Lucas S. Marchand

Etiologic Factors That Lead to Failure After Primary Anterior Cruciate Ligament Surgery.

Anterior cruciate ligament (ACL) reconstruction is common in the active young population. Failure of ACL reconstruction can be due to continued or recurrent instability, stiffness, or patient-reported failure in the setting of seemingly successful surgical reconstruction, such as pain that limits activity. Multiple preoperative, intraoperative, and postoperative variables can be optimized to give the greatest likelihood of success. Some of these include timing of surgery, identification, and treatment of associated ligamentous, meniscal and chondral injuries, tunnel placement, graft choice, fixation, tensioning, and postoperative rehabilitation. This article reviews common causes of ACL reconstruction failure concentrating on modifiable factors.

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.

Orthopaedic traumatology: fundamental principles and current controversies for the acute care surgeon

Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization.

Is the Lesser Trochanter Profile a Reliable Means of Restoring Anatomic Rotation After Femur Fracture Fixation

Background Restoring normal femoral rotation is an important consideration when managing femur fractures. Femoral malrotation after fixation is common and several preventive techniques have been described. Use of the lesser trochanter profile is a simple method to prevent malrotation, because the profile changes with femoral rotation, but the accuracy of this method is unclear. Questions/purposes The purposes of this study were (1) to report the rotational profiles of uninjured femora in an adult population; and (2) to determine if the lesser trochanter profile was associated with variability in femoral rotation. Methods One hundred fifty-five consecutive patients (72% female and 28% male) with a mean age of 32 years (range, 12–56 years) with a CT scanogram were retrospectively evaluated. Patients were included if CT scanograms had adequate cuts of the proximal and distal femur. Patients were excluded if they had prior hip/femur surgery or anatomic abnormalities of the proximal femur. CT scanogram measurements of femoral rotation were compared with the lesser trochanter profile (distance from the tip of the lesser trochanter to the medial cortex of the femur) measured on weightbearing AP radiographs. These measurements were made by a single fellowship-trained orthopaedic surgeon and repeated for intraobserver reliability testing. Presence of rotational differences based on sex and laterality was assessed and correlation of the difference in lesser trochanter profile to the difference in femoral rotation was determined using a coefficient of determination (r2). Results The mean femoral rotation was 10.9° (SD ± 8.8°) of anteversion. Mean right femoral rotation was 11.0° (SD ± 8.9°) and mean left femoral rotation was 10.7° (SD ± 8.7°) with a mean difference of 0.3° (95% confidence interval [CI], -1.7° to 2.3°; p = 0.76). Males had a mean rotation of 9.4°(SD ± 7.7°) and females had a mean rotation of 11.5° (SD ± 9.1°) with a mean difference of 2.1° (95% CI, -0.1° to 4.3°; p = 0.06). Mean lesser trochanter profile was 6.6 mm (SD ± 4.0 mm). Mean right lesser trochanter profile was 6.6 mm (SD ± 3.9 mm) and mean left lesser trochanter profile was 6.5 mm (SD ± 4.0 mm) with a mean difference of 0.1 mm (-0.8 mm to 1.0 mm, p = 0.86). The lesser trochanter profile varied between the sexes; males had a mean of 8.3 mm (SD ± 3.4), and females had a mean of 5.9 mm (SD ± 4.0). The mean difference between sexes was 2.5 mm (1.5-3.4 mm; p < 0.001). The magnitude of the lesser trochanter profile measurement and degree of femoral rotation were positively correlated such that increasing measures of the lesser trochanter profile were associated with increasing amounts of femoral anteversion. The lesser trochanter profile was associated with femoral version in a linear regression model (r2 = 0.64; p < 0.001). Thus, 64% of the difference in femoral rotation can be explained by the difference in the lesser trochanter profile. Intraobserver reliability for both the femoral version and lesser trochanter profile was noted to be excellent with intraclass correlation coefficients of 0.94 and 0.95, respectively. Conclusions This study helps define the normal femoral rotation profile among adults without femoral injury or bone deformity and demonstrated no rotational differences between sexes. The lesser trochanter profile was found to be positively associated with femoral rotation. Increasing and decreasing lesser trochanter profile measurements are associated with increasing and decreasing amounts of femoral rotation, respectively. Clinical Relevance The lesser trochanter profile can determine the position of the femur in both anteversion and retroversion, supporting its use as a method to restore preinjury femoral rotation after fracture fixation. Although some variability in the rotation between sides may exist, matching the lesser trochanter profile between injured and uninjured femora can help reestablish native rotation.

