Gregory L. DeSilva

Autogenous iliac crest bone graft: Complications and functional assessment

Functional outcomes and complications experienced by adult patients who underwent iliac crest bone grafting were evaluated to assess the effect of bone grafts on patient function. In addition to retrospective chart reviews, patients completed the Sickness Impact Profile and a detailed questionnaire on pain. One hundred ninety-two patients met study inclusion criteria. Major complications were recorded in four (2.4%) patients in whom infections developed requiring readmission. Thirty-seven (21.8%) patients had minor complications. One hundred nineteen of 170 patients were available for followup; of these 119 patients, 87 (73.1%) returned completed questionnaires. Thirty-three of 87 (37.9%) patients reported pain 6 months postoperatively. The incidence of pain decrease with time, with 16 of 87 (18.7%) patients continuing to report pain more than 2 years postoperatively. Proportionately more spine patients reported pain at all time points. The mean Sickness Impact Profile score for patients completing questionnaires was nine, suggesting most patients were functioning well 2 years postoperatively. The morbidity of iliac crest grafting remains substantial. Pain symptoms in this study sample seemed to last longer in more patients than earlier series have indicated. Minimizing muscle dissection around donor sites and the advent of bone graft substitutes may help alleviate these problems.

The OTA open fracture classification: a study of reliability and agreement.

Objectives: To determine the reliability of the Orthopaedic Trauma Association (OTA) Open Fracture Classification. Design: Video-based reliability study. Setting: Orthopedic meetings and grand rounds. Patients/participants: Orthopedic surgeons. Intervention: None. Main Outcome Measurements: Interobserver reliability assessment classification. Results: The results demonstrate the system to have high reliability and much improvement compared with published Gustilo–Anderson classification reliability studies. Overall interrater reliability (&kgr;) values were highest for arterial injury, with near perfect agreement across all raters and within each value. Skin injury, bone loss, and contamination demonstrated moderate to substantial levels of agreement. Muscle injury had the most disagreement between raters but still demonstrating a fair level of interrater agreement, which is a level of agreement superior to the literature related to the Gustilo–Anderson classification. Levels of agreement were similar between attending surgeons and residents for all categories. Conclusions: This study, which included a diverse multicenter multinational cohort of orthopaedic surgeons and residents, of the OTA Open Fracture Classification demonstrated moderate to excellent interobserver reliability.

Imaging and Treatment of Scaphoid Fractures and Their Complications

The scaphoid is the most commonly fractured carpal bone, with frequent complications that are predisposed by its anatomical location, anatomical configuration (shape and length), and vascular supply. The most common mechanism of injury is a fall onto an outstretched hand. Imaging plays a significant role in the initial evaluation and treatment of scaphoid fractures and their complications. Radiography should be the first imaging modality in the initial evaluation and follow-up of scaphoid fractures. Computed tomography with its superb spatial resolution enables better visualization and characterization of the fracture line, and the amount of displacement and angulation of the fracture fragments. Using the metal reduction artifact with computed tomography allows good follow-up of scaphoid fractures despite surgical hardware. Magnetic resonance imaging without contrast is the imaging modality of choice for depiction of radiographically occult scaphoid fracture, bone contusion, and associated soft tissue injury; contrast-enhanced imaging aids assessment of scaphoid fracture nonunion, osteonecrosis, fracture healing after bone grafting, and revitalization of the necrotic bone after bone grafting. Proper identification and classification of scaphoid fracture and its complications is necessary for appropriate treatment. This article describes the normal anatomy, mechanism of injury, and classification of stable and unstable fractures, together with the imaging and treatment algorithm of scaphoid fractures and their complications with an emphasis on magnetic resonance imaging.

