J. Tracy Watson

The use of a surgical grade calcium sulfate as a bone graft substitute: results of a multicenter trial.

In a prospective, nonrandomized, multicenter study, 109 patients with bone defects were treated with a surgical grade calcium sulfate preparation as a bone graft substitute. The calcium sulfate pellets were used in place of morselized cancellous bone graft for the treatment of patients with bone defects who usually would require grafting secondary to trauma, periprosthetic bone loss, tumor, or fusion. The calcium sulfate was used alone or mixed with other materials such as bone marrow aspirate, demineralized bone matrix, or autograft. The defects that were treated were contained and were not necessary for the stability of the bony structure. Radiographic and clinical data were collected at predetermined intervals for 12 months. At 6 months postoperatively, radiographic results for all patients showed that 99% of the calcium sulfate had been resorbed and 88% of the defect was filled with trabeculated bone. There were 13 complications; however, only four (3.6%) were attributable to the product. The results of a subgroup of 46 patients with benign bone lesions treated in the same manner are identical to the results of the overall study population. Surgical grade calcium sulfate pellets are considered a convenient, safe, and readily available bone graft substitute that yield consistent successful results.

Platelet Rich Concentrate : Basic Science and Current Clinical Applications

Improvements in resuscitation, dissemination of ATLS protocols, and growth of regional and local trauma centers has increased the survivability after severe traumatic injuries. Furthermore, advances in medical management have increased life expectancy and also patients with orthopaedic injuries. While mechanical stabilization has been a hallmark of orthopaedic fracture care, orthobiologics are playing an increasing role in the management of these patients with complex injuries. Platelet-rich concentrate is an autologous concentration of platelets and growth factors, including transforming growth factor-beta (TGF-β), vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF). The enhancement of bone and soft tissue healing by the placement of supraphysiologic concentration of autologous platelets at the site of tissue injury or surgery is supported by basic science and clinical studies. Due to the increased concentration and release of these factors, platelet-rich plasma can potentially enhance the recruitment and proliferation of tenocytes, stem cells, and endothelial cells. A better understanding of platelet function and appropriate clinical use is essential in achieving the desired outcomes of platelet-rich concentrate in orthopaedic clinical applications.

Computed tomographic assessment of fractures of the posterior wall of the acetabulum after operative treatment.

Background: The purpose of this study was to evaluate the results after operative treatment of fractures of the posterior wall of the acetabulum in relationship to the quality of the fracture reduction as assessed by postoperative two-dimensional computed tomography. Methods: The functional results for sixty-seven patients who had open reduction and internal fixation of an unstable fracture of the posterior wall of the acetabulum and the findings of two-dimensional computed tomography performed postoperatively were analyzed. Sixty-one patients were followed for a mean of four years after the injury, and the remaining six patients who had poor early results necessitating reconstructive surgery were followed for less than two years. All patients were evaluated preoperatively and postoperatively with use of three standard plain radiographs (one anteroposterior and two Judet 45° oblique pelvic radiographs) and a two-dimensional computed tomography scan. The functional outcome for the patients was evaluated with use of a modification of the clinical grading system described by Letournel and Judet. The radiographs were graded according to the criteria described by Matta. The two-dimensional computed tomography scans were used to determine fracture gap and offset measurements. Results: The clinical outcome was graded as excellent in thirty-one patients (46%), very good in twenty (30%), good in eight (12%), and poor in eight (12%). The final radiographic results were graded as excellent in fifty-three hips (79%), good in four (6%), fair in three (5%), and poor in seven (10%). There was a strong association between clinical outcome and final radiographic grade. Fracture reductions were graded as anatomic in sixty-five and imperfect in two, as determined with use of plain radiography. However, postoperative computed tomography revealed an incongruency (offset) of >2 mm in eleven hips and fracture gaps of ≥2 mm in fifty-two. Fracture gaps of ≥10 mm in any dimension or a total gap area of ≥35 mm 2 were associated with a poor result. The main risk factors for a poor result were a residual fracture gap width of ≥10 mm and osteonecrosis of the femoral head. Conclusions: The degree of residual fracture displacement is detected more accurately on postoperative computed tomography scans than on plain radiographs. The accuracy of surgical reduction as assessed on postoperative computed tomography is highly predictive of the clinical outcome. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Comparison of the compression hip screw with the Medoff sliding plate for intertrochanteric fractures.

