Craig S. Bartlett

Cardiac arrest as a result of intraabdominal extravasation of fluid during arthroscopic removal of a loose body from the hip joint of a patient with an acetabular fracture

The case of a fifty-year-old man who suffered an isolated, associated, both-column fracture of the left acetabulum is presented. He underwent an uncomplicated open reduction and internal fixation through an ilioinguinal approach. A follow-up computed tomographic scan was performed postoperatively, which documented intraarticular fragments. Hip arthroscopy was performed to remove the fragments. During the procedure, arthroscopic fluid extravasated through the fracture site under pump pressure and resulted in an intraabdominal compartment syndrome that presented as cardiopulmonary arrest. An emergent exploratory laparotomy was performed to release the fluid and resume blood flow. Despite prolonged asystole, the patient survived without neurologic sequelae. The literature on compartment syndrome secondary to arthroscopic procedures is reviewed. Because of this previously unreported potentially lethal complication, we do not advocate hip arthroscopic procedures for acute or healing acetabular fractures.

Ballistics and Gunshot Wounds: Effects on Musculoskeletal Tissues

&NA; As a result of the increasing number of weapons in this country, as many as 500,000 missile wounds occur annually, resulting in 50,000 deaths, significant morbidity, and striking socioeconomic costs. Wounds are generally classified as low‐velocity (less than 2,000 ft/sec) or high‐velocity (more than 2,000 ft/sec). However, these terms can be misleading; more important than velocity is the efficiency of energy transfer, which is dependent on the physical characteristics of the projectile, as well as kinetic energy, stability, entrance profile and path traveled through the body, and the biologic characteristics of the tissues injured. Although bullets are not sterilized on discharge, most low‐velocity gunshot wounds can be safely treated nonoperatively with local wound care and outpatient management. Typically, associated fractures are treated according to accepted protocols for each area of injury. Treatment of low‐velocity, low‐energy fractures is generally dictated by the osseous injuries, as these are similar in many regards to closed fractures. Soft tissues play a more critical role in highvelocity and shotgun fractures, which are essentially open injuries. Aside from perioperative prophylaxis, antibiotics are probably required only for grossly contaminated wounds; however, because contamination is not always apparent, most authors still recommend routine prophylaxis. High‐energy injuries and grossly contaminated wounds mandate aggressive irrigation and debridement, including a thorough search for foreign material. Open fracture protocols including external fixation or intramedullary nailing and intravenous antibiotic therapy for 48 to 72 hours should be instituted. If there is vascular damage, exploration and repair are best performed after prompt fracture stabilization. Evaluation of the “four Cs”—color, consistency, contractility, and capacity to bleed—provides valuable information regarding the viability of muscle. Skin grafting is preferable when tension is required for wound closure, although other soft‐tissue procedures, such as use of local rotation flaps or free tissue transfer, may be necessary, especially for shotgun wounds. Distal neurologic deficit alone is not an indication for exploration, as it often resolves without surgical intervention.

Treatment of type II and type III open tibia fractures in children.

OBJECTIVES To determine whether severe open tibial fractures in children behave like similar fractures in adults. DESIGN AND SETTING A combined retrospective and prospective review evaluated treatment protocol for type II and type III open tibial fractures in children over a ten-year period from 1984 to 1993. PATIENTS Twenty-three fractures were studied in children aged 3.5 to 14.5 (18 boys and 5 girls). There were six type II, eight type IIIA, and nine type IIIB fractures. Type I fractures were not included. Seven fractures were comminuted with significant butterfly fragments or segmental patterns. INTERVENTION Treatment consisted of adequate debridement of soft tissues, closure of dead space, and stabilization with external fixation. Bone debridement only included contaminated devitalized bone or devitalized bone without soft tissue coverage. Bone that could be covered despite periosteal stripping was preserved. MAIN OUTCOME MEASUREMENTS Clinical and roentgenographic examinations were used to determine time to union. RESULTS All fractures in this series healed between eight and twenty-six weeks. Wound coverage included two flaps, three skin grafts, and two delayed primary closures. No bone grafts were required. There were no deep infections, growth arrests, or malunions. Follow-up has ranged from six months to four years. CONCLUSIONS Open tibia fractures in children differ from similar fractures in adults in the following ways: soft tissues have excellent healing capacity, devitalized bone that is not contaminated or exposed can be saved and will become incorporated, and external fixation can be maintained until the fracture has healed. Periosteum in young children can form bone even in the face of bone loss.

