Michael T. Archdeacon

Autogenous Bone Graft: Donor Sites and Techniques

Autogenous cancellous bone graft provides an osteoconductive, osteoinductive, and osteogenic substrate for filling bone voids and augmenting fracture-healing.The iliac crest remains the most frequently used site for bone-graft harvest, but the proximal part of the tibia, distal end of the radius, distal aspect of the tibia, and greater trochanter are alternative donor sites that are particularly useful for bone-grafting in the ipsilateral extremity.The most common complication associated with the harvest of autogenous bone graft is pain at the donor site, with less frequent complications including nerve injury, hematoma, infection, and fracture at the donor site.Induced membranes is a method that uses a temporary polymethylmethacrylate cement spacer to create a bone-graft-friendly environment to facilitate graft incorporation, even in large segmental defects.

Infrapectineal plating for acetabular fractures: a technical adjunct to internal fixation.

Acetabular fractures with medial displacement patterns, particularly medial displacement of the quadrilateral surface, may be technically challenging to treat. Minimal bone stock, limited anatomic access, and difficulty in obtaining stable internal fixation in the true pelvis contribute to the surgical challenge of open reduction and internal fixation. Applying a medial buttress plate across the quadrilateral plate below the iliopectineal line in the true pelvis can be a helpful adjunct to internal fixation in these fractures. The quadrilateral plate is approached from the opposite side of the injury through a standard ilioinguinal approach or a modified Stoppa approach. An undercontoured plate is secured posteriorly along the sciatic buttress posterior to the joint and the quadrilateral plate and anteriorly on the posterior surface of the pubic ramus. By resisting medial secondary redisplacement, this technique adds to stable fixation for acetabular fractures involving medial displacement, particularly of the quadrilateral plate.

Fractures of the talar neck.

Fractures of the talus have been described for 400 years. This article reviews the history of this injury and its treatment. It also discusses the modern results and complications involved with the injury and treatment.

The influence of insurance status on the transfer of femoral fracture patients to a level-I trauma center.

BACKGROUND The aim of the present study was to evaluate transfer patterns and insurance status for patients with a femoral fracture who were definitively managed within a six-hospital health-care system. We hypothesized that insurance status significantly influenced transfer of these patients to the level-I trauma center and that the level-I center provided definitive care for a disproportionate percentage of uninsured femoral fracture patients. METHODS The present retrospective cohort study was performed within a six-hospital health-care system. The system comprises a single American College of Surgeons-designated level-I trauma center and five nondesignated community hospitals. We identified 243 patients with 251 femoral shaft fractures that had been definitively treated with intramedullary nail fixation within the system. From the health-care system billing database and trauma registries, we obtained diagnosis and procedure codes, insurance status, and trauma center transfer data. Differences in the proportions of uninsured and insured patients were calculated. RESULTS One hundred and seventy-two (71%) of the 243 patients who were definitively managed within our health-care system initially had been taken to the regional level-I center, and thirty-eight patients (16%) had been transferred to the trauma center. Of the thirty-eight patients who had been transferred, eighteen (47%) had met appropriate transfer criteria. Of the twenty patients with an isolated femoral fracture who had been transferred from hospitals with regular orthopaedic coverage, four (20%) had met appropriate transfer criteria. Twenty-two (58%) of the thirty-eight patients who had been transferred were uninsured, and all thirty-three patients who had not been transferred were insured (p = 0.0008); this observation remained when controlling for injury severity and available orthopaedic coverage (p < 0.0001). The proportion of insured patients definitively managed at the trauma center (52%) differed significantly from the proportion of insured patients definitively managed at the community hospitals (100%) (p < 0.0001). CONCLUSIONS The majority (71%) of the patients with a femoral fracture who had been managed definitively within our health-care system, regardless of injury severity, had been taken directly to the trauma center. This finding suggests over-triage, which errs on the side of patient well-being. Because there was a significant difference in insurance status between patients who had been transferred to the level-I center and those who had not been transferred as well as between patients who had been definitively managed at the level-I center and those who had been managed in community hospitals, it can be assumed that insurance status as well as injury severity and orthopaedic surgeon availability influence the decision to transfer femoral fracture patients to a level-I trauma center.

