Daniel R. Schlatterer

Negative Pressure Wound Therapy in Grade IIIB Tibial Fractures: Fewer Infections and Fewer Flap Procedures?

BackgroundGrade IIIB open tibia fractures are devastating injuries. Some clinicians advocate wound closure or stable muscle flap coverage within 72 hours to limit complications such as infection. Negative pressure wound therapy was approved by the FDA in 1997 and has become an adjunct for many surgeons in treating these fractures. Opinions vary regarding the extent to which negative pressure wound therapy contributes to limb salvage. Evidence-based practice guidelines are limited for use of negative pressure wound therapy in Grade IIIB tibia fractures. This systematic literature review of negative pressure wound therapy in Grade IIIB tibia fractures may substantiate current use and guide future studies.Questions/purposesWe sought to answer the following: (1) Does the use of negative pressure would therapy compared with gauze dressings lead to fewer infections? (2) Does it allow flap procedures to be performed safely beyond 72 hours without increased infection rates? (3) Is it associated with fewer local or free flap procedures?MethodsWe conducted a systematic review of six large databases (through September 1, 2013) for studies reporting use of negative pressure wound therapy in Grade IIIB open tibia fractures, including information regarding infection rates and soft tissue reconstruction. The systematic review identified one randomized controlled trial and 12 retrospective studies: four studies compared infection rates between negative pressure wound therapy and gauze dressings, 10 addressed infection rates with extended use, and six reported on flap coverage rates in relation to negative pressure wound therapy use beyond 72 hours. None of the 13 studies was eliminated owing to lack of study quality.ResultsNegative pressure wound therapy showed a decrease in infection rates over rates for gauze dressings in two of four studies (5.4% [two of 35] versus 28% [seven of 25], and 8.4% [14 of 166] versus 20.6% [13 of 63]), an equivalent infection rate in one study (15% [eight of 53] versus 14% [five of 16]), and an increased infection rate in the fourth study (29.5% [23 of 78] versus 8% [two of 25]). In terms of the second question regarding infection rates with negative pressure wound therapy beyond 72 hours, eight of 10 studies concluded there was no increase in infection rates, whereas two of 10 reported an increase in infection rates associated with negative pressure wound therapy use beyond 72 hours. Infection rates varied from 0% to 57% in these 10 studies. Five studies reported low infection rates of 0% to 7% and five reported rates of 27% to 57%. The third question (addressed by six studies) regarded the potential decreased use of a soft tissue flap in patients treated with extended negative pressure wound therapy. Flap rates were reduced by 13% to 60% respectively compared with those of historical controls. Grade IIIB tibia fractures by definition required soft tissue procedures. The patients in these six studies had Grade IIIB tibia fractures after the first débridement. However, after extended negative pressure wound therapy, fewer patients required flaps than grading at the first débridement would have predicted.ConclusionsThere is an increasing body of data supporting negative pressure wound therapy as an adjunctive modality at all stages of treatment for Grade IIIB tibia fractures. There is an association between decreased infection rates with negative pressure wound therapy compared with gauze dressings. There is evidence to support negative pressure wound therapy beyond 72 hours without increased infection rates and to support a reduction in flap rates with negative pressure wound therapy. However, negative pressure wound therapy use for Grade IIIB tibia fractures requires extensive additional study.Level of EvidenceLevel III, therapeutic study.

Optimal parameters to avoid thermal necrosis during bone drilling: A finite element analysis

The drilling bone may potentially cause excessive frictional heat, which can lead to local bone necrosis. This heat generation and local necrosis has been suggested to contribute to the resorption of bone around the placed screws, ending in loss of screw purchase in the bone and inadvertent loosening and/or the bone‐implant construct. In vivo studies on this subject have inherent obstacles not the least of which is controlling the variables and real time bone temperature data acquisition. Theoretical models can be generated using computer software and the inclusion of known constants for the mechanical properties of metal and bone. These known Data points for the variables (drill bit and bone) enables finite element analysis of various bone drilling scenarios. An elastic–plastic three‐dimensional (3D) acetabular bone mode was developed and finite element model analysis (FEA) was applied to various simulated drilling procedures. The FEA results clearly indicate that the depth of drilling and the drill speed both have a significant effect on the temperature during drilling procedures. The reduction of the feeding speed leads to a reduction in bone temperature. Our data suggests that reducing the feeding speed regardless of RPMs and pressure applied could be a simple useful and effective way to reduce drilling temperatures. This study is the first step in helping any surgeon who drills bone and places screws to better understand the ideal pressure to apply and drill speed to employ and advance rate to avoid osteonecrosis.

Orthopaedic tumors: What problems are we solving, and are universities and major medical centers doing enough?

Little has been published about the complexity of orthopaedic tumors compared to others tumors. The current study in the literature treated this problem in terms of classification, surgical intervention and impact on the patient. In this article, factors risks of tumors will be we identified. A strategy based on three dimensional simulations will be explained in order to improve the clinical trials.

Reply to Letter to the Editor: Negative Pressure Wound Therapy in Grade IIIB Tibial Fractures: Fewer Infections and Fewer Flap Procedures?

