Benoit

APTF: anteroposterior tibiofibular ratio, a new reliable measure to assess syndesmotic reduction.

Objectives: To assess the accuracy of a new radiographic measurement of the distal tibia and fibula on the lateral view of the ankle in normal adults: the anteroposterior tibiofibular (APTF) ratio. Method: Thirty adults without history of trauma or disease of the ankle were included. Bilateral ankles were x-rayed with a true lateral view of the ankle. A line from the anterior tibial physis scar to the posterior tibial cortex, passing by the intersection of the physis and the fibula anterior cortex, was drawn. The APTF ratio was calculated as the ratio of the anterior segment to the posterior segment. The measurements were done by 3 independent evaluators. Intra- and interobserver reliability was obtained using intraclass correlation. Results: The APTF ratio was 0.94 ± 0.13 with a range of 0.63–1.31. Sex and age had no effect on the results. Inter- and intraobserver reliability was good to very good with an intraclass correlation between 0.6 and 0.8. A strong correlation between the left and the right APTF ratio was observed (r = 0.501 and P = 0.001). Conclusion: The distal tibiofibular joint anatomy in the sagittal plane can be accurately assessed with a new reliable radiographic measurement, the APTF ratio. The reduction of this joint during surgery can be confirmed with a true lateral view of the ankle. The anterior fibula cortex crosses the tibial physeal scar at the center of the line crossing this point and the anterior cortex of the tibia at the level of the physeal scar in the normal ankle.

Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide

OBJECTIVES The purpose of this study was to determine which screws could be safely inserted percutaneously into a proximal humerus locking plate using a new external aiming guide without injuring the axillary nerve. We also sought to evaluate that all the screws could be accurately inserted ina locked position with the external guide. METHODS Eight cadaveric specimens were implanted with a proximal humerus locking plate using a minimally invasive direct-lateral deltoid splitting approach using an attached external aiming guide for screw insertion. The anatomic proximity of the axillary nerve to the guidewires and screws was measured following soft tissue dissection and inspection of the nerve. RESULTS The two superior holes (C1 and C2) were proximal to the axillary nerve with an average distance of 15.1 mm. Screw F was on average 6.6 mm distal to the axillary nerve but within 2 mm of the nerve in two specimens. In all specimens, the locking screws were appropriately seated in a locked position using the external aiming guide. CONCLUSIONS This study suggests that percutaneous fixation of a proximal humerus locking plate with an external aiming guide can be safely used for proximal humerus fractures. The limited number of screws that can be inserted into the proximal fragment using the current external guide arm may compromise fixation of more unstable fractures. Therefore, the indications for percutaneous locking plate fixation of the proximal humerus using an external aiming guide should be limited to stable fracture patterns that can be anatomically reduced.

Hueter anterior approach for hip resurfacing: assessment of the learning curve.

The results of metal-on-metal hip resurfacing arthroplasty have been very encouraging. However, extensile approaches such as the posterior have been recommended to ensure proper component placement. This article evaluates the safety and the learning curve with the less invasive Hueter hip resurfacing using an anterior approach on an orthopedic traction table. The first 50 hip resurfacings using this approach are compared with the previous 50 procedures performed through a surgical dislocation approach. The authors conclude that it is a reasonable alternative to more extensile surgical approaches for a high-volume resurfacing arthroplasty surgeon. Further long-term studies and comparisons to other approaches will determine if the anterior approach provides advantages in terms of patient function and time to recovery.

