Matthew A. Mormino

Injury to the Tarsometatarsal Joint Complex

Abstract Tarsometatarsal joint complex fracture‐dislocations may result from direct or indirect trauma. Direct injuries are usually the result of a crush and may involve associated compartment syndrome, significant soft‐tissue injury, and open fracture‐dislocation. Indirect injuries are often the result of an axial load to the plantarflexed foot. Midfoot pain after even a minor forefoot injury should raise suspicion; up to 20% of tarsometatarsal joint complex injuries are missed on initial examination. An anteroposterior radiograph with abduction stress may reveal subtle injury, but computed tomography is the preferred imaging modality. The goal of treatment is the restoration of a pain‐free, functional foot. The preferred treatment is open reduction and internal fixation, using screw fixation for the medial three rays and Kirschner wires for the fourth and fifth tarsometatarsal joints. Satisfactory outcome can be expected in approximately 90% of patients.

The relationship of proximal locking screws to the axillary nerve during antegrade humeral nail insertion of four commercially available implants.

Objective: The purpose of this study was to determine the proximity of proximal interlocking mechanisms in 4 current antegrade humeral nails to the axillary nerve and its branches. Design: Cadaveric study. Setting: Anatomy laboratory. Main Outcome Measure: Anatomic relationships. Methods: Four humeral nail designs (labeled SS, SL, SZ, and SN) were each inserted in successive antegrade fashion in 10 cadaveric upper extremity specimens. Three variables were measured: from acromion to the axillary nerve, from acromion to entry sites of proximal locking devices, and from locking devices to axillary nerves and their branches. Results: In nail SS, the proximally directed oblique locking screw came into contact with the ascending branch of the axillary nerve in 6 of 10 specimens. Mean distance from spiral blades in nails SS and SL were 26 mm to the axillary nerve and 16 mm to its ascending branch. Interlocking screws for nails SZ, SN, and SL did not violate the axillary nerve or its branches in any specimen. Mean distance from lateral acromion to the axillary nerve measured 58.7 mm. Conclusion: Nail SS’s oblique locking screw may injure the ascending branch of the axillary nerve. Three of the 4 nails tested did not endanger the axillary nerve. However, when transverse proximal locking screws are inserted from a lateral-to-medial direction, they may endanger an arborized axillary nerve. Blunt dissection should be performed with a visible path to bone before instrumentation to reduce the risk of axillary nerve injury.

Anterior plate supplementation increases ankle arthrodesis construct rigidity.

Background: The success of ankle arthrodesis for the treatment of post-traumatic ankle arthritis depends on achieving and maintaining rigid fixation of the prepared tibiotalar interface. The purpose of this study was to examine the biomechanical effect of anterior plate supplementation of a popular three-screw fusion construct. Methods: Six fresh-frozen cadaver ankles were prepared and instrumented with three partially threaded screws compressing the tibiotalar interface. Testing was done with and without supplementary anterior plate fixation under three different decoupled loading conditions: plantarflexion/dorsiflexion, inversion/eversion, and rotation. Motion at the tibiotalar interface was recorded. Results: Anterior plating increased construct stiffness by a factor of 3.5, 1.9, and 1.4 for the sagittal, coronal, and torsion modes, respectively. Less motion occurred at the tibiotalar interface in all to the three different loading conditions (p = 0.031) with plate supplementation. Conclusions: Compared to screws alone, anterior plate supplementation increases construct rigidity and decreases micromotion at the ankle fusion interface.

Outcomes Following Distal Humeral Fracture Fixation with an Extensor Mechanism-On Approach

BACKGROUND Distal humeral fractures have traditionally been managed with surgical approaches that disrupt the extensor mechanism. We hypothesized that an extensor mechanism-on approach for operative fixation of distal humeral fractures with parallel or orthogonal plate constructs would allow excellent healing, a motion arc of the elbow exceeding 100°, and maintenance of extensor mechanism strength. METHODS Distal humeral open reduction and internal fixation (ORIF) was performed with either orthogonal or parallel plate constructs in seventy-nine elbows. Thirty-seven elbows were fixed via an extensor mechanism-on surgical approach, and twenty-four of them were available for additional evaluation. Radiographs as well as MEPI (Mayo Elbow Performance Index), DASH (Disabilities of the Arm, Shoulder and Hand), and SF-36 (Short Form-36) scores were obtained. RESULTS All thirty-seven fractures healed primarily. Three elbows underwent later release because of stiffness. The median arc of elbow motion was 126° (range, 60° to 141°). The mean MEPI was 91.5 points and the mean DASH score was 15.9 points, indicating excellent scores with mild impairment. The median percent loss of triceps strength was 10% (range, 0% to 49%) compared with the contralateral, normal elbow. CONCLUSIONS Open treatment of distal humeral fractures with an extensor mechanism-on approach results in excellent healing, a mean elbow flexion-extension arc exceeding 100°, and maintenance of 90% of elbow extension strength compared with that of the contralateral, normal elbow.

