David L. Rothberg

Reducing the Risk of Bone Cement Implantation Syndrome During Femoral Arthroplasty

Patients with pathologic hip fractures or impending pathologic proximal femur fractures are at a high risk for developing bone cement implantation syndrome during cemented femoral arthroplasty. Comorbid conditions of patients who sustain these fractures, including cardiopulmonary compromise and permeable, highly vascular bone related to metastatic disease, put them at risk for sudden death. Reducing intraoperative intramedullary pressure, a modifiable intraoperative intervention, may decrease this risk. The goals of this study were to determine the pressure generated by low- and high-viscosity cement during femoral implantation and the pullout strength of the bone-cement-implant interface.Ten pairs of cadaveric femurs were divided into 2 groups: those receiving low-viscosity cement and those receiving high-viscosity cement during femoral arthroplasty. Pressure was recorded with sensors implanted in the lateral femoral cortex at proximal, middle, and distal implant positions in both groups during cement insertion and prosthesis implantation. Each construct underwent pullout failure testing after thorough cement curing. Significantly higher pressures were generated with high-viscosity cement for implant fixation, whereas the pullout force to failure was similar between groups.Low-viscosity cementation may be used to reduce the risk of bone cement implantation syndrome in high-risk patients with pathologic hip fractures or impending pathologic proximal femur fractures. The proposed mechanism of risk reduction is through lower intramedullary pressure with no bone-cement-implant interface pullout strength reduction. Further clinical trials are needed to prove this biomechanical effect.

Fractures of the Proximal Humerus

Proximal humeral fractures are common, with low-energy injuries occurring in the elderly population and less frequent high-energy fractures striking young people. This article discusses the anatomy, clinical evaluation, and treatment of these fractures.

Tibial Nailing with the Knee Semi-Extended: Review of Techniques and Indications: AAOS Exhibit Selection.

Tibial shaft fractures are the most common long bone fractures, with an incidence of approximately twenty-six per 100,000 per year1. Intramedullary nailing has become the preferred treatment for the majority of unstable diaphyseal tibial fractures. A large body of literature documents a high rate of union, acceptable alignment in all planes, and a low complication rate when diaphyseal tibial fractures are treated with intramedullary nailing2,3. Intramedullary nailing is increasingly being applied to a broader range of tibial fracture patterns, including open injuries, proximal and distal metaphyseal fractures, and fractures with intra-articular extension3-6. Historically, intramedullary nailing of the tibia has been most commonly performed with the knee in a deeply flexed (120° to 130°) position as originally described by Kuntscher in the 1940s2. Transpatellar and parapatellar approaches have been described, and these necessitate knee flexion in order to avoid injury to the patella7,8. Although intramedullary nailing of the tibia has been refined substantially over the years and has proven to be successful for a variety of fracture patterns, challenges persist. With traditional intramedullary tibial nailing performed with the knee flexed, maintenance of reduction and mitigation of deforming forces are especially difficult with fractures in the proximal one-quarter of the tibia9. Although the literature is still inconclusive, concern also remains regarding persistent knee pain after tibial nailing with the knee flexed10,11. Lastly, we believe that intramedullary nailing of the tibia with the knee flexed makes it challenging to acquire adequate intraoperative fluoroscopic imaging and to place supplemental fixation or convert to an open reduction when necessary. Semi-extended tibial nailing was initially developed by Tornetta and Collins12 for proximal-quarter tibial fractures, but it is being increasingly applied as a tool …

Capsular Tear in Line With the Inferior Glenohumeral Ligament: A Cause of Anterior Glenohumeral Instability in 2 Patients

Anterior glenohumeral instability typically involves lesions associated with the inferior glenohumeral ligament complex. Multiple lesions have been described in this setting, including Bankart, humeral avulsion of the inferior glenohumeral ligament complex, and mid-substance capsular tears. These lesions are indicative of the high-force traumatic nature of anterior shoulder dislocation. Two cases of recurrent anterior shoulder instability are presented with a capsular tear perpendicular to the usual orientation and not consistent to the amount of force involved in a dislocation. Arthroscopy revealed a capsular defect from the glenoid to the humeral head in the anterior inferior glenohumeral ligamentous complex in both. This lesion is an unusual circumstance, providing another pathology to include in the differential diagnosis of anterior glenohumeral instability.

Internal Fixation of Osteoporotic Fractures

Osteoporosis leads to bone fragility and increased risk of fracture. Despite advances in diagnosis and treatment, the prevalence continues to rise. Osteoporotic fracture treatment has a unique set of difficulties related to poor bone quality and traditional approaches, and implants may not perform well. Fixation failure and repeat surgery are poorly tolerated and highly undesirable in this patient population. This review illustrates the most recent updates in internal fixation, implant design, and surgical theory regarding treatment of patients with osteoporotic fractures.

Does Early versus Delayed Spanning External Fixation Impact Complication Rates for High-energy Tibial Plateau and Plafond Fractures?