Augmentation of tibial plateau fractures with Trabecular Metal™: a biomechanical study

BackgroundRestoration and maintenance of the plateau surface are the key points in the treatment of tibial plateau fractures. Any deformity of the articular surface jeopardizes the future of the knee by causing osteoarthritis and axis deviation. The purpose of this study is to evaluate the effect of Trabecular Metal (porous tantalum metal) on stability and strength of fracture repair in the central depression tibial plateau fracture.MethodSix matched pairs of fresh frozen human cadaveric tibias were fractured and randomly assigned to be treated with either the standard of treatment (impacted cancellous bone graft stabilized by two 4.5 mm screws under the comminuted articular surface) or the experimental method (the same screws supporting a 2 cm diameter Trabecular Metal (TM) disc placed under the comminuted articular surface). Each tibia was tested on a MTS machine simulating immediate postoperative load transmission with 500 Newton for 10,000 cycles and then loaded to failure to determine the ultimate strength of the construct.ResultsThe trabecular metal construct showed 40% less caudad displacement of the articular surface (1, 32 ± 0.1 mm vs. 0, 80 ± 0.1 mm) in cyclic loading (p < 0.05). Its mechanical failure occurred at a mean of 3275 N compared to 2650 N for the standard of care construct (p < 0, 05).ConclusionThe current study shows the biomechanical superiority of the trabecular metal construct compared to the current standard of treatment with regards to both its resistance to caudad displacement of the articular surface in cyclic loading and its strength at load to failure.

Incidence rate of mild traumatic brain injury among patients who have suffered from an isolated limb fracture: Upper limb fracture patients are more at risk.

OBJECTIVES This study compares the incidence rate of mild traumatic brain injury (mild TBI) detected at follow-up visits (retrospective diagnosis) in patients suffering from an isolated limb trauma, with the incidence rate held by the hospital records (prospective diagnosis) of the sampled cohort. This study also seeks to determine which types of fractures present with the highest incidence of mild TBI. PATIENTS AND METHODS Retrospective assessment of mild TBI among orthopaedic monotrauma patients, randomly selected for participation in an Orthopaedic clinic of a Level I Trauma Hospital. Patients in the remission phase of a limb fracture were recruited between August 2014 and May 2015. No intervention was done (observational study). MAIN OUTCOME MEASUREMENTS Standardized semi-structured interviews were conducted with all patients to retrospectively assess for mild TBI at the time of the fracture. Emergency room related medical records of all patients were carefully analyzed to determine whether a prospective mild TBI diagnosis was made following the accident. RESULTS A total of 251 patients were recruited (54% females, Mean age=49). Study interview revealed a 23.5% incidence rate of mild TBI compared to an incidence rate of 8.8% for prospective diagnosis (χ(2)=78.47; p<0.0001). Patients suffering from an upper limb monotrauma (29.6%; n=42/142) are significantly more at risk of sustaining a mild TBI compared to lower limb fractures (15.6%; n=17/109) (χ(2)=6.70; p=0.010). More specifically, patients with a proximal upper limb injury were significantly more at risk of sustaining concomitant mild TBI (40.6%; 26/64) compared to distal upper limb fractures (20.25%; 16/79) (χ(2)=7.07; p=0.008). CONCLUSIONS Results suggest an important concomitance of mild TBI among orthopaedic trauma patients, the majority of which go undetected during acute care. Patients treated for an upper limb fracture are particularly at risk of sustaining concomitant mild TBI.

Comorbid mild traumatic brain injury increases pain symptoms in patients suffering from an isolated limb fracture

OBJECTIVES This study seeks to evaluate the effects of a mild traumatic brain injury (mTBI) on pain in patients with an isolated limb fracture (ILF) when compared to a matched cohort group with no mTBI (control group). PATIENTS AND METHODS All subjects included in this observational study suffered from an ILF. Groups were matched according to the type of injury, sex, age, and time since the accident. Main outcome measurements were: Standardized semi-structured interviews at follow-up of a Level I Trauma Center, and a questionnaire on fracture-related pain symptoms. Factors susceptible to influence the perception of pain, such as age, sex, severity of post-concussive symptoms, and worker compensation were also assessed. RESULTS A total of 68 subjects (36 females; 45 years old) with an ILF were selected, 34 with a comorbid mTBI and 34 without (24/34 with an upper limb fracture per group, 71% of total sample). Patients with mTBI and an ILF reported significantly higher pain scores at the time of assessment (mean: 49days, SD: 34.9), compared to the control group (p<0.0001; mean difference 2.8, 95% confidence interval 1.8-4.0). Correlational analyses show no significant association between the level of pain and factors such as age, sex, severity of post-concussive symptoms, and worker compensation. CONCLUSIONS Results suggest that mTBI exacerbate perception of pain in the acute phase when occurring with an ILF, and were not explained by age, sex, post-concussive symptoms, or worker compensation. Rather, it appears possible that neurological sequelae induced by mTBI may interfere with the normal recovery of pain following trauma.

