatively showed significantly better overall scores and physical and psychosocial dimension scores for amputation osteomyoplasty patients. Based on the results of this study, the outcomes of amputation osteomyoplasty appear to be safe and may be more beneficial than traditional amputation, in terms of improved functional outcomes for patients after severe lower-extremity trauma.

Gritti-stokes amputations in the trauma patient: clinical comparisons and subjective outcomes.

BACKGROUND The Gritti-Stokes amputation procedure is a modification of the traditional transfemoral amputation, with resection of the bone at a supracondylar femoral level and fixation of the patella to the distal part of the femur as an end-cap. Although well-established in patients with vascular compromise, no evidence exists on its use in the trauma setting. METHODS Fourteen consecutive patients who underwent Gritti-Stokes amputation and fifteen consecutive patients who underwent traditional transfemoral amputation by fellowship-trained orthopaedic traumatologists at a level-I trauma center were evaluated at more than fourteen months postoperatively. The Sickness Impact Profile (SIP) questionnaire was also administered to both patient groups at more than thirty-six months postoperatively to assess patient-reported functional outcomes. RESULTS Despite the two groups not having significant differences in preoperative variables or demographics, the Gritti-Stokes group had significantly improved SIP questionnaire overall and domain scores. This procedure also left the patients with a significantly longer residual limb (an average of 46.1 cm of residual femoral length versus 34.6 cm for the transfemoral group). The Gritti-Stokes group also had a significantly increased rate of walking without assistive devices (five patients versus none in the transfemoral amputation group). CONCLUSIONS The Gritti-Stokes amputation appears to be safe and beneficial when utilized in the trauma population.

Osteomyoplastic transtibial amputation: technique and tips

Treatment of severe lower extremity trauma, diabetic complications, infections, dysvascular limbs, neoplasia, developmental pathology, or other conditions often involves amputation of the involved extremity. However, techniques of lower extremity amputation have largely remained stagnant over decades.This article reports a reproducible technique for transtibial osteomyoplastic amputation.

Achieving educational excellence: a strategic initiative to enhance orthopedic resident academic performance.

Orthopedic resident training involves not only the hands-on learning of surgery but also should equally involve instructing the core knowledge of musculoskeletal medicine. Our program has developed a strategy that enhances resident educational performance; the educational curriculum entails conferences daily. Conferences include gross and surgical anatomy, orthopedic basic science, multidisciplinary trauma, radiology, pathology, journal club, and orthopedic subspecialty conferences. The primary purpose of the conference schedule is to provide the residents with a comprehensive education in orthopedic surgery. It is not geared toward taking the Orthopaedic In-Training Examination (OITE). The OITE is administered annually by the American Academy of Orthopaedic Surgeons (AAOS) and serves as an objective measure of knowledge acquisition. There has been a scientifically validated correlation between performance on the OITE and passage of the American Board for Orthopaedic Surgery Part I Examination. As a collective program, we have achieved at or above the 98th percentile nationally from 2004 to 2009. This academic success has not impacted the total surgical case volume negatively or interfered with Residency Review Committee (RRC) policies.

Necessity for fibular fixation associated with distal tibia fractures

INTRODUCTION Intramedullary (IM) nailing is a well-accepted treatment for distal third tibia fractures in combination with injury to the fibula. However, the indications for operative stabilisation of the fibula remain controversial. METHODS The authors performed a retrospective review on a consecutive series of patients who underwent intramedullary nailing of a non-comminuted distal third tibia fracture with or without fibular fixation at a Level I urban trauma centre. A review of surgical records identified 120 patients who initially were included in this study, while a total of 98 patients who met the inclusion criteria were included in the final analysis. RESULTS Our results found no difference in the mean value of coronal and sagittal plane alignment in both the immediate post-operative and follow-up time periods. We also saw no statistically significant difference when comparing malalignment between patients treated with or without fibula fixation. There were no deep infections between the two groups. No significant differences were seen between the fibular fixation group and the non-fixation group. Distal screw removal due to prominence or pain was the most common reason for future surgery in both groups. CONCLUSION These findings suggest that the addition of fibular fixation does not affect whether or not alignment is maintained in either the immediate post-operative or short-term follow-up period.