Radiographic Investigation of the Distal Extension of Fractures into the Articular Surface of the Tibia (The RIDEFAST Study)

Objective: To determine whether radiographic measurements are predictive of involvement of the distal tibia articular surface in tibial shaft fractures. Design: Retrospective review. Setting: Academic Level-I trauma hospital. Patients: Two-hundred seventeen patients with tibial shaft fractures distal to the isthmus (OTA/AO: 42-A1-3; 42-B1-3; 42-C1-3; and 43-A1-3). Intervention: Analysis of anteroposterior (AP) and lateral radiographs. The following parameters were measured: (1) angle between the predominant fracture line and the plane of the tibial plafond (&agr;-angle), (2) length of the shaft fracture, (3) distance from the most inferior extent of the shaft fracture to the tibial plafond (DTP), (4) width of the tibial plafond, (5) width of the tibial isthmus, (6) ratio of fracture length to DTP (FTP), and (7) fibular fracture distance. Main Outcome Measure: Distal intra-articular involvement (DIA). Results: A total of 217 patients were identified, 56 (26%) with DIA. The FTP ratio as measured on both the AP (odds ratio: 8.20, confidence interval, 4.26–17.22, P < 0.0001) and lateral radiographs (10.00, 4.78–23.23, <0.0001) was the most effective screening measurement for DIA. AP and lateral FTP ratios of 0.224 and 0.255, respectively, achieved a negative predictive value of 100%, eliminating the need for computed tomography in 16%–23% of injuries. Conclusion: Involvement of the distal articular surface in patients with distal tibial shaft fractures is significantly associated with fracture geometry and pattern. The FTP ratio may be used as an effective screening tool to rule out of intra-articular involvement. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Serial Radiographs Do Not Change the Clinical Course of Nonoperative Stable OTA/AO 44-B1 Ankle Fractures

Objective: To assess radiographic markers of ankle stability in stable OTA/AO 44-B1 ankle fractures. Design: Retrospective review. Setting: Academic Level-I trauma hospital. Patients: One hundred thirty-four patients with stable OTA/AO 44-B1 (Danis–Weber B, Supination-External Rotation-II) ankle fractures. Intervention: Analysis of mortise view radiographs at the time of initial evaluation and final follow-up. Variables measured: (1) medial clear space; (2) Mueller-Nose Distance. Main Outcome Measure: Change in radiographic measurements resulting in conversion to operative intervention. Results: Patients followed up an average of 2.6 visits in our clinics (SD 1.06). Patients received an average of 11.2 individual radiographic images to evaluate their injury (SD 3.9, maximum 29). No patients progressed to surgery in this cohort. Mean medial clear space at the time of injury was 3.4 mm (SD 0.8) and was 3.3 mm (SD 0.7) at the time of final follow-up (P = 0.1). Mean Mueller-Nose measurement at the time of injury was 3.5 mm (SD 1.0) and was 3.5 mm (SD 0.8) at the time of final follow-up (P = 0.47). Conclusions: No patients with stable OTA/AO 44-B1 fractures proceeded to surgery for loss of tibiotalar reduction or any other cause. Radiographic relationships were conserved during the follow-up, and serial radiographs may not be needed when managing these patients. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.OBJECTIVE To assess radiographic markers of ankle stability in stable AO 44-B1 ankle fractures. DESIGN Retrospective review. SETTING Academic level-I trauma hospital. PATIENTS One-hundred thirty-four patients with stable OTA/AO 44-B1 (Danis-Weber B, Supination-External Rotation-II) ankle fractures. INTERVENTION Analysis of mortise view radiographs at time of initial evaluation and final follow-up. VARIABLES MEASURED 1. Medial clear space (MSC); 2. Mueller-Nose (MN) Distance. MAIN OUTCOME MEASURE Change in radiographic measurements resulting in conversion to operative intervention. RESULTS Patients followed up an average of 2.6 visits in our clinics (SD 1.06). Patients received an average of 11.2 individual radiographic images to evaluate their injury (SD 3.9, maximum 29). No patients progressed to surgery in this cohort. Mean MCS at the time of injury was 3.4mm (SD 0.8) and was 3.3mm (SD 0.7) at the time of final follow up (p=0.1). Mean MN measurement at the time of injury was 3.5mm (SD 1.0) and was 3.5mm (SD 0.8) at the time of final follow up (p=0.47). CONCLUSION No patients with stable OTA/AO 44-B1 fractures proceeded to surgery for loss of tibiotalar reduction or any other cause. Radiographic relationships were conserved during the follow up and serial radiographs may not be needed when managing these patients. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Inflammatory cytokine response is greater in acute tibial plafond fractures than acute tibial plateau fractures

