Madhav A. Karunakar

Body mass index as a predictor of complications after operative treatment of acetabular fractures

BACKGROUND Obesity, a growing public health concern, is often thought to be an important risk factor for postoperative complications. We hypothesized that body mass index is predictive of complications after operative treatment of acetabular fractures. METHODS A retrospective chart review identified 169 consecutive patients in whom an acetabular fracture had been treated with open reduction and internal fixation at a level-1 trauma center. The patients were stratified into four classes according to their body mass index: normal (<25), overweight (> or =25 but <30), obese (> or =30 but <40), and morbidly > or =40). The perioperative outcomes that were evaluated included estimated blood loss, wound infection, nerve palsy, deep venous thrombosis, pulmonary embolism, and heterotopic ossification. Multivariate general linear models were used to test for the relationship between body mass index and perioperative outcomes while controlling for potential intervening variables (including surgical approach, fracture type, and surgeon experience). Odds ratios were calculated as well. RESULTS When body mass index was measured as a continuous variable, it was found to have a significant relationship with estimated blood loss (p = 0.003), prevalence of wound infection (p = 0.002), and prevalence of deep venous thrombosis (p = 0.03). Odds ratio analysis revealed that obese subjects (body mass index of > or =30) were 2.1 times more likely than patients of normal weight (body mass index of <25) to have an estimated blood loss of >750 mL and 2.6 times more likely to have a deep venous thrombosis. Morbidly obese patients (body mass index of > or =40) were five times more likely to have a wound infection. CONCLUSIONS Body mass index is predictive of complications after operative treatment of acetabular fractures.

Surgical Treatment of Nonarticular Distal Tibia Fractures

Abstract Distal tibia metaphyseal fractures can be difficult to manage. Treatment selection is influenced by the proximity of the fracture to the plafond, fracture displacement, comminution, and injury to the soft‐tissue envelope. Nonsurgical management is possible for stable fractures with minimal shortening. Indications for intramedullary nailing have expanded to include distal metaphyseal tibia fractures. Intramedullary nailing allows atraumatic, closed stabilization while preserving the vascularity of the fracture site and integrity of the soft‐tissue envelope. Intramedullary canal anatomy at this level prevents intimate contact between the nail and endosteum, however, and concerns have been raised regarding the biomechanical stability of fixation and risk of malunion. Plate fixation is effective in stabilizing distal tibia fractures. Conventional techniques involve extensive dissection and periosteal stripping, which increase the risk of softtissue complications. Percutaneous plating techniques use indirect reduction methods and allow stabilization of distal tibia fractures while preserving vascularity of the soft‐tissue envelope. External fixation is effective in the setting of contaminated wounds or extensive soft‐tissue injury. Careful preoperative planning with consideration for fracture pattern and soft‐tissue condition helps guide implant selection and minimize postoperative complications.

Indometacin as prophylaxis for heterotopic ossification after the operative treatment of fractures of the acetabulum

Our study was designed to compare the effect of indometacin with that of a placebo in reducing the incidence of heterotopic ossification in a prospective, randomised trial. A total of 121 patients with displaced fractures of the acetabulum treated by operation through a Kocher-Langenbeck approach was randomised to receive either indometacin (75 mg) sustained release, or a placebo once daily for six weeks. The extent of heterotopic ossification was evaluated on plain radiographs three months after operation. Significant ossification of Brooker grade III to IV occurred in nine of 59 patients (15.2%) in the indometacin group and 12 of 62 (19.4%) receiving the placebo. We were unable to demonstrate a statistically significant reduction in the incidence of severe heterotopic ossification with the use of indometacin when compared with a placebo (p = 0.722). Based on these results we cannot recommend the routine use of indometacin for prophylaxis against heterotopic ossification after isolated fractures of the acetabulum.