In Vitro Forces in the Normal and Cruciate-Deficient Knee During Simulated Squatting Motion

Three orthogonal components of the tibiofemoral and patellofemoral forces were measured simultaneously for knees with intact cruciate ligaments (nine knees), following anterior cruciate ligament resection (six knees), and subsequent posterior cruciate ligament resection (six knees). The knees were loaded using an experimental protocol that modeled static double-leg squat. The mean compressive tibial force increased with flexion angle. The mean anteroposterior tibial shear force acted posteriorly on the tibia below 50 deg flexion and anteriorly above 55 deg. Mediolateral shear forces were low compared to the other force components and tended to be directed medially on both the patella and tibia. The mean value of the ratio of the resultant tibial force divided by the quadriceps force decreased with increasing flexion angle and was between 0.6 and 0.7 above 70 deg flexion. The mean value of the ratio of the resultant tibiofemoral contact force divided by the resultant patellofemoral contact force decreased with increasing flexion and was between 0.8 and 1.0 above 55 deg flexion. Cruciate ligament resection resulted in no significant changes in the patellar contact forces. Following resection of the anterior cruciate ligament, the tibial anteroposterior shear force was directed anteriorly over all flexion angles tested. Subsequent resection of the posterior cruciate ligament resulted in an approximately 10 percent increase in the quadriceps tendon and tibial compressive force.

A Prospective Functional Outcome and Motion Analysis Evaluation of the Hip Abductors After Femur Fracture and Antegrade Nailing

Objective: To determine if dynamic hip abductor weakness during gait, evaluated through component measures of hip kinematics and hip kinetics, demonstrate longitudinal improvement after antegrade intramedullary nailing of femoral shaft fractures and if these improvements correlate with patient reported functional outcomes. Design: Prospective patient protocol. Setting: University-based, level I trauma center. Patients: Eight nonconsecutive, isolated femur fracture patients. Intervention: Antegrade intramedullary nailing of isolated femoral shaft fractures. Main Outcome Measure: Hip kinematics (hip abduction angle and ipsilateral lateral trunk lean), hip kinetics (hip abductor moment), and patient-reported functional outcome measures (Short Form - Musculoskeletal Function Assessment Survey) were assessed at 2 time points [Time1 = independent ambulation without ambulatory aide, 2.0 (±0.6) months; Time2 = approximately 6 months after injury with clinical and radiographic fracture healing, 7.2 (±1.5) months]. Results: After surgical fixation of a femoral shaft fracture, subjects demonstrated significant time-dependent, negative effects on gait secondary to dynamic hip abductor weakness measured in terms of hip kinematics [hip abduction angle (P = 0.012) and lateral trunk lean (P = 0.046)] and hip kinetics [hip abductor moment (P = 0.029 at loading response; P = 0.022 at terminal stance)]. A significant improvement in the dysfunction index was found between the early and late assessments (21.3 ± 15.0, 6.5 ± 8.9, P = 0.008). At late assessment of functional outcome (22.5 ± 3.7 months), a significant correlation was observed between the dysfunction index and hip kinematics (ipsilateral trunk lean) at both Time1 (R = -0.811, P = 0.015) and Time2 (R = -0.713, P = 0.047). Conclusions: After isolated femur fracture, patients treated with antegrade intramedullary nailing demonstrated a significant negative effect on hip kinematics and kinetics, and this effect was time-dependent. Early postsurgical ipsilateral trunk lean correlated with long-term functional outcome scores; therefore, excessive frontal plane movement during gait in the early postoperative stages may be indicative of a poorer self-reported longer-term functional outcome.

The modified Stoppa approach for acetabular fracture.