The purpose of the study was to compare the inflammatory cytokine and matrix metalloproteinase (MMP) concentrations in synovial fluid after acute plafond fracture with acute tibial plateau fracture. Between December 2011 and August 2014, we prospectively enrolled patients with acute tibial plateau and plafond fractures. Synovial fluid aspirations were obtained from injured and uninjured joints. The concentrations of IL‐1β, IL‐1RA, IL‐6, IL‐8, IL‐10, MCP‐1, TNF‐α, MMP‐1, ‐3, ‐9, ‐10, ‐12, and ‐13 were quantified using multiplex assays. A Bonferroni correction was used so that the adjusted alpha level for significance was p < 0.004. We enrolled 45 tibial plateau fractures and 19 plafond fractures. Mean patient age was 42 years (range, 20–60) and 64% were male patients. There were 24 low‐energy (OTA 41B) plateau fractures and eight low‐energy (OTA 43B) plafond fractures. There were 21 high‐energy (6 OTA 41B3 and 15 OTA 41C) plateau fractures and 11 high‐energy (OTA43C) plafond fractures. All cytokines and MMPs except MMP‐13 were significantly elevated in plafond fractures compared to uninjured ankles. When comparing acutely injured joints, IL‐8 (p < 0.001), IL‐1β (p = 0.002), and MMP‐12 (p = 0.001) were significantly higher in plafond fractures compared to plateau fractures. Concentrations of IL‐1RA (p = 0.008) and MCP‐1 (p = 0.005) were higher in plafond fractures, and MMP‐10 (p = 0.01) was higher in plateau fractures, but these differences did not reach significance. In conclusion, several cytokines and MMPs were significantly elevated in acute plafond fractures as compared to acute tibial plateau fractures.

External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures

INTRODUCTION On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)<15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution. PATIENTS AND METHODS Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables. RESULTS In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative. CONCLUSION With the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS<15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.

Predictors of amputation in high-energy forefoot and midfoot injuries

INTRODUCTION High energy injuries to the midfoot and forefoot are highly morbid injury groups that are relatively unstudied in the literature. Patients sustaining injuries of this region are challenging to counsel at the time of injury because so little is known about the short and long term results of these injuries. The purpose of this study was to investigate injury specific factors that were predictive of amputation in patients sustaining high energy midfoot and forefoot injuries. PATIENTS AND METHODS 137 patients with 146 injured feet [minimum of two fractures located in the forefoot and midfoot, excluding phalanges, talus, calcaneus, with a high energy mechanism]. RESULTS 121 of 146 feet (83%) were treated operatively; 27 patients sustained 34 total surgical amputation events. 30-day amputation rate was 13.9% and 1-year amputation rate was 18.9%; 27 of 146 feet ultimately sustained amputation with 23 of 27 sustaining a below the knee amputation (BKA) and 17 of 23 (73.9%) received a BKA as their first amputation. Statistically significant predictors of amputation included the number of bones fractured in the foot (p=0.015), open injury to the plantar or dorsal surfaces of the foot, Gustilo grade, vascular injury, and complete loss of sensation to any surface of the foot (all p<0.001). Specific fracture patterns predictive of any amputation were fracture of all five metatarsals (p<0.001) and fracture of the first metatarsal (p=0.003). Presence of a dislocation or fracture of the distal tibia were not predictive of amputation. Midterm patient-reported-outcomes (N=51) demonstrated no difference in physical function for patients with and without amputations. CONCLUSIONS High-energy forefoot and midfoot injuries are associated with a high degree of morbidity; 1/5th of patients sustaining these injuries proceeded to amputation within 1year. Injury characteristics can be used to counsel patients regarding severity and amputation risk.

Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis

BACKGROUND The aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement. METHODS Six patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4±1.9years (range 1.0-6.5). RESULTS One patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status. CONCLUSION In the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.