Dana J. Farrell

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

OBJECTIVES To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach. DESIGN Retrospective review. SETTING Two level one trauma centres. PATIENTS Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up. INTERVENTION Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients). MAIN OUTCOME MEASUREMENTS Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p=0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p<0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p=0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p=0.333). CONCLUSIONS A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome. LEVEL OF EVIDENCE Level III.

Plate augmentation for femoral nonunion: more than just a salvage tool?

ObjectiveThe aim of the current study was to determine whether plate augmentation was a successful treatment algorithm for selected femoral nonunions initially managed with intramedullary nailing.Materials and methodsA total of 30 femoral nonunion cases were managed using the plate augmentation strategy with 13 primary cases and 17 multi-operated femurs (avg 2.8 ineffective procedures). Adjunctive strategies included autologous bone grafting and/or BMP for atrophic/oligotrophic and bone defect cases. Deformity correction was performed when required.ResultsOsseous union occurred in 29 of 30 cases. One multi-operated case with bone defect and prior infection required repeat autologous grafting prior to union.ConclusionPlate augmentation should be added to the armamentarium for management of selected femoral nonunion that have failed initial intramedullary nailing.

Bicolumnar 90-90 Plating of Low-Energy Distal Humeral Fractures in the Elderly Patient

Fragility fractures of the distal humerus in elderly patients, especially the low transcondylar fracture pattern, can be difficult to optimally manage. Although the fractures are typically low energy resulting in either extra-articular or simple intra-articular patterns, gaining fixation into the distal fragments can be difficult with open reduction internal fixation (ORIF) using traditional 90-90 or parallel plating techniques. Anatomy preserving reconstruction with ORIF is preferred over total elbow arthroplasty (TEA) if possible. In this study, 15 patients were managed with a bicolumnar 90-90 plating construct as a novel method of enhancing distal fixation in these fractures. Fourteen patients went on to radiographic union at an average of 77 days after surgery with an average arc of motion of 105°. One patient was lost to follow-up. Bicolumnar 90-90 plating of distal humerus fractures in elderly patients may represent a viable alternative to traditional ORIF or TEA.

Primary Posterior Blade Plate Tibiotalar Arthrodesis: A Salvage Procedure for Complex Nonreconstructable Pilon Fractures

A subset of C2/C3 pilon fractures, open pilon injuries, metaphyseal bone comminution, and those involving substantial soft tissue or vascular injury may be nonreconstructable. Such injuries are at risk of progress to nonunion and failing open reduction internal fixation (ORIF). The risk of infection, malunion, and nonunion is relatively high with such injury patterns. In such cases, tibiotalar arthrodesis is performed after ORIF fails as a salvage procedure. Overall, the literature agrees that all pilon fractures will develop posttraumatic osteoarthritis, and these patients are ultimately treated with an arthrodesis or in narrow population with total ankle arthroplasty. Given these combined findings, it follows that patients identified as high risk of failing ORIF could benefit from the use of primary arthrodesis. The proposed technique provides a reliable approach designed to achieve ankle fusion. It provides a means to achieve reliable union rates and spares the subtalar joint. In addition, it avoids the anterior soft tissue envelope, and hardware irritation is tempered as the final implants are covered by a muscular layer. Last, patients who are at higher risk of failing ORIF are selected and spared, having to undergo trial ORIF, time to nonunion, work absence, and rehab.

Cadaveric investigation on radial nerve strain using different posterior surgical exposures for extraarticular distal humeral ORIF: merits of nerve decompression through a lateral paratricipital exposure.

Objective: To determine whether the type of posterior surgical approach for distal humeral fracture open reduction and internal fixation influenced radial nerve strain during simulated operative retraction in a cadaveric model. Methods: Three different posterior surgical exposures: triceps splitting, lateral paratricipital, and paratricipital with release of the lateral intermuscular septum were used. Radial nerve strain was measured using a microDVRT, while traction was applied with a digital force gauge at forces 0.1–0.3 kg. Results: The lateral paratricipital with nerve decompression was superior to both the triceps splitting approach (P < 0.048) and paratricipital method without decompression (P < 0.036). There was no significant difference between the triceps splitting method and paratricipital exposure without intermuscular septum release. Conclusions: Radial nerve decompression through release of the lateral intermuscular septum through a lateral paratricipital exposure ideally decreases nerve strain during humeral open reduction and internal fixation in our cadaveric model.

Could Achilles Teondon Ruptures be Associated with Low Serum Free and Total Testosteron Levels

Purpose Serum free testosterone (FT) and total testosterone (TT) level were drawn in males with Achilles tendon rupture at time of injury and compared to healthy normal historical data as a means of evaluating if decreased sex hormone level is a risk factor for tendon injury. We hypothesized that males diagnosed with Achilles tendon ruptures will have lower FT and TT levels than age-matched normal levels in the literature.

Open Reconstruction of Complex Proximal Metadiaphyseal Fragility Fractures of the Humerus

Purpose: A proactive surgical and rehabilitation protocol was implemented to manage humeral fractures involving both the proximal end and shaft in an older patient population. Primary treatment goals were early return to function and reliable fracture union with minimal complications. Methods: From 2008 to 2012, 21 such operations were performed; 18 were considered “fragility” fractures based on mechanism, patient age, and evidence of osteopenia or osteoporosis. Open reduction and internal fixation (ORIF) was employed using direct reduction and fixation with a long periarticular locking plate. Physiotherapy was commenced 2 weeks postoperatively. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was used to assess functional outcome at a time point greater than 1 year postoperative. Results: The study group consisted primarily of elderly females (83% with a median age of 69 years) whom sustained complex metadiaphyseal proximal humeral fractures after simple mechanical fall (78%). Uneventful union occurred in all cases. Local complications included 1 case of partial radial nerve palsy, which had resolved completely by 1 year. No cases of infection were identified. Long-term return to functionality was evident with a median DASH score of 12 (mean = 21, standard deviation = 20, n = 13). Seventy five percent of patients reported minimal or no pain (question [Q] 24), and 75% achieved return of overhead function (Q6, 12, and 15). Conclusion: Treatment of complex metadiaphyseal fragility fractures with anatomic reduction, fixed angle plating, and early physiotherapy returns the older patient to optimized functionality with minimal risk of complication. The DASH outcomes are equivalent to ORIF of isolated proximal humerus fractures and clinically indistinguishable from the general population.