The Medoff sliding plate was designed to achieve compression along the femoral neck and the longitudinal axis of the femoral shaft theoretically to improve the treatment of intertrochanteric hip fractures. The Medoff sliding plate was compared with a standard compression hip screw in a randomized, prospective study for the fixation of 160 stable and unstable intertrochanteric fractures with an average followup of 9.5 months (range, 6-26 months). Overall, 91 fractures were treated using the compression hip screw and 69 were treated with the Medoff sliding plate. Stable fracture patterns (46) united without complication in both treatment groups. Unstable fractures (114) had an overall failure rate of 9.6%, 14% (nine patients) with the compression hip screw and 3% (two patients) with the Medoff plate; this difference was significantly different. The time to union for the 114 unstable fractures was not significantly different between the two devices. For all patients, no differences in lengths of hospitalization, return to ambulatory status before fracture, postoperative living status, or postoperative pain was observed between the two device groups. Use of the Medoff plate for all fracture types was associated with a significantly higher amount of blood loss and operating time.

Open Reduction and Internal Fixation of Posterior Wall Fractures of the Acetabulum

The results of 94 patients with posterior wall fractures of the acetabulum associated with hip instability treated within 3 weeks of injury by open reduction and internal fixation were reviewed. Patients were followed up for an average of 3.5 years (range, 1-13 years). Fracture reductions were graded as anatomic (0-1 mm displacement) in 92 patients and imperfect (2-3 mm displacement) in two patients, as determined by plain radiography. However, postoperative computed tomography scans obtained in 59 patients revealed incongruency of more than 2 mm in six patients and fracture gaps of 2 mm or more in 44 patients. Complications included deep wound infection (one patient), deep vein thrombosis, (seven patients), and revision surgery to redirect an errant screw (one patient). Clinical outcome was graded as excellent in 34 patients (36%), good in 49 (52%), fair in two (2%), and poor in nine (10%). Radiographic results were excellent in 79 hips (84%), good in four (4%), fair in two (2%), and poor in nine (10%). There was a strong association between clinical outcome and radiographic grade. Variables identified as risk factors for an unsatisfactory result included age greater than 55 years, a delay greater than 24 hours from the time of injury for reduction of a hip dislocation, a residual fracture gap greater than 1 cm, and severe intraarticular comminution. The apparent disparity between the accuracy of surgical fracture reduction, as determined by plain radiographs obtained postoperatively, and clinical outcome is explained only partially by the limitations of plain radiography. Other variables are involved, many of which are under the surgeons control but some are not. As is the case with other acetabular fracture types, the best results are predicated on anatomic fracture reduction.

Timing of Wound Closure in Open Fractures Based on Cultures Obtained After Debridement