W e would like to support the interesting conclusions from a systematic review recently presented by Schlatterer and colleagues [1]. Their study addresses treatment for Grade IIIB tibial fractures and points to negative pressure wound therapy as an option that is changing the way many traumatologists think about the treatment of these difficult-to-manage wounds. As Schlatterer and colleagues point out, some clinicians support wound closure or stable muscle flap coverage within 72 hours to limit complications. The authors, however, found evidence to suggest that negative pressure wound therapy can be performed safely beyond 72 hours without increasing the risk of infection. These complex wounds can cause terrible morbidity and constitute a public health problem for many centers [2]. Through the years, researchers have devised a hierarchy of procedures within a hypothetical reconstructive ladder to guide the surgical treatment of wounds. This traditional reconstructive ladder, in its various iterations, subsequently has become a paradigm that helps to inform the choice of closure method across an array of defects. Currently, the increased availability of negative pressure wound therapy has illuminated its key benefits, including faster granulation tissue formation, less periwound edema, decreased closure time, less-frequent dressing changes, control of bacterial proliferation, and potential cost reduction. Although Janis et al. [3] have now incorporated negative pressure wound therapy as a new step in the traditional reconstructive ladder, we are advocating a different approach. In our experience, a descent in the usual reconstructive ladder (that is, from flaps to skin grafts or primary closure) is feasible if neoadjuvant negative pressure wound therapy is applied in the course of treating some complex wounds. This downscaled approach was taken in 106 patients with complex wounds seen between February 2011 and August 2014. All patients were initially subjected to negative pressure wound therapy via VAC system (Kinetic Concepts Inc, San Antonio, TX, USA). In 90 patients whose wounds were measured, the average wound area was 87 cm. (RE: Schlatterer DR, Hirschfeld AG, Webb LX. Negative pressure wound therapy in grade IIIB tibial fractures: Fewer infections and fewer flap procedures? Clin Orthop Relat Res. 2015;473:1802–1811). The authors certify that they, or any member of their immediate families, have no commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. J. A. Farina Jr MD, PhD (&), C. E. F. de Almeida MD, PhD, E. G. S. C. Marques MD, J. L. G. Jorge MD, R. V. K. S. Lima MD Division of Plastic Surgery of Department of Surgery and Anatomy, Ribeirão Preto Medical School of University of São Paulo-Brazil, Av. Bandeirantes, 3900 Monte Alegre, Ribeirão Preto, São Paulo 14049-900, Brazil e-mail: jafarinajr@fmrp.usp.br Letter to the Editor Published online: 21 August 2015 The Association of Bone and Joint Surgeons1 2015

A review of translational medicine. The future paradigm: how can we connect the orthopaedic dots better?

Abstract Introduction: Patients with complex medical and surgical problems often travel great distances to prestigious university medical centers in search of solutions and in some cases for nothing more than a diagnosis of their condition. Translational medicine (TM) is an emerging method and process of facilitating medical advances efficiently from the scientist to the clinician. Most established clinicians and those in training know very little about this new discipline. The purpose of this article is to illustrate TM in varied scientific, medical and surgical fields. Materials and methods: Anecdotal events in medicine and orthopaedics based upon a practicing orthopaedic surgeons training and clinical experience are presented. Results: TM is rapidly assuming a greater presence in the medical community. The National Institute of Health (NIH) recognizes this discipline and has funded TM projects. Numerous institutions in Europe and the USA offer advanced degrees in TM. Finally there is a European Society for Translational Medicine (EUTMS), an International Society for Translational Medicine, and an Academy of Translational Medical Professionals (ATMP). Discussion: The examples of TM presented in this article support the argument for the formation of more TM networks on the local and regional levels. The need for increased participation of researchers and clinicians requires further study to identify the economic and social impact of TM. Conclusions: The examples of TM presented in this article support the argument for the formation of more TM networks on the local and regional levels. Financial constraints for TM can be overcome by pooling government, academic, private, and industry resources in an organized fashion with oversight by a lead TM researcher.

Innervation of the Elbow Joint: A Cadaveric Study

PURPOSE To describe elbow innervation patterns in 15 cadaveric extremities. METHODS Fifteen fresh-frozen cadaveric upper extremities were dissected under loupe magnification. The median, radial, musculocutaneous, and ulnar nerves were dissected at the elbow joint and explored both proximally and distally to find capsular branches and identifiable anatomical patterns. RESULTS In 11 of specimens, the ulnar nerve innervated the articular surface of the elbow joint with an average 1.5 branches. The radial nerve gave off a branch to the posterolateral capsule in 10 cases of the specimens, originating 11 ± 3 cm above the lateral epicondyle. After piercing the lateral intermuscular septum, this radial nerve branch innervated the anterolateral capsule in 12 cases (80%). The median nerve sent branches to the joint in 1 specimen. The musculocutaneous nerve innervated the anterior capsule with 1 or 2 branches in 10 of 13 specimens. CONCLUSIONS The majority of the innervation of the anterior capsule comes from the radial and musculocutaneous nerves with minimal contribution from the median nerve. The ulnar and radial nerves innervate the posteromedial and posterolateral capsule, respectively. CLINICAL RELEVANCE Accurate understanding of peripheral nerve anatomy is essential for future elbow denervation studies.