Brian P. Scannell

Maintenance of hardware after early postoperative infection following fracture internal fixation.

BACKGROUND The development of a deep wound infection in the presence of hardware after open reduction and internal fixation presents a clinical dilemma, and there is scant literature to aid in decision-making. The purpose of the present study was to determine the prevalence of osseous union with maintenance of hardware after the development of postoperative infection within six weeks after internal fixation of a fracture. METHODS The present study included 121 patients from three level-I trauma centers, retrospectively identified from billing and trauma registries, in whom 123 postoperative wound infections with positive intraoperative cultures had developed within six weeks after internal fixation of acute fractures. The incidence of fracture union without hardware removal was calculated, and the parameters that predicted success or failure were evaluated. RESULTS Eighty-six patients (eighty-seven fractures; 71%) had fracture union with operative débridement, retention of hardware, and culture-specific antibiotic treatment and suppression. Predictors of treatment failure were open fracture (p = 0.03) and the presence of an intramedullary nail (p = 0.01). Several variables were not significant but trended toward an association with failure, including smoking, infection with Pseudomonas species, and involvement of the femur, tibia, ankle, or foot. CONCLUSIONS Deep infection after internal fixation of a fracture can be treated successfully with operative débridement, antibiotic suppression, and retention of hardware until fracture union occurs. These results may be improved by patient selection based on certain risk factors and the specific bacteria and implants involved.

Skeletal Traction Versus External Fixation in the Initial Temporization of Femoral Shaft Fractures in Severely Injured Patients

BACKGROUND : Damage control with external fixation (DC-EF) of femoral shaft fractures in polytrauma patients is becoming standard treatment in many trauma centers. However, skeletal traction (ST) has long been used in the temporization of fractures. The purpose of this study was to compare the major physiologic clinical outcomes of provisional ST with DC-EF of femoral shaft fractures in severely injured patients. METHODS : We retrospectively reviewed 205 patients sustaining blunt trauma, a femoral shaft fracture, and an Injury Severity Score > or =17 from 2001 to 2007 at a level I trauma center. Patients underwent definitive fixation in the first 24 hours with intramedullary nailing (IMN) (N = 126), initial DC-EF with delayed definitive treatment (N = 19), or initial ST with delayed definitive treatment (N = 60). Incidences of adult respiratory distress syndrome, multiple organ failure, sepsis, pneumonia, pulmonary embolism, and deep vein thrombosis were evaluated. Length of stay (LOS), intensive care unit LOS, days of mechanical ventilation, and mortality were also compared. RESULTS : There were no significant differences between ST and DC-EF groups in age, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score on arrival, mean time to definitive fixation (4.1 days versus 5.0 days, respectively), or Abbreviated Injury Scale for chest. However, the ST group had a higher Abbreviated Injury Scale-head (2.5 versus 1.0, p = 0.0026). There were no significant differences in subsequent rates of adult respiratory distress syndrome, multiple organ failure, pulmonary embolism, deep vein thrombosis, pneumonia, mechanical ventilation days, intensive care unit LOS, and death. However, the ST group had a lower rate of sepsis (8.3% versus 31.6%, p = 0.0194) and a shorter LOS (26.5 days versus 36.2 days, p = 0.0237) than the EF group. CONCLUSION : DC-EF of femur fractures in severely injured patients offers no significant advantage in clinical outcomes compared with ST. Unless initially subjected to general anesthesia for life saving procedures, the use of ST as a temporization method remains a practical option.

Lower extremity joint kinematics during stair climbing in knee osteoarthritis.

PURPOSE Knee osteoarthritis (OA) is one of the most prevalent chronic lower extremity diseases, causing profound limitation of movement and ability to perform activities of daily living. The purpose of this study was to compare various hip, knee, and ankle joint kinematic variables between knee OA subjects and matched healthy controls during stair ascent and descent. METHODS Eighteen subjects with knee OA (age = 60.2 ± 9.9 yr, mass = 90.3 ± 16.7 kg, height = 168.4 ± 9.9 cm) and 18 healthy matched controls (age = 60.3 ± 10.7 yr, mass = 81.1 ± 21.2 kg, height = 168.3 ± 11.9 cm) participated in the study. Subjects performed five ascending and descending trials on a custom-built staircase while their motion was captured three-dimensionally using an eight-camera optical video motion capture system. RESULTS Significant group × direction interactions were found for average hip flexion angle at foot strike (P = 0.04), for average ankle adduction angle at foot strike (P = 0.01), and for peak ankle dorsiflexion angle during support (P = 0.05) and swing (P = 0.01). Specifically, knee OA and control subjects demonstrated greater hip flexion angle at foot strike and ankle dorsiflexion angle during swing but showed smaller ankle dorsiflexion angle during support during stair ascent compared with descent. Furthermore, compared with controls, knee OA patients demonstrated greater hip abduction at foot strike (-3.1° ± 3.9°) and smaller peak knee flexion during support (60.4° ± 5.0°) and swing (86.7° ± 5.4°). Time of peak hip abduction (34.2% ± 7.1%), hip flexion (7.0% ± 12.3%), knee flexion (69.8% ± 4.6%), dorsiflexion (51.4% ± 2.9%), and ankle adduction (37.3% ± 20.8%) during support occurred later in the gait cycle for knee OA patients. CONCLUSIONS These data demonstrate that knee OA directly influences specific knee joint kinematics and induces kinematic alterations at the hip and ankle perhaps to compensate for the existing knee joint pathology.