Outer Gloves in Orthopaedic Procedures: A Polyester/stainless Steel Wire Weave Glove Liner Compared with Latex

OBJECTIVE To compare the efficacy of traditional double latex gloving with that of a highly cut-resistant polyester/stainless steel wire weave glove (PSSWWG) over a single latex inner glove for the prevention of perforation of the inner latex glove. DESIGN The primary surgeon and first assistant were involved in a prospective randomized study. Group I consisted of twenty-five procedures in which double latex gloves were used. Group II consisted of twenty-five procedures in which a PSSWWG liner was worn over an inner latex glove. All inner gloves were tested for perforations; all gloves exchanged that were presumed to have a perforation were noted and also tested. The type and length of the procedure were recorded. The dominant hand was recorded for all participants, along with their comments on the PSSWWG liners performance. SETTING Orthopaedic Trauma Service, Hospital for Special Surgery. New York. PATIENTS/PARTICIPANTS Major operative cases, November 1996 to February 1997. MAIN OUTCOME MEASUREMENTS Inner latex glove perforations. RESULTS With the use of PSSWWG liners, the percentage of inner gloves found with a perforation dropped from 19 percent in the double latex group to 15 percent in the PSSWWG liner group (not statistically significant, p = 0.4). Two thirds of the perforations were in the primary surgeons gloves, located in either the index finger or thumb. Nearly 80 percent of all perforations went unrecognized in both groups. Ninety-five percent of all perforations were in gloves that had been in use for more than 120 minutes (statistically significant, p = 0.01). CONCLUSIONS The particular cut-resistant glove studied (Sceptor) did not significantly reduce the rate of inner glove perforations. Other studies with different cut-resistant glove types and protocols have proven the liners effective. We would still recommend using outer cloth or cut-resistant type gloves when bone fragments are being manipulated or when using sharp implants or saws. At a minimum, surgical gloves should be changed every two hours.

Bladder incarceration in a traumatic symphysis pubis diastasis treated with external fixation : A case report and review of the literature

Fractures of the pelvis constitute a small but significant proportion of skeletal injuries. However, they are associated with significant morbidity and mortality, including damage to the urogenital system, especially the urethra and urinary bladder. We report the rare finding of bladder herniation and entrapment after reduction of a traumatic symphyseal diastasis by external fixation and the diagnosis of these injuries with computed tomography. A comprehensive review of the literature is also performed, to improve understanding and provide guidelines for evaluation and treatment of pelvic injuries with suspected bladder involvement.

A Three-dimensional Comparison of Intramedullary Nail Constructs for Osteopenic Supracondylar Femur Fractures

Objectives: This study developed a new 6 degree-of-freedom, unconstrained biomechanical model that replicated the in vivo loading environment of femoral fractures. The objective of this study was to determine whether various distal fixation strategies alter failure mechanisms and/or offer mechanical advantages when performing retrograde intramedullary nail (IMN) stabilization of supracondylar femur fractures in osteoporotic bone. Methods: Forty fresh-frozen human femora were allocated into 2 groups of matched pairs: “locked” (fixed angle locking construct with both distal locking screws rigidly attached to the IMN) versus “unlocked” (conventional locking technique with 2 distal locking screws targeted through the distal locking screw holes of the IMN) and “locked” versus “washer” (fixed angle locking with the most distal screw exchanged for a bolt with condyle washers) distal fixation of a retrograde IM nails. A comminuted fracture (OTA 33-A3) was simulated with a wedge osteotomy. Bone density measurements were completed on all specimens before instrumentation. Instrumented femurs were loaded axially to failure, whereas 6 degree-of-freedom translations and angulations were measured using Roentgen stereophotogrammetric analysis. Results: Mean (±SD) load born by “locked” specimens (1609 ± 667 N) at clinical failure was 38.1% greater (P = 0.09) than the corresponding mean load born by “unlocked” specimens (1165 ± 772 N). Clinical failure for the “washer” group (1738 ± 772 N) was 29.9% greater (P = 0.07) than the corresponding mean of the “locked” counterparts (1338 ± 822 N). Failure load was most clearly related to bone density in the “unlocked” fixation group. Conclusions: Predicting failure load based on bone density using a least squares estimate suggests that the washer construct provides superior fixation to other treatment techniques. The failure mechanism for a comminuted, supracondylar fracture cannot be analyzed accurately with a 1-dimensional measurement. The most common failure mechanism in this model was medial translation and varus angulation.

Compliance with the Eastern Association for the Surgery of Trauma guidelines for prophylactic antibiotics after open extremity fracture