BackgroundHigh-energy tibial plateau and tibial plafond fractures have a high complication rate and are frequently treated with a staged approach of spanning external fixation followed by definitive internal fixation after resolution of soft tissue swelling. A theoretical advantage to early spanning external fixation is that earlier fracture stabilization could prevent further soft tissue damage and potentially reduce the occurrence of subsequent infection. However, the relative urgency of applying the external fixator after injury is unknown, and whether delay in this intervention is correlated to subsequent treatment complications has not been examined.Questions/purposesIs delay of more than 12 hours to spanning external fixation of high-energy tibial plateau and plafond fractures associated with increased (1) infection risk; (2) compartment syndrome risk; and (3) time to definitive fixation, length of hospitalization, or risk of secondary surgeries? We further stratified our results based on injury site: plateau and plafond. In practical clinical terms, many of these high-energy C-type articular fractures will arrive at the regional trauma center in the evening and this investigation attempted to explore if these injuries need to be placed in temporizing fixators that evening or if they may be safely addressed in a dedicated trauma room the next morning.MethodsWe performed a retrospective review of all patients at a Level I university trauma center with high-energy tibial plateau and plafond fractures who underwent staged treatment with a spanning external fixation followed by subsequent definitive internal fixation between 2006 and 2012. Patients who received a fixator within 12 hours of recorded injury time were classified as early external fixation; those who received a fixator greater than 12 hours from injury were classified as delayed external fixation. There were 80 patients (42 plateaus and 38 plafonds) in the early external fixation cohort and 79 patients (45 plateaus and 34 plafonds) in the delayed external fixation cohort. Deep infection rate was 13% in plateau fractures and 18% in plafond fractures. Rates of infection, compartment syndrome, secondary surgeries, time to definitive fixation, and length of hospitalization were recorded.ResultsControlling for differences in open fracture severity between groups, there was no difference in infection for plafond (early fixation: 12 of 38 [32%]; delayed fixation: seven of 34 [21%]; adjusted relative risk = 1.39 [95% confidence interval {CI}, 0.45–4.31], p = 0.573) and plateau (early fixation: eight of 42 [19%]; delayed fixation: nine of 45 [20%]; adjusted relative risk: 0.93 [95% CI, 0.31–2.78], p = 0.861) groups. For compartment syndrome risk, there was no difference between early and delayed groups for plateau fractures (early fixation: six of 42 [14%]; delayed fixation: three of 45 [7%]; relative risk = 0.47 [0.12–1.75], p = 0.304) and plafond fractures (early fixation: two of 38 [5%]; delayed fixation: three of 34 [9%]; relative risk = 1.67 [0.30–9.44], p = 0.662). There was no difference for length of hospitalization for early (9 ± 7 days) versus delayed fixation (9 ± 6 days) (mean difference = 0.24 [95% CI, −2.9 to 3.4], p = 0.878) for patients with plafond fracture. Similarly, there was no difference in length of hospitalization for early (10 ± 6 days) versus delayed fixation (8 ± 4 days) (mean difference = 1.6 [95% CI, −3.9 to 0.7], p = 0.170) for patients with plateau fracture. Time to definitive fixation for plateau fractures in the early external fixation group was 8 ± 6 days compared with 11 ± 7 days for the delayed external fixation group (mean difference = 2.9 [95% CI, 0.13–5.7], p = 0.040); there was no difference in time to definitive fixation for early (12 ± 7 days) versus delayed (12 ± 6 days) for patients with plafond fractures (mean difference = 0.39 [95% CI, −2.7 to 3.4], p = 0.801). There was no difference in risk of secondary surgeries between early external fixation (21 of 38 [55%]) and delayed external fixation (13 if 34 [38%]) for plafond fractures (adjusted relative risk = 0.69 [95% CI, 0.41–1.16], p = 0.165) and no difference between early fixation (24 of 42 [57%]) and delayed fixation (26 of 45 [58%]) for plateau fractures (adjusted relative risk = 1.0 [95% CI, 0.70–1.45], p = 1.00).ConclusionsWe were unable to detect a difference in infection, compartment syndrome, secondary procedures, or length of hospitalization for patients who undergo early versus delayed external fixation for high-energy tibial plateau or plafond fractures. This may affect decisions for resource use at trauma centers such as whether high-energy periarticular lower extremity fractures need to be spanned on the evening of presentation or whether this procedure may wait until the morning trauma room. Given the high complication rate of these injuries and clinical relevance of this question, this may also need to be examined in a prospective manner.Level of EvidenceLevel IV, therapeutic study.

One-year postoperative knee pain in patients with semi-extended tibial nailing versus control group.

