Michael J. Bellino

Assessment of compromised fracture healing.

&NA; No standard criteria exist for diagnosing fracture nonunion, and studies suggest that assessment of fracture healing varies among orthopaedic surgeons. This variability can be problematic in both clinical and orthopaedic trauma research settings. An understanding of risk factors for nonunion and of diagnostic tests used to assess fracture healing can facilitate a systematic approach to evaluation and management. Risk factors for nonunion include medical comorbidities, age, and the characteristics of the injury. The method of fracture management also influences healing. Comprehensive evaluation includes an assessment of the patients symptoms, signs, and immune and endocrine status as well as the biologic capacity of the fracture, presence of infection, and quality of reduction and fixation. Diagnostic tests include plain radiography, CT, ultrasonography, fluoroscopy, bone scan, MRI, and several laboratory tests, including assays for bone turnover markers in the peripheral circulation. A systematic approach to evaluating fracture union can help surgeons determine the timing and nature of interventions.

Risk factors for development of heterotopic ossification of the elbow after fracture fixation

BACKGROUND Postoperative heterotopic ossification (HO) about the elbow may occur after surgical fixation of fractures and can contribute to dysfunction. Factors associated with HO formation after surgical fixation of elbow trauma are not well understood. METHODS All patients who underwent surgery for elbow trauma at our institution from October 2001 through August 2010 were retrospectively reviewed. Patients with prior injury or deformity to the involved elbow were excluded. Demographic data; fracture type; surgical treatment; and presence, location, and size of HO were recorded. The Fisher exact test, χ(2) test, and multivariate logistic regression were used with an α value of .05 used for significance. RESULTS A total of 159 patients were identified, with 89 (37 men and 52 women) meeting inclusion and exclusion criteria. The mean age was 54.4 years (range, 18-90 years), and the mean follow-up time was 180 days. Age, male gender, lateral collateral ligament repair, and dual-incision approach were not associated with increased ectopic bone formation. Distal humeral fractures were a significant predictor of heterotopic bone. In patients in whom HO ultimately developed, it was visible on radiographs obtained 2 weeks postoperatively in 86% of cases. CONCLUSION This investigation found predictors for the development of HO after surgical fixation of intra-articular elbow fractures. Furthermore, HO went on to develop at the time of final follow-up in only 14% of patients without HO on radiographs obtained 2 weeks postoperatively. This may suggest that absence of HO on radiographs obtained 2 weeks postoperatively may predict a more favorable outcome.

Single column locking plate fixation is inadequate in two column acetabular fractures. A biomechanical analysis

BackgroundThe objective of this study was to determine whether one can achieve stable fixation of a two column (transverse) acetabular fracture by only fixing a single column with a locking plate and unicortical locking screws. We hypothesized that a locking plate applied to the anterior column of a transverse acetabular fracture would create a construct that is more rigid than a non-locking plate, and that this construct would be biomechanically comparable to two column fixation.MethodsUsing urethane foam models of the pelvis, we simulated transverse acetabular fractures and stabilized them with 1) an anterior column plate with bicortical screws, 2) an anterior locking plate with unicortical screws, 3) an anterior plate and posterior column lag screw, and 4) a posterior plate with an anterior column lag screw. These constructs were mechanically loaded on a servohydraulic material testing machine. Construct stiffness and fracture displacement were measured.Result and DiscussionWe found that two column fixation is 54% stiffer than a single column fixation with a conventional plate with bicortical screws. There was no significant difference between fixation with an anterior column locking plate with unicortical screws and an anterior plate with posterior column lag screw. We detected a non-significant trend towards more stiffness for the anterior locking plate compared to the anterior non-locking plate.ConclusionIn conclusion, a locking plate construct of the anterior column provides less stability than a traditional both column construct with posterior plate and anterior column lag screw. However, the locking construct offers greater strength than a non-locking, bicortical construct, which in addition often requires extensive contouring and its application is oftentimes accompanied by the risk of neurovascular damage.

Surgical treatment of flail chest and rib fractures.

Despite significant advances in critical care management, flail chest remains a clinically significant finding, with a mortality rate of up to 33%. Nonsurgical management is associated with prolonged ventilator support, pneumonia, respiratory difficulties, and lengthy stays in the intensive care unit, as well as chronic pain from nonunion and malunion of the bony thorax. Treatment with aggressive pulmonary toilet, ventilator support, and different modalities of pain control remains the benchmark of care. However, several recent randomized controlled studies of surgical intervention of flail chest have demonstrated an improvement in the number of ventilator days, intensive care unit and hospital stays, incidence of pneumonia, and respiratory function and hospital costs, as well as faster return to work. The success of these surgical constructs compared with those of historical attempts at open fixation is largely the result of modern plating technology and improvement in surgical approaches. Clinical evidence continues to grow regarding proper indications and techniques for surgical stabilization of flail chest.