Context: Prophylactic antibiotics, paired with wound care and surgical intervention, is considered the standard of care for patients with open fracture. Guidelines from the Eastern Association for the Surgery of Trauma (EAST) recommend specific prophylactic antimicrobial therapy based on the type of open fracture. Aims: We quantified adherence to EAST guideline recommendations and documented the incidence of infection in patients with open fracture. Settings and Design: A retrospective, observational study of all patients with open fracture admitted to our facility from January 2004 to December 2008 was conducted. Materials and Methods: Patients were divided into compliant and noncompliant groups according to the EAST guideline recommendations. Compliance was defined as an appropriate spectrum of therapy for guideline suggested duration. We assessed for surgical and non-surgical site infections, and morbidity outcomes. Statistical Analysis: Nominal data were explored using summary measures. Continuous variables were compared using the Student t-test or the Mann–Whitney U-test. Dichotomous data were compared using χ2 statistic or Fishers exact test. Results: The final analysis included 214 patients. Prophylactic antibiotics were guideline compliant in 28.5% of patients, and ranged from 10.0% in type 3b fractures to 52.7% in type 1 fractures. The most common reason for non-compliance was the use of guideline recommended coverage that exceeded the suggested duration (71.2%). Patients who received non-compliant therapy required prolonged hospital lengths of stay (6 vs. 3 days, P = 0.0001). The overall incidence of infection was similar regardless of guideline compliance (17.0% vs. 11.5%, P = 0.313). Conclusions: Prophylactic antibiotics for open fracture frequently exceeded guideline recommendations in duration and spectrum of coverage, especially in more severe fracture types. Non-compliance with EAST recommendations was associated with increased in-hospital morbidity.

Surgical Site Infections in Patients With Type 3 Open Fractures: Comparing Antibiotic Prophylaxis With Cefazolin Plus Gentamicin Versus Piperacillin/Tazobactam.

Objectives: The purpose of this study was to compare rates of surgical site infection (SSI) in patients with type 3 open fractures who had received cefazolin plus gentamicin versus piperacillin/tazobactam for antibiotic prophylaxis. Design: Retrospective cohort study. Setting: Level 1 trauma center. Patients: Seven hundred sixty-six patients admitted between January 1, 2004, and December 31, 2012, with open fractures were identified using the National Trauma Data Bank by searching International Classification of Diseases, Ninth Revision (ICD-9) codes. Electronic medical record review revealed 134 patients with type 3 open fractures, of which 72 were included in the final analysis. Intervention: Administration of cefazolin plus gentamicin or piperacillin/tazobactam for type 3 open fracture antibiotic prophylaxis. Main Outcome Measurements: SSI, nonunion, death, and rehospitalization rates at 1 year. Results: Surgical site infection at 1 year occurred in 12 of 37 patients (32.4%) in the cefazolin plus gentamicin group and 11 of 35 patients (31.4%) in the piperacillin/tazobactam group (P = 1.000). Nonunion, death, and rehospitalization rates at 1 year were similar between the 2 groups. Although there was no statistically significant difference in SSI at 30 days between groups, the rate was higher in the cefazolin plus gentamicin group (21.6% vs. 11.4%; P = 0.246). Conclusions: At our institution, use of piperacillin/tazobactam as compared with cefazolin plus gentamicin for antibiotic prophylaxis in patients with type 3 open fractures showed similar rates of SSI, nonunion, mortality, and rehospitalization at 1 year after injury. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral head reduction osteoplasty for fracture dislocation: A surgical technique

BACKGROUND Femoral head fractures with subchondral impaction and cartilage loss are difficult to treat successfully. Although multiple surgical management options have been described, no one technique has proven superior, particularly in the young high-demand population. TECHNIQUE A femoral head reduction osteoplasty was performed following a surgical dislocation of the hip. A peripherally based wedge of bone was resected off the damaged central third of the head followed by reduction and fixation of the remaining fragments. This technique resulted in a smaller yet congruent femoral head. METHODS A healthy 40-year old labourer sustained a traumatic crush injury while at work, resulting in a left femoral head fracture dislocation with an associated posterior wall acetabular fracture. Significant femoral head impaction and cartilage loss limited the treatment options. RESULTS Intraoperative reduction and postoperative imaging demonstrated near anatomic reconstruction of femoral head with a congruent hip joint. Superiorly at the level of resection, the medial-lateral diameter was reduced by 5-6mm (approximately 12-15% the diameter of the original head) by the osteoplasty. At five years, Harris Hip Score was 86, Oxford Hip Score 36, and UCLA score 89. Hip abductor strength was full, range of motion near normal, and the patient ambulated without antalgia. Radiographs demonstrate a congruent joint and patchy avascular necrosis without collapse. The patient maintained full employment as a labourer. CONCLUSIONS Femoral head reduction osteoplasty is a viable option that may produce durable intermediate-term results for complex femoral head fracture with superior impaction and chondral damage. LEVEL OF EVIDENCE Level V.

Calcaneal fracture-dislocation with fracture of the sustentaculum and lateral column: a unique injury pattern.

Calcaneus fractures associated with dislocation of the subtalar joint are uncommon but potentially devastating injuries. Anterior subtalar dislocations are especially rare, with some disagreement in the literature on what defines this injury pattern. Talonavicular joint dislocation has been invariably described as a component of the injury. The purpose of this report was to describe a unique highenergy injury pattern not well described in the literature and to report the outcomes with different initial treatments. We present a series of patients with a variant injury pattern that includes fracture of the sustentaculum, anterolateral dislocation of the subtalar joint, and fracture of the calcaneocuboid joint causing shortening of the lateral column, without injury to the talonavicular joint.