Functional Outcome after Blade plate reconstruction of distal tibia metaphyseal nonunions: A study of 11 cases

Objectives To present the functional outcome of a cohort of 11 patients prospectively followed before and after blade plate reconstruction of a distal tibia metaphyseal nonunion. Design Prospective case series. Setting University hospital tertiary referral center. Patients Eleven patients with an average age of 48 years. Average duration of nonunion was 11 months. Patients had undergone an average of 3.1 procedures before the index surgery. Three patients had prior deep infections, and one patient had an active infection. Intervention A precontoured 4.5-mm cannulated blade plate was applied to the medial tibial surface through a posteromedial approach. Autograft was added in eight patients to fill bone voids. Main Outcome Measures AOFAS scores were assigned to each patient preoperatively and at most recent follow-up. Results All patients healed their nonunions after the index surgery. Average time to radiographic union was 16 weeks. Average time to full weight bearing was 12 weeks. AOFAS scores improved in all patients from an average preoperative score of 29 to an average postoperative score of 89. The only complication was a deep infection, which was treated successfully with one irrigation and débridement and 6 weeks of intravenous antibiotics. Conclusion Blade plate reconstruction of distal tibia metaphyseal nonunion is a safe and reliable method that results in a high union and low complication rate.

The radiographic acromiohumeral interval is affected by arm and radiographic beam position

ObjectiveThe objective was to determine whether arm and radiographic beam positional changes affect the acromiohumeral interval (AHI) in radiographs of healthy shoulders.Materials and methodsControlling for participant’s height and position as well as radiographic beam height and angle, from 30 right shoulders of right-handed males without shoulder problems four antero-posterior (AP) radiographic views each were obtained in defined positions. Three independent, blinded physicians measured the AHI to the nearest millimeter in 120 randomized radiographs. Mean differences between measurements were calculated, along with a 95% confidence interval.ResultsControlling for observer effect, there was a significant difference between AHI measurements on different views (p < 0.01). All pair-wise differences were statistically significant after adjusting for multiple comparisons (all p values < 0.01).ConclusionsEven in healthy shoulders, small changes in arm position and radiographic beam orientation affect the AHI in radiographs.

Functional outcomes of Denis zone III sacral fractures treated nonoperatively.

Objectives: The purpose of this study is to report the outcomes of nonoperative treatment in patients with Denis Zone III sacral fractures at a minimum of 2 years follow up. Design: Retrospective review of prospectively collected data of a consecutive series of patients. Setting: Level I trauma center. Patients: A consecutive series of 15 patients (15-47 years old) with Denis Zone III sacral fractures treated nonoperatively from 1997 to 2002 was studied. Eleven patients were available for follow-up questionnaires; nine participated in a physical examination. Time to final follow up averaged 43 months (range, 25-67 months). Intervention: Demographic data; mechanism of injury; injury-specific assessment of bowel, bladder, and sexual function; physical examination; and fracture pattern were collected from a prospectively collected database. Main Outcome Measurements: At a minimum of 2-year follow up, evaluation of SF-36 scores, Roland Morris back pain questionnaire, and Gibbons classification was conducted. Results: All fractures healed. Six patients had a postinjury increase in kyphosis (range, 1°-17°) without a correlation to final outcomes. Mean SF-36 scores were all uniformly lower than the normalized general population and were biased by frequent associated injuries. Final Roland-Morris scores averaged 3.3 ± 3.3. Gibbons classification scores initially averaged 2 ± 1.2 and decreased to 1.5 ± 0.8, each within their standard deviations. Eight had residual bowel, bladder, and/or sexual dysfunction. Conclusions: Nonoperative treatment of Denis Zone III sacral fractures yields consistent healing. Despite improvement in initial neurologic deficits, residual complaints were common.

Suture Button Fixation Versus Syndesmotic Screws in Supination–External Rotation Type 4 Injuries: A Cost-Effectiveness Analysis:

Background: In stress-positive, unstable supination–external rotation type 4 (SER IV) ankle fractures, implant selection for syndesmotic fixation is a debated topic. Among the available syndesmotic fixation methods, the metallic screw and the suture button have been routinely compared in the literature. In addition to strength of fixation and ability to anatomically restore the syndesmosis, costs associated with implant use have recently been called into question. Purpose: This study aimed to examine the cost-effectiveness of the suture button and determine whether suture button fixation is more cost-effective than two 3.5-mm syndesmotic screws not removed on a routine postoperative basis. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: Studies with the highest evidence levels in the available literature were used to estimate the hardware removal and failure rates for syndesmotic screws and suture button fixation. Costs were determined by examining the average costs for patients who underwent surgery for unstable SER IV ankle fractures at a single level-1 trauma institution. A decision analysis model that allowed comparison of the 2 fixation methods was developed. Results: Using a 20% screw hardware removal rate and a 4% suture button hardware removal rate, the total cost for 2 syndesmotic screws was US

Evaluation of popliteal artery injury risk with locked lateral plating of the tibial plateau

20,836 and the total effectiveness was 5.846. This yielded a total cost of

Peripelvic abscesses: A diagnostic dilemma

3564 per quality-adjusted life-year (QALY) over an 8-year time period. The total cost for suture button fixation was