The Prevalence of Sacroiliac Joint Degeneration in Asymptomatic Adults

BACKGROUND Degenerative changes of the sacroiliac joint have been implicated as a cause of lower back pain in adults. The purpose of this study was to determine the prevalence of sacroiliac joint degeneration in asymptomatic patients. METHODS Five hundred consecutive pelvic computed tomography (CT) scans, made at a tertiary-care medical center, of patients with no history of pain in the lower back or pelvic girdle were retrospectively reviewed and analyzed for degenerative changes of the sacroiliac joint. After exclusion criteria were applied, 373 CT scans (746 sacroiliac joints) were evaluated for degenerative changes. Regression analysis was used to determine the association between age and the degree of sacroiliac joint degeneration. RESULTS The prevalence of sacroiliac joint degeneration was 65.1%, with substantial degeneration occurring in 30.5% of asymptomatic subjects. The prevalence steadily increased with age, with 91% of subjects in the ninth decade of life displaying degenerative changes. CONCLUSIONS Radiographic evidence of sacroiliac joint degeneration is highly prevalent in the asymptomatic population and is associated with age. Caution must be exercised when attributing lower back or pelvic girdle pain to sacroiliac joint degeneration seen on imaging. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The learning curve for the direct anterior approach for total hip arthroplasty: a single surgeon’s first 500 cases

Background Concerns arise over the early complications encountered during the learning curve for the direct anterior approach for total hip arthroplasty. The purpose of this study is to examine the learning experience of a single surgeon in adapting this approach. Methods The 1st 500 primary total hip arthroplasties are reviewed. The patients were evaluated out to 3 months. Rates of major complications, reoperations, periprosthetic fractures, heterotopic ossification, leg length discrepancies and lateral femoral cutaneous nerve deficits were identified for each of 100 patients. Results The major complication rate decreased from 5% to 2% throughout the series. Reoperation rates fluctuated from 2% in the 1st 100 cases to 3% in the 4th 100 cases to 1% in the 5th 100 cases. The periprosthetic fracture rate decreased from 9% to 2%. Conclusions The incidence of heterotopic ossification declines throughout the series and is attributed to changes in irrigation technique and quantity. The incidence of major complications decreases with increasing experience. The most dramatic improvements occur after the 1st group of 100 cases.

The posterior approach to pelvic ring injuries: A technique for minimizing soft tissue complications.

Surgical techniques and fixation strategies for the treatment of unstable posterior pelvic ring injuries continue to evolve. The safety of the posterior surgical approach in particular has been questioned due to historically high rates of wound related complications. More contemporary studies have shown lower infection rates, however concern still persists. These concerns for infection and wound necrosis have led, in part, to increased interest in closed reduction and percutaneous fixation for treatment of these injuries but an open posterior approach remains the optimal strategy in some injury patterns. We describe herein a modified posterior approach to the pelvis designed to minimize wound related complications and present our clinical results demonstrating wound complication rates consistent with contemporary publications.

Conventional versus virtual radiographs of the injured pelvis and acetabulum

BackgroundEvaluation of the fractured pelvis or acetabulum requires both standard radiographic evaluation as well as computed tomography (CT) imaging. The standard anterior-posterior (AP), Judet, and inlet and outlet views can now be simulated using data acquired during CT, decreasing patient discomfort, radiation exposure, and cost to the healthcare system. The purpose of this study is to compare the image quality of conventional radiographic views of the traumatized pelvis to virtual radiographs created from pelvic CT scans.MethodsFive patients with acetabular fractures and ten patients with pelvic ring injuries were identified using the orthopedic trauma database at our institution. These fractures were evaluated with both conventional radiographs as well as virtual radiographs generated from a CT scan. A web-based survey was created to query overall image quality and visibility of relevant anatomic structures. This survey was then administered to members of the Orthopaedic Trauma Association (OTA).ResultsNinety-seven surgeons completed the acetabular fracture survey and 87 completed the pelvic fracture survey. Overall image quality was judged to be statistically superior for the virtual as compared to conventional images for acetabular fractures (3.15 vs. 2.98, p = 0.02), as well as pelvic ring injuries (2.21 vs. 1.45, p = 0.0001). Visibility ratings for each anatomic landmark were statistically superior with virtual images as well.DiscussionVirtual radiographs of pelvic and acetabular fractures offer superior image quality, improved comfort, decreased radiation exposure, and a more cost-effective alternative to conventional radiographs.

Does Intraoperative Fluoroscopy Optimize Limb Length and the Precision of Acetabular Positioning in Primary THA

Reduced limb length discrepancy and more accurate cup positioning are purported benefits of using fluoroscopy for total hip arthroplasty (THA). The authors compared limb length discrepancy and cup position in 200 patients (group I, posterior approach without fluoroscopy; group II, anterior supine approach with fluoroscopy) who underwent primary THA. Mean limb length discrepancy was 2.7 mm (SD, 5.2 mm; range, -9.8 to 20.9 mm) and 0.7 mm (SD, 3.7 mm; range, -11.8 to 10.5 mm) for groups I and II, respectively (P=.002). In group I, 7% of hips had limb length discrepancy greater than 1 cm compared with 3% in group II. Mean cup inclination measured 40.8° (SD, 5.0°; range, 26.1°-53.7°) in group I and 43.4° (SD, 5.6°; range, 31.3°-55.9°) in group II (P=.008). In group I, 96% of cups had inclination within 10° of the mean compared with 92% in group II (P=.24). Mean anteversion measured 35.3° (SD, 7.1°; range, 17.8°-60.7°) in group I and 25.9° (SD, 8.2°; range, 1.5°-44.8°) in group II (P=.0001). In group I, 87% of hips exhibited anteversion within 10° of the mean compared with 76% in group II (P=.045). Although the anterior approach with intraoperative fluoroscopy reduced mean limb length discrepancy, the clinical significance of this reduction is unclear. Fluoroscopy reduced the incidence of limb length discrepancy greater than 1 cm. However, the use of fluoroscopy did not help to improve the precision of cup positioning.

Pelvic Ring Injuries

Pelvic ring injuries are increasingly common in motor vehicle trauma. The minority of pelvic ring injuries require operative fixation. This paper outlines the basic techniques for posterior pelvic ring reduction and fixation including relevant biomechanics of posterior pelvic ring fixation.