The Perfused, Pulseless Supracondylar Humeral Fracture: Intermediate-Term Follow-up of Vascular Status and Function

BACKGROUND This study provides intermediate-term follow-up data on the vascular status of a cohort of children with a perfused, pulseless supracondylar humeral fracture who were managed with closed reduction, percutaneous pinning, and observation. METHODS Pediatric patients who sustained a perfused, pulseless supracondylar humeral fracture in the period from 2007 to 2011 and who had at least six months of clinical follow-up were identified and returned for evaluation. The primary outcome was vascular status as indicated by palpation of the radial pulse, the wrist brachial index, and arterial patency on duplex ultrasound. Secondary outcomes included functional parameters assessed with the Pediatric Outcomes Data Collection Instrument (PODCI), arm circumference, arm length, elbow motion, neurologic findings, muscle endurance, grip strength, and intolerance to cold. RESULTS Follow-up data were obtained for twenty of thirty-six patients with a Gartland type-III fracture who had been managed with closed reduction and percutaneous pinning. Five patients had a return of a palpable pulse in the operating room after closed reduction and percutaneous pinning. All twenty had a palpable radial pulse at the time of the latest follow-up, and all nerve palsies resolved. Duplex ultrasound performed at the time of follow-up showed that fourteen patients had a patent brachial artery, five had brachial artery occlusion with large collateral vessels, and one had severe arterial stenosis. All fourteen patients with a patent brachial artery, two of the five with an occluded brachial artery, and the patient with a stenotic brachial artery had a normal wrist brachial index. Three patients with an occluded brachial artery had an abnormal wrist brachial index (0.73, 0.71, and 0.80). No differences between the injured and uninjured sides were observed with regard to arm circumference, arm length, elbow motion, muscle endurance, or grip strength. Thirteen of the twenty patients had higher functioning in all domains of the PODCI questionnaire compared with the general population. Two patients (one with an occluded artery and one with a patent artery) had lower values on the global functioning score. CONCLUSIONS After an average of twenty months of follow-up, children with a perfused, pulseless supracondylar humeral fracture that had been treated with closed reduction, percutaneous pinning, and observation demonstrated a palpable distal radial pulse, normal growth of the arm, and good/excellent functional outcomes, although five of the twenty patients had an occluded brachial artery. LEVEL OF EVIDENCE Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of intraoperative red blood cell salvage and autotransfusion in the treatment of acetabular fractures.

Objectives: To determine if cell saver (CS) use in patients with acetabular fractures reduces the volume or rate of allogeneic blood transfused intraoperatively and postoperatively and if this translated to a decrease in blood-related charges to the patient. Design: Retrospective review. Setting: Level 1 trauma center. Patients: One hundred eighty-six patients with operatively treated acetabular fractures. Intervention: All patients underwent open reduction internal fixation of their acetabular fracture. The decision to use CS was at the surgeons discretion. Main Outcome Measurements: The volume and rate of intraoperative and postoperative allogeneic blood transfused and blood-related charges were evaluated. Results: CS was used in 60 cases (32%), and the average volume of blood autotransfused was 345 mL. No differences were observed in the rates (58.3% vs 48%, P = 0.1883) or the mean volumes (770 vs 518 mL, P = 0.0537) of intraoperative and postoperative allogeneic blood transfusions between the CS and the non-CS groups. Total blood-related charges in the CS group were significantly higher than that in the nonCS group (

Cell-based tissue engineering augments tendon-to-bone healing in a rat supraspinatus model

1958 vs

Although Inconvenient, Baclofen Pumps Do Not Complicate Scoliosis Surgery in Patients with Cerebral Palsy

694, P < 0.0001). Subanalyses based on fracture pattern, injury severity score, body mass index, days to surgery, and estimated blood loss were performed. In each subanalyses, no differences were observed in intraoperative and postoperative transfusion rates and volumes, and total blood-related charges were higher in the CS groups. Conclusions: In the routine use of CS in acetabular surgery, there was no reduction in the volume or rate of allogeneic blood transfused intraoperatively or postoperatively. However, blood-related charges were significantly increased.

Surgical Correction of Scoliosis in Patients With Duchenne Muscular Dystrophy: 30-Year Experience.