Split depression tibial plateau fractures: A biomechanical study

Objective To determine the biomechanical characteristics of four different fixation constructs for split depression fractures of the lateral tibial plateau (OTA classification 41B3.1). Design Laboratory investigation using a cadaveric simulated split depression tibial plateau fracture model. Setting Split depression tibial plateau fractures were created, reduced, and instrumented in a matched pair design. Specimens were tested for stiffness using a materials testing machine. Intervention Tibias were instrumented with an L-buttress plate, four 3.5-millimeter subchondral raft screws with an antiglide plate, an L-buttress plate with cancellous allograft, or four 3.5-millimeter subchondral raft screws placed through a periarticular plate. Main Outcome Measurements Vertical subsidence of the lateral tibial plateau was measured for the entire construct and for the local depression. The relative medial and lateral condylar tilt with central loading was also measured. Results There was no significant difference between the four fixation methods for overall longitudinal stiffness of the proximal tibial fracture fixation construct (range, 2,026 to 2,666 newtons per millimeter). The local depression stiffness for the raft–periarticular plate and raft–antiglide plate were 425 newtons per millimeter and 342 newtons per millimeter, respectively, versus 243 newtons per millimeter and 210 newtons per millimeter for the two large fragment buttress constructs. There was no significant difference between the local depression stiffness for the two raft constructs. There was no significant difference between the local depression stiffness for the two buttress plate constructs. Local depression stiffness was found to be significantly greater for the raft–periarticular plate construct when compared with the large fragment buttress plate construct without bone graft (p = 0.0314). Condylar tilt data showed a significant difference between the medial tilt observed in the prefracture specimen and the lateral tilt observed after fixation (p ≤ 0.017) for all constructs. Conclusions There was no significant difference in the overall construct stiffness between the four fixation constructs. Fixation constructs with a raft of subchondral screws were more resistant to local depression loads. This supports the use of a raft construct when a central depression is a significant component of the overall fracture pattern. Condylar tilt data showed a persistent weakness in the postfixation lateral plateau regardless of fixation construct when compared with the intact specimen. This supports the current clinical practice of delayed weight-bearing for ten to twelve weeks.

Bicondylar tibial plateau fractures: a biomechanical study.

The optimal treatment of bicondylar tibial plateau fractures remains controversial. The current study was designed to answer the following questions: (1) can a lateral fixed angle plate provide similar construct stability to dual plating techniques and (2) does the size of the medial buttress plate used in dual plating techniques have an effect on construct stability? Bicondylar tibial plateau fractures were created, reduced, and instrumented in a matched pair design using a cadaveric simulated bicondylar tibial plateau fracture model. Tibias were instrumented with one of three constructs: a lateral periarticular plate and posteromedial small fragment dynamic compression plate, a lateral periarticular plate and posteromedial ⅓-tubular plate, or a lateral fixed angle plate. Biomechanical testing was done to determine construct stiffness, maximum load to failure, and medial condylar displacement for each of the three constructs. There was no significant difference measured between the two dual plating constructs and the lateral fixed angle plate for overall construct stiffness or with respect to medial condylar fragment displacement. A lateral fixed angle plate may have clinical applications in the treatment of bicondylar tibial plateau fractures.

Operative treatment of unstable pediatric pelvis and acetabular fractures.

The management of unstable pediatric pelvic and acetabular fractures continues to be controversial. Recent reports have suggested that closed management of unstable pelvic and acetabular fractures can result in significant long-term morbidity. The purpose of this study was to evaluate the results of operative stabilization of unstable pelvic and acetabular fractures in children and adolescents. Eighteen patients less than 16 years of age with unstable pelvic and acetabular fractures were treated operatively over a 7-year period. Fracture healing, time to union, complications, and functional outcome were assessed. All fractures healed by 10 weeks. No patients suffered wound complications, infection, or growth arrest at an average follow-up of 30 months. These results support operative fixation of unstable pediatric pelvic and acetabular fractures to restore pelvic symmetry and periarticular anatomy. Favorable clinical results can be achieved with a low incidence of complications.

The modified ilioinguinal approach.