Judet et al and Letournel and Judet laid the groundwork for the current understanding and management of acetabular fractures. They developed a classification system and novel surgical approaches that still serve as the standard of care. Modifications of these approaches (eg, ilioinguinal, Kocher-Langenbeck) have been developed to improve surgical outcomes. The Stoppa approach is used in the repair of inguinal hernias. Hirvensalo et al and Cole and Bolhofner described a modified Stoppa approach involving an anterior intrapelvic (AIP) extraperitoneal approach through the rectus abdominis muscle for internal fixation of pelvic and acetabular fractures. This approach provides direct access to the pubis, the posterior surface of the ramus, the quadrilateral surface, the pubic eminence, and the infrapectineal surface, as well as the sciatic buttress, sciatic notch, and the anterior sacroiliac joint. The modified Stoppa (ie, AIP) approach provides improved exposure of the quadrilateral surface and posterior column. Additionally, with the AIP approach, the so-called middle window of the ilioinguinal approach can frequently be avoided, resulting in minimal dissection of the inguinal canal, femoral nerve, and external iliac vessels.

Management of extra-articular fractures of the distal tibia: intramedullary nailing versus plate fixation.

Abstract Intramedullary nailing and plate fixation represent two viable approaches to internal fixation of extra‐articular fractures of the distal tibia. Although both techniques have demonstrated success in maintaining reduction and promoting stable union, they possess distinct advantages and disadvantages that require careful consideration during surgical planning. Differences in soft‐tissue health and construct stability must be considered when choosing between intramedullary nailing and plating of the distal tibia. Recent advances in intramedullary nail design and plate‐and‐screw fixation systems have further increased the options for management of these fractures. Current evidence supports careful consideration of the risk of soft‐tissue complications, residual knee pain, and fracture malalignment in the context of patient and injury characteristics in the selection of the optimal method of fixation.

Combined olecranon osteotomy and posterior triceps splitting approach for complex fractures of the distal humerus

Complex fractures involving the intercondylar/supracondylar distal humerus with extension into the mid to proximal humeral shaft are difficult to manage through a single standard surgical approach. We present and review a technique that combines an olecranon osteotomy with a posterior triceps splitting approach to the humerus. This technique was used in two patients who presented with severe intercondylar fractures of the distal humerus and extension proximally to the midshaft of the humerus. The technique allowed extensive distal humerus exposure, including the supracondylar/intercondylar region, and excellent exposure of the humeral shaft proximally to the surgical neck.

The Clamshell Osteotomy: A New Technique to Correct Complex Diaphyseal Malunions

BACKGROUND The treatment of complex diaphyseal malunions is challenging, requiring extensive preoperative planning and precise operative technique. We have developed a simpler method to treat some of these deformities. METHODS Ten patients with complex diaphyseal malunions (including four femoral and six tibial malunions) underwent a clamshell osteotomy. The indications for surgery included pain at adjacent joints and deformity. After surgical exposure, the malunited segment was transected perpendicular to the normal diaphysis proximally and distally. The transected segment was again osteotomized along its long axis and was wedged open, similar to opening a clamshell. The proximal and distal segments of the diaphysis were then aligned with use of an intramedullary rod as an anatomic axis template and with use of the contralateral extremity as a length and rotation template. The patients were assessed clinically and radiographically at a mean of thirty-one months (range, six to fifty-two months) after the osteotomy. RESULTS Complete angular correction was achieved in each case; the amount of correction ranged from 2 degrees to 20 degrees in the coronal plane, from 0 degrees to 32 degrees in the sagittal plane, and from 0 degrees to 25 degrees in the axial plane (rotation). Correction of length ranged from 0 to 5 cm, and limb length was restored to within 2 cm in all patients. All osteotomy sites were healed clinically by six months. While no deep infections occurred, superficial wound dehiscence occurred in two patients along the approach for the longitudinal portion of the osteotomy, emphasizing the importance of careful soft-tissue handling and patient selection. CONCLUSIONS The clamshell osteotomy provides a useful way to correct many forms of diaphyseal malunion by realigning the anatomic axis of the long bone with use of a reamed intramedullary rod as a template. This technique provides an alternative that could decrease preoperative planning time and complexity as well as decrease the need for intraoperative osteotomy precision in a correctly chosen subset of patients with diaphyseal deformities.