Rotator cuff pathology causes substantial pain/disability and health care costs. Cell‐based tissue engineering offers promise for improved outcomes in tendon to bone healing. Cells from the tendon‐bone interface were used here to amplify surgical defect healing in a rat model. Cells from tendon‐to‐bone interface of the rotator cuff were seeded in sponges and implanted into critical rotator cuff defects: Group I, control; II, surgical defect only; III, suture‐repaired defect; IV, surgical defect, repair with sponge only; V, surgical defect, repair with sponge with cells. Three, 6‐, and 12‐week results were assessed for histologic features. At 3 weeks, histologic indices in Group V were significantly increased versus other treatment groups. Group V (12 weeks) showed significantly improved collagen organization versus other treatment groups; there was no difference in collagen organization in Group I versus V. In summary, increased cellularity, inflammation, vascularity, and collagen organization were present at 3 weeks; increased collagen organization at 12 weeks in Group V provides evidence for improved healing with cells. Data further support the utility of tendon‐bone interface cells in rotator cuff healing.

Orthopaedic firearm injuries in children and adolescents: An eight-year experience at a major urban trauma center.

Study Design. Retrospective review of prospectively collected data. Objective. To compare patients with operative cerebral palsy with and without an intrathecal baclofen pump (ITB) to determine whether an ITB increases the complexity of scoliosis surgery and/or increases the risk of wound complications. Summary of Background Data. Options for baclofen pump placement include before, during, or after scoliosis surgery. There is some concern that prior placement of an ITB and catheter can further complicate cerebral palsy scoliosis surgery and increase the risk for wound complications. Methods. Prospectively collected cases from a multicenter cerebral palsy scoliosis database were reviewed for patients who underwent posterior spinal instrumentation and fusion for a major coronal deformity. These patients were then divided on the basis of whether they had ITB at the time of initial scoliosis surgery. The 2 groups were compared to determine differences in demographics, operative parameters, radiographical outcomes, and rates of wound complications. Results. Of 187 patients identified, 32 had an ITB previously placed (ITB group) and 155 did not (non-ITB group). Both groups were similar in regard to age, sex, Gross Motor Function Classification Scale score, and preoperative Cobb magnitude. When comparing operative parameters, there were no differences in the total operating room time (ITB = 375 ± 127 min, non-ITB = 423 ± 178 min; P = 0.149) or total estimated blood loss (ITB = 2323 ± 1489 mL, non-ITB = 2081 ± 1572 mL; P = 0.424). Postoperatively, the 2 groups had similar correction rates (71% vs. 67%, P = 0.303). As for perioperative wound complications, there were no differences in rates (P = 0.546) between the ITB (16%) and non-ITB group (15%). Conclusion. Although it may be inconvenient for the surgeon, ITBs do not increase the complexity of surgery or the risk for wound complications. When counseling patients and their caregivers on the timing of pump placement, it does not seem to compromise the care of the patient if the baclofen pump is placed first. Further study is needed to evaluate the safety of pump placement during or after scoliosis surgery. Level of Evidence: 4

Cartilage Degeneration, Subchondral Mineral and Meniscal Mineral Densities in Hartley and Strain 13 Guinea Pigs

Background: The natural history of scoliosis in Duchenne muscular dystrophy (DMD) is progressive and debilitating if neglected. The purpose of this study was to evaluate outcomes related to spinal deformity surgery in patients with DMD over a 30-year period. Methods: This was a single center retrospective study of all operatively treated scoliosis in DMD patients over 30 years. Minimum follow-up was 2 years. Owing to changes in instrumentation over time, patients were divided into 2 groups: Luque or pedicle screws (PS) constructs. Radiographic, perioperative variables, pulmonary function test (preoperatively and postoperatively), and complication data were evaluated. Results: There were 60 subjects (Luque: 47, PS: 13). The Luque group was on average 13 years old, 53 kg, and had 7 years of follow-up. Coronal Cobb was 31±12 degrees preoperatively, 16±11 degrees at first postoperatively, and 21±15 degrees at final follow-up (P⩽0.001). Pelvic obliquity was 7±6 degrees preoperatively, 5±5 degrees at first postoperatively (P=0.43), and 5±4 degrees at final follow-up (P=0.77). The majority of this group was fused to L5 (45%) or the sacrum (49%). The PS group was on average 14 years old, 65 kg, and had 4 years of follow-up. Coronal Cobb was 43±19 degrees preoperatively, 12±9 degrees at first postoperatively (P⩽0.001), and 12±8 degrees at final follow-up. Pelvic obliquity was 6±5 degrees preoperatively, 3±3 degrees at first postoperatively (P=0.06), and 2±2 degrees at final follow-up (P=0.053). The majority were fused to the pelvis (92%). Both groups’ pulmonary function declined with time. Both groups had high complication rates (Luque 68%; PS group 54%). The Luque group had more implant-related complications (26%); the PS group had a higher rate of early postoperative infections (23%). Conclusions: Over a 30-year period of operative treatment of scoliosis in DMD, both PS constructs and Luque instrumentation improved coronal Cobb. The PS group had improved and maintained pelvic obliquity. Both groups had high complication rates. Level of Evidence: Level IV—therapeutic.