A modified ilioinguinal approach for acetabular fractures is presented. The approach allows surgical exposure of the anterior column as well as the contralateral rami, the symphysis pubis, and the medial wall of the acetabulum. Direct access to the quadrilateral surface and retroacetabular surface for plate or screw application is also possible.

Complications of high-energy bicondylar tibial plateau fractures treated with dual plating through 2 incisions.

Objectives: To characterize the rate of complications after operative fixation of bicondylar (OTA/AO 41-C) tibial plateau fractures and to evaluate the contribution of common risk factors. Design: Retrospective review. Setting: Level 1 regional trauma center. Patients/Participants: One hundred thirty-eight patients older than 18 years with 140 bicondylar tibial plateau fractures were participated in this study. Intervention: Open reduction and internal fixation using medial and lateral plate construct through 2 incisions. Main Outcome Measurements: Development of a deep infection or a nonunion. Results: The overall major complication rate was 27.9%: 23.6% deep infection and 10.0% nonunion. Open fractures were associated with a higher rate of infection: 43.8% versus 21.0% for closed injuries (odds ratio = 2.96, P = 0.05). Fasciotomy closure before definitive fixation was associated with significantly fewer deep infections compared with internal fixation with open fasciotomy wounds: 11.8% versus 50.0% (odds ratio = 7.5, P = 0.05). The presence of compartment syndrome, tobacco use, diabetes, and timing of surgery had no statistically significant association on the rate of infection or nonunion. Conclusions: Nonunion and deep infections occur commonly after staged open reduction and internal fixation of high-energy tibial plateau fractures. Open fractures and open fasciotomy wounds at the time of internal fixation are associated with higher rates of infection. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Safe Zone for the Placement of Medial Malleolar Screws

BACKGROUND Hardware placement for fracture fixation can put soft-tissue structures at risk for injury or abutment. The prominence of the hardware is a frequent cause of pain after the fixation of ankle fractures. This study was designed to assess the risk of injury or abutment of the posterior tibial tendon with the placement of medial malleolar screws. METHODS Ten unmatched cadaveric limbs that had been disarticulated at the knee were used, and the medial malleolus was exposed by dissection of the skin. With use of fluoroscopy and direct visualization of the deep fascia, three Kirschner wires were placed through the tip of the medial malleolus and directed parallel to the medial articular surface. The first wire was placed in the center of the anterior colliculus. Two additional wires were placed parallel and posterior to the initial wire at 5-mm intervals. The wires were overdrilled, and 4.0-mm screws were inserted over the Kirschner wires. The specimens were dissected to inspect for trauma and the proximity of the screws to the posterior tibial tendon. The medial malleolus was divided into three zones on the basis of anatomic landmarks. Zone 1 is the anterior colliculus; Zone 2, the intercollicular groove; and Zone 3, the posterior colliculus. RESULTS Screws placed in Zone 1 (the anterior colliculus) did not contact the posterior tibial tendon in any specimens. Screws placed in Zone 2 (the intercollicular groove) were, on the average, 2 mm from the posterior tibial tendon. Screws placed in Zone 3 (the posterior colliculus) resulted in tendon abutment in all ten specimens and in tendon injury in five of the ten specimens. CONCLUSIONS Screws inserted posterior to the anterior colliculus place the posterior tibial tendon at significant risk for injury or abutment.

Classification of Common Acetabular Fractures: Radiographic and CT Appearances

OBJECTIVE Accurate characterization of acetabular fractures can be difficult because of the complex acetabular anatomy and the many fracture patterns. In this article, the five most common acetabular fractures are reviewed: both-column, T-shaped, transverse, transverse with posterior wall, and isolated posterior wall. Fracture patterns on radiography are correlated with CT, including multiplanar reconstruction and 3D surface rendering. CONCLUSION In the evaluation of the five most common acetabular fractures, assessment of the obturator ring, followed by the iliopectineal and ilioischial lines and iliac wing, for fracture allows accurate classification. CT is helpful in understanding the various fracture patterns.