Lon S. Weiner

SPECT/CT in the Management of Osteochondral Lesions of the Talus:

Background: The treatment of osteochondral lesion of the talus (OLT) is mainly based upon the stage of the disease so accurate imaging is crucial. SPECT/CT combines bone scan with high-resolution CT and can provide functional-anatomical images in a single stage. The purpose of this study was to assess the value of SPECT/CT in the management of OLT. Materials and Methods: From 2004 to 2009, 22 patients with OLT were identified that had both SPECT/CT and MRI of the foot and ankle. All charts were reviewed to ascertain the reason for ordering the SPECT/CT and the additional information obtained. AOFAS outcome scores were calculated at the time of followup. Results: Twelve patients underwent ankle arthroscopy for debridement or drilling of the osteochondral lesion. The mean AOFAS score in these 12 patients was 83.6. SPECT/CT helped preoperative planning by identifying the exact location of the active lesion, especially in multifocal disease or revision surgeries while showing the depth of the active lesion. Ten patients had conservative management due to minimal or no activity over the lesion on SPECT/CT images. The mean AOFAS score in these ten patients was 78.8 which was comparable to the operative group. Conclusion: We believe SPECT/CT was able to provide additional diagnostic value by demonstrating a co-existing pathology as a potential cause of pain and in preoperative planning by showing the depth of activity and the precise location of the active segment in multiple lesions. Level of Evidence: III, Retrospective Case Control Study

Closed incision negative pressure therapy decreases complications after periprosthetic fracture surgery around the hip and knee

INTRODUCTION Periprosthetic fractures (PPFXs) are becoming increasingly common following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients sustaining PPFXs face considerable perioperative morbidity, with relatively increased rates of surgical site infection. We sought to evaluate the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing perioperative wound complications following lower extremity periprosthetic fracture surgery. METHODS We performed a retrospective review of 69 consecutive patients who underwent surgery to address lower extremity periprosthetic fractures around hip or knee implants performed over a 6.5-year period. The population was divided into two groups based on the surgical dressing used at the conclusion of the procedure: (1) a sterile, antimicrobial hydrofiber dressing, or (2) ciNPT. There were no baseline demographic differences between the two groups. Rates of wound complications, surgical site infection, and reoperation related to the surgical site were compared between groups. Continuous variables were analyzed using a students t-test, and categorical variables using either chi-square or fishers exact test. RESULTS Patients treated with ciNPT developed fewer wound complications (4% vs. 35%; p=0.002), fewer deep infections (0% vs. 25%; p=0.004), and underwent fewer reoperations related to the surgical site (4% vs. 25%; p=0.021) compared to patients treated with standard of care. CONCLUSIONS Our findings suggest that ciNPT may reduce wound complications, SSIs, and reoperations in patients undergoing lower extremity periprosthetic fracture surgery. This is the first study to investigate ciNPT as a treatment for periprosthetic fracture surgery, and has the potential to change the postoperative management of these patients.

Open Reduction Internal Fixation of Posterior Malleolus Fractures via a Posteromedial Approach

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures with a posterior malleolus component are complex injuries to manage. Due to the heterogeneous morphology of these fractures and lack of high-quality evidence, methods of surgical fixation are controversial and highly variable. The most commonly used surgical methods include indirect reduction via a percutaneous anterior approach or direct reduction via a posterolateral approach. For large posterior malleolus fractures with medial extension, direct reduction via a posteromedial approach is an alternative surgical option. The purpose of this study was to report on a large series of posterior malleolus fractures treated via a novel posteromedial approach. The study hypothesized that fixation of large posterior malleolus fractures with medial extension via a posteromedial approach results in anatomic reduction and stable plate fixation. Methods: From 2008 to 2015, 23 of 244 (9.4%) consecutive operative ankle fractures were identified as posterior malleolus fractures treated using a posteromedial approach (Figure 1). All patients had pre-operative computed tomography scans to confirm the presence of a posterior malleolus fracture with medial extension (Figure 2-4). A posteromedial incision was made and fracture was reduced with the saphenous vein retracted anteriorly and the posterior tibial tendon retracted posteriorly. Patient charts were retrospectively reviewed for demographics, injury history, surgical details, follow-up time, and any post-operative complications. Post-operative radiographs were reviewed to ensure that anatomic reduction and stable fixation was maintained (Figure 5). Results: 73.9% (17/23) of the patients were female and the average age at the time of surgery was 54.6 years (range, 26-86 years). There were no open fractures, but 8/23 (34.7%) patients required external fixation prior to open reduction internal fixation (ORIF) for soft tissue management. The average follow-up time was 11.0 months (range, 0.3 to 41.4 months). All patients healed completely on a clinical and radiographic basis. Anatomic reduction and stable plate fixation was obtained intra-operatively in all patients and maintained at maximal follow-up. Eight (34.7%) patients underwent removal of hardware. There was a 13.0% (3/23) post-operative complication rate: 1 patient had cellulitis, 1 patient had osteomyelitis involving the fibula, and 1 patient had symptomatic heterotopic ossification. All complications resolved with appropriate management. Conclusion: ORIF of posterior malleolus fractures via a posteromedial approach achieved anatomic reduction, stable plate fixation, and complete healing in all patients. Posteromedial approach enables direct visualization and anatomic reduction of large posterior malleolus fractures. Fixation of the posteromedial tibial plafond is important because, unlike the posterolateral aspect, there are no ligamentous insertions that can provisionally reduce the fracture fragment by ligamentotaxis. In concurrence with previous literature, our study demonstrates that posteromedial approach is a reasonable alternative to other more commonly used methods for treating these fractures.