Successful Treatment of a Recalcitrant Pleural Effusion with Rib Fracture Fixation

Pulmonary complications of rib fractures typically occur in the immediate postinjury period, as a result of the forces causing the injury or subsequent rib fracture displacement. Pneumothorax, hemothorax, pulmonary contusions, or parenchymal lacerations are frequently seen with significant chest wall trauma. Hemopneumothorax is typically treated with tube thoracostomy, and full resolution of the pleural injury is expected; continued pleural fluid accumulation despite these measures is unanticipated, rare, and quite problematic. We report a case of hemorrhagic pleural effusion after rib fractures that were recurrent despite several tube thoracostomies and computed tomography-guided aspirations. The patient subsequently underwent operative fixation of her rib fractures, with successful resolution of her symptomatic pleural effusion.

Septic knee-induced deep venous thrombosis in a young adult.

This article describes a case of a 26-year-old man presenting with left knee pain of 1 weeks duration, fever, and acute onset of shortness of breath the day of admission. An arthrocentesis of the knee joint was grossly positive for methicillin-resistant Staphylococcus aureus. A left lower extremity venous duplex showed thrombosis of the superficial femoral, popliteal, posterior tibial, peroneal, and gastrocnemius veins. Pulmonary computed tomography-angiography was positive for acute pulmonary emboli. Initial management consisted of anticoagulation, intravenous antibiotics, and 2 arthroscopic irrigation and debridement procedures. After a normal transesophageal echocardiogram, a diagnosis of septic knee-induced deep venous thrombosis (DVT) of the left lower leg with subsequent septic pulmonary emboli was established. The patient was discharged to a long-term care facility for a 6-week monitored course of intravenous antibiotics. His DVT and pulmonary emboli were managed successfully with oral warfarin. Two months after his initial presentation, the patient returned with acute worsening knee pain. A knee arthrocentesis was unremarkable; however, radiographic imaging revealed fulminant osteomyelitis of the distal femur. He has since undergone open arthrotomy with excisional irrigation and debridement and is on a chronic oral antibiotic regimen. Sparse pediatric literature has shown an association between musculoskeletal sepsis and thrombosis. Only 1 case of septic knee-induced DVT exists in the adult literature, and it was not associated with pulmonary emboli. Our case provides evidence that DVT must be considered by the treating physician as a possible and devastating complication of septic arthritis.

Diabetic Neuroarthropathy of the Shoulder

Neuroarthropathy of the foot and ankle is a relatively common complication of diabetes mellitus. Likewise, neuroarthropathy of the shoulder has been well reported in relation to syringomyelia. Diabetes mellitus, however, has rarely been reported to cause neuroarthropathy of any joint in the upper extremity and has never previously been reported in the shoulder. This article presents a case of a 77-year-old woman who presented with a secondary complaint of mild right shoulder pain, which had been present since she sustained a proximal humerus fracture four months earlier. The patients past medical history was notably positive for diabetes mellitus with substantial peripheral neuropathy in the upper and lower extremities. Radiographic examination revealed significant degeneration of the humeral head, consistent with neuroarthropathy of the shoulder. Computed tomography and magnetic resonance imaging demonstrated no syrinx within the spinal cord. The patients medical history included no etiologies of neuroarthropathy of the shoulder that had been previously reported in the literature. After a thorough literature review, we believe this to be the first case of diabetic shoulder neuroarthropathy to be documented. No significant differences in clinical or radiographic presentations appear to be present between reported etiologies of this pathology, including diabetes mellitus. Consequently, we recommend that diabetes mellitus always be considered as an etiology in the differential diagnosis of neuroarthropathy of the shoulder.