BACKGROUND The timing of wound closure in open fractures has remained an inexact science. Numerous recommendations have been made for the management of these injuries regarding the optimal time to perform competent wound closure, with all advice based on subjective parameters. The purpose of this study was to determine the utility of a prospective protocol with use of wound cultures obtained after irrigation and debridement as a guide to the timing of wound closure following an open fracture of an extremity. METHODS Four hundred and twenty-two open fractures had emergency irrigation and debridement, fracture stabilization, and open wound management. Wound cultures were obtained for aerobic and anaerobic analysis following debridement. At forty-eight hours after debridement, patients were again returned to surgery. If the initial culture results were positive, a repeat irrigation and debridement was carried out, and additional cultures were obtained after debridement. This procedure was repeated, and the wound was not closed until negative culture results were achieved. RESULTS Of the 422 open fractures, 346 were available for long-term follow-up. The overall deep infection rate was 4.3%. Gustilo Type-II fractures had a deep infection rate of 4%, and Type-III fractures had an infection rate of 5.7%. Type-III fractures demonstrated differences among the fracture patterns within this type, as infection developed in 1.8% of Type-IIIA injuries, 10.6% of Type-IIIB fractures, and 20% of Type-IIIC fractures. Fractures requiring multiple debridement procedures and those in patients with diabetes or an increased body mass index demonstrated higher rates of infection. With the numbers studied, fractures in which the wound was closed in the presence of positive cultures (a protocol breach) did not have a significantly increased risk of deep infection (p = 0.0501). CONCLUSIONS The use of this standardized protocol was shown to achieve a very low rate of deep infection compared with historical controls. An increased number of irrigation and debridement procedures are required to achieve this improved outcome. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Retrograde nailing of the femoral shaft.

Retrograde intramedullary nailing of fractures of the femoral shaft with use of a distal intercondylar intra-articular entry portal is a relatively new surgical technique. This method of nailing represents a modification of the previously described procedure in which an extra-articular entry portal in the medial femoral condyle was used. The earlier procedure was plagued by technical difficulties, which limited its use; these problems were mainly related to the fact that the entry portal was not in line with the intramedullary canal, as well as to the fact that purpose-specific implants and instrumentation were not available. Modification of this technique, by using the intercondylar entry portal and a nail designed for retrograde insertion, has proved very effective in clinical studies. There have been theoretical concerns regarding postoperative knee function and intraoperative injury to important anatomic structures, such as branches of the femoral nerve; however, laboratory and clinical findings have dispelled many of these concerns and have provided firm support for continued use of the technique. Nonetheless, further study is required to delineate the long-term outcome of knee joint function. Current indications for use of this technique include multisystem injuries, multiple fractures (including ipsilateral lower-limb combination injuries), ipsilateral vascular injuries, periprosthetic fractures, and morbid obesity.

Local Antibiotic Delivery Using Tailorable Chitosan Sponges: The Future of Infection Control?

Objectives: Local antibiotic delivery is a viable and attractive option for preventing infection. Unfortunately, the current options are limited and often necessitate surgical removal. This study evaluates the ability of a biodegradable and biocompatible chitosan sponge to minimize infection by delivering local antibiotics within the wound. Methods: A complex musculoskeletal wound was created on the hindlimb of goats and contaminated with Pseudomonas aeruginosa (lux) or Staphylococcus aureus (lux) bacteria. These bacteria are genetically engineered to emit photons, allowing for quantification with a photon-counting camera system. The wounds were closed and similarly débrided and irrigated with 9 L normal saline using bulb-syringe irrigation 6 hours after inoculation. Goats were assigned to different treatment groups: a control group with no adjunctive treatment and an experimental group using a chitosan sponge loaded with either amikacin (for wounds contaminated with P. aeruginosa) or vancomycin (for wounds contaminated with S. aureus). The wounds were closed after the procedure and evaluated 48 hours after initial contamination. Serum levels of the antibiotics were also measured at 6, 12, 24, 36, and 42 hours after treatment was initiated. Results: The wounds treated with the antibiotic-loaded chitosan sponge had significantly less bacteria than the untreated wounds (P < 0.05). The highest serum levels were 6 hours after treatment but remained less than 15% of target serum levels for systemic treatment. At study end point, all sponges were between 60% and 100% degraded. Conclusions: The chitosan sponges are effective delivering the antibiotic and reducing the bacteria within the wounds.

Ultrasound for the early diagnosis of fracture healing after interlocking nailing of the tibia without reaming.