Incidence of symptomatic venous thromboembolism in 2372 knee and hip replacement patients after discharge: data from a thromboprophylaxis registry in Montreal, Canada

Background Low-molecular-weight heparin (LMWH) is a recommended anticoagulant for thromboprophylaxis after major orthopedic surgery. Dabigatran etexilate is an oral anticoagulant recognized as noninferior to LMWH. We aimed to assess the incidence of symptomatic venous thromboembolic events (VTEs) after discharge in patients who underwent joint replacement, using a hospital registry. Patients and methods Patients who underwent total knee and hip arthroplasty between September 2011 and March 2015 were selected. Subcutaneous enoxaparin (30 mg twice daily) was given during hospitalization. At discharge, patients received either enoxaparin 30 mg twice daily/40 mg once daily or dabigatran 220 mg/150 mg once daily. Patients were seen or called at 2, 6, and 12 weeks after surgery. Outcomes were the number of VTEs, including deep venous thrombosis, pulmonary embolism, and the number of major/minor bleeding events after discharge. Results After discharge, 1468 patients were prescribed enoxaparin and 904 dabigatran (1396 total knee arthroplasty and 976 total hip arthroplasty patients). Mean age was 66±10 years, and 60% were female. The cumulative incidence of VTEs during the 12-week follow-up was 0.7%. One patient sustained a VTE during the switch window. Seven patients sustained a pulmonary embolism (0.3%). There was no statistical difference between the total knee arthroplasty and total hip arthroplasty groups. The incidence of major and minor bleeding events during follow-up was 0.3% and 30.3%, respectively. These events had a higher incidence in the dabigatran group compared to the enoxaparin group after discharge (p<0.05), but not between knee and hip replacement groups for major bleeding events. Conclusion A pharmaceutical prophylaxis protocol using LMWH and dabigatran during the post-discharge period resulted in low incidences of VTE and equivalence between treatments. However, the increased number of major and minor bleeding events in patients taking dabigatran is of concern regarding the safety and needs to be evaluated using analyses adjusted for risk factors.

Simultaneous Ipsilateral Quadriceps and Triceps Tendon Rupture in a Patient with End-Stage Renal Failure

Introduction Quadriceps tendon ruptures (QTR) frequently occur in patients with end-stage renal failure, while triceps brachii tendon ruptures (TTR) are less common. This is the first properly documented report of a simultaneous ipsilateral traumatic rupture of both of these tendons. Case Report A 50-year-old patient, on hemodialysis for end-stage renal failure, fell on his right side. He presented with sudden right knee and elbow pain, with functional impairment of both joints. X-rays showed avulsion-like osseous lesions on the olecranon and patella with a low-riding patella. Ultrasound confirmed complete quadriceps and triceps avulsion ruptures. Both lesions were treated surgically. Fixation was performed with anchors using the Krackow suture technique for both tendons. Postoperative clinical and radiological results were satisfactory, and follow-up was uneventful. The patient regained his preinjury functional level with a complete range of motion of both his knee and elbow. Discussion Isolated QTR and TTR are frequent lesions in chronic renal failure patients treated with hemodialysis. Simultaneous ipsilateral rupture of both tendons however is extremely rare and should therefore not be overlooked. Surgical treatment is recommended for complete ruptures.