Imaging and management of thumb carpometacarpal joint osteoarthritis

Primary osteoarthritis (OA) involving the thumb carpometacarpal (CMC) joint is a common and frequently debilitating disease. Clinical examination and radiographs are usually sufficient for diagnosis; however, familiarity with the cross-sectional anatomy is useful for diagnosis of this condition. The most widely used classification system for the radiographic staging of thumb carpometacarpal joint OA was first presented by Eaton and Littler, ranging from mild (stages I and II) to severe (stage IV) disease. If conservative treatment fails, surgical treatment is considered. A variety of surgical techniques have been developed and implemented for the management of this pervasive and disabling condition. The purpose of this article is to review the anatomy of the basal joints of the thumb, pathophysiology, preoperative imaging, and various surgical techniques that are utilized in the treatment of OA of the basal joints of the thumb with emphasis on normal postoperative radiographic findings and possible postoperative complications.

The Internet as a Source of Information for De Quervain's Tendinitis

BackgroundMany individuals are turning to the Internet for information about various health conditions, and in our study we evaluated the quality and readability of information on the internet about De Quervain’s tendinitis.MethodsWe chose the search terms “De Quervain’s Tendinitis,” “De Quervain’s Tenosynovitis,” and “De Quervain’s Syndrome,” and entered them into the search engines “Google,” “Bing,” and “Yahoo” and compiled the search results. The websites were then evaluated and assigned a quality score, a Flesch-Kincaid (FK) reading level, and a subjective quality score. They were then grouped according to the search term used, search engine used, and the order (priority) returned by the search engines. ANOVA analysis and pairwise comparisons of quality and readability among groups, as well as correlation analysis were performed.ResultsThe FK readability average was 10.3, above the recommended level. The search term De Quervain’s tenosynovitis returned the highest objective quality results. There was no statistical difference found between the different search engines. The first 10 results from the searches were of higher quality than results 11–20, and there was a positive correlation between objective and subjective quality scores but no correlation between readability and objective quality.ConclusionsWe concluded that quality information about De Quervain’s tendinitis is available on the internet and is most likely to be found using the search term De Quervain’s tenosynovitis and in the first 10 results of an internet search. However, most information is written above the recommended 6th grade reading level.

Sural Versus Perforator Flaps for Distal Medial Leg Wounds.

Soft tissue coverage of distal medial ankle wounds is a challenging problem in orthopedic surgery because of the limited local tissues and prominent instrumentation. Traditionally, these wounds required free tissue transfer to achieve suitable coverage and subsequent bony union. To better respect the reconstructive ladder and to avoid the inherent difficulty of free flap coverage, rotational flaps have been used to cover these wounds. Both sural fasciocutaneous flaps and rotational fasciocutaneous perforator (propeller) flaps have been described for distal medial soft tissue coverage. The authors performed a retrospective chart review of patients who underwent distal medial leg coverage with the use of either sural flaps or rotational fasciocutaneous perforator flaps. The authors identified 14 patients by Current Procedural Terminology code who met the study criteria. The average age and degree of medical comorbidities were comparable in the 2 groups. The authors reviewed their medical records to evaluate fracture healing, flap size, complications, and return to normal shoe wear. All 7 sural flaps healed without incident, with underlying fracture healing. Of the 7 perforator flaps, 6 healed without incident, with underlying fracture healing. One perforator-based flap was complicated by superficial tip necrosis and went on to heal with local wound care. All patients returned to normal shoe wear. Both sural artery rotational flaps and posterior tibial artery-based rotational flaps are viable options for coverage of the distal medial leg. Coverage can be achieved reliably without microsurgery, anticoagulation, or monitoring in the intensive care unit.

Simultaneous soft tissue coverage of both medial and lateral ankle wounds: Sural and rotational flap coverage after revision fixation in an infected diabetic ankle fracture

AIMS To describe a case of simultaneous medial and lateral soft tissue coverage for exposed orthopaedic implants in the setting of revision fixation of a non-united ankle fracture. This was achieved using a sural flap as well as a propeller flap. METHODS Case report. RESULTS Both the sural and posterior tibial artery based rotational propeller flap healed without incident. The underlying fracture healed successfully and the patient returned to normal shoe wear. CONCLUSIONS The sural flap in conjunction with the posterior tibial artery based rotational flap is effective in providing simultaneous medial and lateral soft tissue coverage to the ankle.