The purpose of this study was to determine whether patients with a tibia fracture who were treated with an intramedullary nail using a semi-extended, extra-articular, parapatellar approach had anterior knee pain at a higher than acceptable incidence compared with control patients. Eighteen patients with OTA type 42 A-C tibia fractures nailed using this approach were compared with an uninjured control group (n = 22). Lysholm Knee Score questionnaires were given to all participants and compared between groups. Fracture patients completed the LKS at 6 months and 1 year postoperatively. Additional data collected included age, sex, mechanism of injury, OTA classification, Gustilo/Anderson and Tscherne classification, nail-apex distance, complications, weight-bearing status, additional fixation needed, and postoperative procedures. Mean age and demographics were similar between the fracture and control group: 42.9 vs 47.9 years, respectively, (P=.36) and 11 vs 9 men, respectively (P=.11). Lysholm Knee Scores among the subgroups (age, sex, medial vs lateral parapatellar approach, soft-tissue status, and nail-apex distance) showed no statistically significant differences (P>05 for all comparisons). Mean nail-apex distance was -16.3 mm. Mean LKS score 1-year postoperatively was 87.3 (range, 59-100) in the fracture group and 89.7 (range, 23-100) in the control group (P=.69). At 1-year postoperatively, patients in the fracture group did not have increased anterior knee pain compared with the control group.

Is This Autograft Worth It?: The Blood Loss and Transfusion Rates Associated With Reamer Irrigator Aspirator Bone Graft Harvest

Objectives: To investigate the blood loss and transfusion rate associated with the use of reamer irrigator aspirator (RIA). Design: Retrospective review. Setting: Academic Level-I trauma hospital. Patients: One hundred eight patients requiring bone graft harvest for surgical reconstruction of nonunion or failed arthrodesis. Intervention: Bone graft harvest preformed via RIA or iliac crest bone graft (ICBG). Main Outcome Measure: Blood loss as measured by a change in preoperative and postoperative hematocrit (Hct). In addition, postoperative transfusion reported intraoperative blood loss, volume of graft harvested, and major complications. Results: The average Hct drop was found to be 13.7 (4.1–27.4) in the RIA cohort of 61 patients and 7.36 (1.2–14.5) in the ICBG cohort of 47 patients (P = 0.013). Operative reports documented an average estimated blood loss of 674 mL (100–2000 mL) in the RIA cohort compared with 255 mL (50–1000 mL) in the ICBG cohort (P < 0.001). Twenty-seven patients (44%) required blood transfusion after RIA, whereas 10 patients (21%) required blood transfusion after ICBG (odds ratio 5.32, 95% confidence interval 2.2–6.3, P < 0.001). RIA procedures collected an average 53 mL (20–100 mL) of bone graft compared with 27 mL (15–50 mL) with ICBG. There was no significant difference between groups regarding age, sex, medical comorbidities, or postoperative major complications. Conclusions: This series demonstrated that 44% of patients undergoing RIA bone graft harvest required transfusion, with a mean Hct drop of 13.7 across all subjects, which is significantly greater than that associated with ICBG. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cephalomedullary nail versus sliding hip screw for fixation of AO 31 A1/2 intertrochanteric femoral fracture: A 12-year comparison of failure, complications, and mortality

Background:In the United States intertrochanteric and pertrochanteric fractures occur at a rate of more than 150,000 cases annually. Current standard of care for these fractures includes fixation with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). The purpose of this study was to compare failure and medical complications of intertrochanteric femoral fractures repaired by CMN or SHS. Methods:This study is a retrospective cohort study that included 249 patients with AO/OTA 31 A1.1-3, 31 A2.1-3 nonpathological fractures of the femur, of which 137 received CMN and 112 received SHS. Analysis was stratified by fracture type as stable (AO 31A1.1-2.1) or unstable (AO 31A2.2-3). Results:The tip-apex distance in stable fractures fixed with CMN was 17.3±5.9 compared to 26.2±7.9 in the stable SHS group (P<0.001) while it was 19.0±5.3 in the unstable CMN group compared to 24.0±6.7 in the unstable SHS patients (P=0.004). Among patients with stable fracture patterns there was no difference in collapse, complications, failure, or mortality (all P>0.05). Among patients with unstable fractures CMN had significantly less collapse (P<0.001) and failure (P=0.046) but no difference in complications (P=0.126) or mortality (P=0.586). Conclusions:There were no significant differences in failure or complication rates when comparing the CMN to the SHS in stable intertrochanteric fractures. CMN demonstrated significantly reduced failure and collapse rates in unstable intertrochanteric fractures when compared to SHS; however, this study had a relatively small sample size of unstable fractures and all results must be interpreted within this context.

Flash Autoclave Settings May Influence Eradication but Not Presence of Well-Established Biofilms on Orthopaedic Implant Material†

Flash autoclaving is one of the most frequently utilized methods of sterilizing devices, implants or other materials. For a number of decades, it has been common practice for surgeons to remove implantable devices, flash autoclave and then reimplant them in a patient. Data have not yet indicated the potential for biofilms to survive or remain on the surface of orthopaedic‐relevant materials following flash autoclave. In this study, monomicrobial and polymicrobial biofilms were grown on the surface of clinically relevant titanium materials and exposed to flash autoclave settings that included varying times and temperatures. Data indicated that when the sterilization and control temperatures of an autoclave were the same, biofilms were able to survive flash autoclaving that was performed for a short duration. Higher temperature and increased duration rendered biofilms non‐viable, but none of the autoclave settings had the ability to remove or disperse the presence of biofilms from the titanium surfaces. These findings may be beneficial for facilities, clinics, or hospitals to consider if biofilms are suspected to be present on materials or devices, in particular implants that have had associated infection and are considered for re‐implantation.