Fourteen fractures (8 open, 6 closed) were treated with small-diameter interlocking tibial nails and observed for at least 1 year. Radiographs were obtained to monitor the maintenance of reduction and fracture healing. The treating orthopaedic surgeon was blinded to the results of ultrasound studies, which were obtained at 2-week intervals for 10 weeks postoperatively and read by a radiologist who was blinded to the clinical and radio-graphic progress. Ultrasound correctly predicted fracture healing in all 9 fractures that subsequently progressed to fracture union. Of the 5 fractures that did not heal and required secondary procedures, ultrasound predicted delayed healing in 4 fractures. Overall, ultrasound was able to predict fracture healing before it was radiographically evident. Ultrasound may provide important prognostic information concerning tibial fracture healing after treatment using interlocking nails without reaming. Additional study is warranted.

Epidemiology of Fracture Nonunion in 18 Human Bones.

Importance Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique, yet progression to nonunion is not fully explained by these risk factors. Objective To test a hypothesis that fracture characteristics and patient-related risk factors assessable by the clinician at patient presentation can indicate the probability of fracture nonunion. Design, Setting, and Participants An inception cohort study in a large payer database of patients with fracture in the United States was conducted using patient-level health claims for medical and drug expenses compiled for approximately 90.1 million patients in calendar year 2011. The final database collated demographic descriptors, treatment procedures as per Current Procedural Terminology codes; comorbidities as per International Classification of Diseases, Ninth Revision codes; and drug prescriptions as per National Drug Code Directory codes. Logistic regression was used to calculate odds ratios (ORs) for variables associated with nonunion. Data analysis was performed from January 1, 2011, to December 31, 2012. Exposures Continuous enrollment in the database was required for 12 months after fracture to allow sufficient time to capture a nonunion diagnosis. Results The final analysis of 309 330 fractures in 18 bones included 178 952 women (57.9%); mean (SD) age was 44.48 (13.68) years. The nonunion rate was 4.9%. Elevated nonunion risk was associated with severe fracture (eg, open fracture, multiple fractures), high body mass index, smoking, and alcoholism. Women experienced more fractures, but men were more prone to nonunion. The nonunion rate also varied with fracture location: scaphoid, tibia plus fibula, and femur were most likely to be nonunion. The ORs for nonunion fractures were significantly increased for risk factors, including number of fractures (OR, 2.65; 95% CI, 2.34-2.99), use of nonsteroidal anti-inflammatory drugs plus opioids (OR, 1.84; 95% CI, 1.73-1.95), operative treatment (OR, 1.78; 95% CI, 1.69-1.86), open fracture (OR, 1.66; 95% CI, 1.55-1.77), anticoagulant use (OR, 1.58; 95% CI, 1.51-1.66), osteoarthritis with rheumatoid arthritis (OR, 1.58; 95% CI, 1.38-1.82), anticonvulsant use with benzodiazepines (OR, 1.49; 95% CI, 1.36-1.62), opioid use (OR, 1.43; 95% CI, 1.34-1.52), diabetes (OR, 1.40; 95% CI, 1.21-1.61), high-energy injury (OR, 1.38; 95% CI, 1.27-1.49), anticonvulsant use (OR, 1.37; 95% CI, 1.31-1.43), osteoporosis (OR, 1.24; 95% CI, 1.14-1.34), male gender (OR, 1.21; 95% CI, 1.16-1.25), insulin use (OR, 1.21; 95% CI, 1.10-1.31), smoking (OR, 1.20; 95% CI, 1.14-1.26), benzodiazepine use (OR, 1.20; 95% CI, 1.10-1.31), obesity (OR, 1.19; 95% CI, 1.12-1.25), antibiotic use (OR, 1.17; 95% CI, 1.13-1.21), osteoporosis medication use (OR, 1.17; 95% CI, 1.08-1.26), vitamin D deficiency (OR, 1.14; 95% CI, 1.05-1.22), diuretic use (OR, 1.13; 95% CI, 1.07-1.18), and renal insufficiency (OR, 1.11; 95% CI, 1.04-1.17) (multivariate P < .001 for all). Conclusions and Relevance The probability of fracture nonunion can be based on patient-specific risk factors at presentation. Risk of nonunion is a function of fracture severity, fracture location, disease comorbidity, and medication use.