Nathan C. Tiedeken

The irreducible floating hip: a unique presentation of a rare injury

A floating hip injury occurs in the setting of poly-trauma and is a rare and difficult problem to manage. Floating hip injuries require vigilant attention not only to the osseous injuries but also the surrounding compartments and soft tissue envelope. We report the case of a 35-year-old male with a lower extremity posterior wall acetabular fracture, ipsilateral femoral shaft fracture and a postero-superior hip dislocation. Closed reduction failed, necessitating an open reduction internal fixation of his hip dislocation and acetabular fracture. The patient then developed a thigh compartment syndrome requiring a fasciotomy. Despite the obvious bony injuries, orthopedic surgeons must be vigilant of the neurovascular structures and soft tissues that have absorbed a great amount of force. A treatment plan should be formulated based on the status of the overlying soft tissue, fracture pattern and the patients physiologic stability.

Polyethylene glycol improves elution properties of polymethyl methacrylate bone cements

BACKGROUND Bone cements are used as adjuncts to fracture fixation methods and can also function as a local drug delivery system. The ability to elute drugs makes bone cement a promising and powerful chemotherapy treatment modality for osseous tumors. However, because of poor elution rates, the clinical application of this drug delivery mode remains challenging. Soluble fillers, such as sugars, salts, or biocompatible polymers, offer a solution to improve elution rates. This study quantified the effect of polyethylene glycol (PEG) on the elution properties of three commercially available bone cements. METHODS Two grams of Vertebroplastic, Palacos, and Confidence bone cement powder containing three concentrations (0%, 20%, or 50%) of PEG filler were hand mixed with 10 mg of methotrexate. This powder mixture was then polymerized with 1.0 mL of the cement specific liquid monomer. The cylindrical elution samples were placed in saline solution and methotrexate elution was recorded for 720 h. RESULTS The cumulative and daily elution rate increased as the concentration of PEG increased for each bone cement. However, the percent of increase depended on the bone cement used. Cumulative methotrexate elution increased by 40%-54% in case of the highest PEG filler concentration when compared with controls. CONCLUSIONS PEG soluble filler offers a promising method for improving methotrexate drug elution in bone cement. Future studies need to optimize the PEG and bone cement ratio that produces the greatest drug elution profile without sacrificing the biomechanical properties of bone cement.

Wartime Soft Tissue Coverage Techniques for the Deployed Surgeon

Background Since the start of the conflict in the Middle East in 2001, military orthopedic surgeons have faced complex orthopedic injuries including high-energy soft tissue wounds, traumatic amputations, and open fractures. Although orthopedic surgeons are well trained in the management of osseous injuries, the treatment of soft tissue injuries can be technically challenging and unfamiliar. Early washout, debridement of devitalized tissue, external fixation of bony injuries, and antibiotic therapy remain the foundation of early wound management. However, these unique extremity injuries have no standard plan of care, and definitive treatment options continue to evolve. The following report highlights the typical cases seen in the wartime setting and offers possible solutions for the associated soft tissue injuries. Methods A single orthopedic surgeon at a Role 3 combat support hospital performed all cases in this series. This study is a report of the cases that the orthopedic surgeon encountered while deployed and the various techniques that can be used to manage the complex wounds seen in a deployed setting. Findings Twelve patients were included in this report and the data are shown. Of the 12 patients, 6 were injured by an improvised explosive device (IED), 4 were injured by a high-velocity gunshot wound (HVGSW), 1 was injured by a gunshot wound (GSW), and 1 was injured in an auto versus pedestrian motor vehicle crash. The wound sizes ranged from 10 to 300 cm2. All patients required more than one irrigation and debridement before wound closure. There was a successful outcome in 11 of the 12 patients. The only patient without a known successful outcome was lost to follow up. Six patients were treated with split thickness skin graft (STSG) alone. Four patients were treated with STSG plus an additional means of coverage. One patient was treated with a random flap and one patient was treated with a full thickness skin graft. Integra was used in two of the patients. Each of the patients in whom integra was used had exposed bone and had a successful outcome with respect to tissue coverage. Discussion This study details different soft tissue coverage techniques that must be learned and possibly employed by the deployed surgeon. Limitations of this study include its retrospective nature and the selected sampling of cases. At initial presentation, the management of war wounds secondary to high-velocity gunshot wounds and improvised explosive devices can be quite daunting. Adhering to firm surgical principles of thorough and meticulous debridement is the foundation of later soft tissue reconstructive options. Once the tissue is deemed clear of infection and contamination, there are myriad treatment options utilizing flaps, synthetic materials, and skin grafting. These are relatively straightforward techniques that the general orthopedic surgeon can utilize while deployed in a combat setting. In the end, it is critical for deployed surgeons to learn multiple techniques to provide definitive soft tissue coverage in a wartime theater.

A Comparison of Three C-Arm Draping Techniques to Minimize Contamination of the Surgical Field.

Summary: The use of intraoperative fluoroscopy has become a routine and useful adjunct within orthopaedic surgery. However, the fluoroscopy machine may become an additional source of contamination in the operating room, particularly when maneuvering from the anterior–posterior position to the lateral position. Consequently, draping techniques were developed to maintain sterility of the operative field and surgeon. Despite a variety of methods, no studies exist to compare the sterility of these techniques specifically when the fluoroscopy machine is in the lateral imaging position. We evaluated the sterility of 3 c-arm draping techniques in a simulated operative environment. The 3 techniques consisted of a traditional 3-quarter sterile sheet attached to the side of the operative table, a modified clip-drape method, and a commercially available sterile pouch. Our study demonstrated that the traditional method poses a high risk for sterile field contamination, whereas the modified clip-drape method and commercially available sterile pouch kept floor contamination furthest from the surgical field. With the current data, we urge surgeons to use modified techniques rather than the traditional draping method.

Open perilunate injury with lunate revascularization after complete ligamentous avulsion

Perilunate dislocations are a devastating injury to the carpus that carry a guarded long-term prognosis. Mayfield type 4 perilunate dislocations are rare, high-energy injuries that carry a risk for avascular necrosis (AVN) of the lunate. When AVN ensues and the carpus collapses, primary treatment with a proximal row carpectomy or arthrodesis has been advocated. This case reports a successful clinical result and revascularization of an extruded lunate with open reduction and internal fixation. This type 4, Gustilo grade 1 open perilunate dislocation exhibited complete avulsion of all lunate ligamentous attachments. Management included open reduction and internal fixation as well as carpal tunnel release through a combined dorsal and volar approach. Despite concerns for lunate AVN due to complete disruption of lunate vascularity, a 10-month postoperative clinical and radiographic examination demonstrated no pain with activities of daily living as well as a revascularized lunate.

Landing on Your Own Two Feet: A Case Report of Bilateral Calcaneus and Open Pilon Fractures

High energy fractures of the distal tibial plafond and calcaneus have been associated with high functional morbidity and wound complications. Although both of these fractures result from a similar mechanism, they have rarely been reported to occur on an ipsilateral extremity. The combination of these 2 injuries on the same extremity would increase the likelihood of an adverse surgical or functional outcome. We present the case and management strategy of a 43-year-old male with bilateral open pilon fractures and closed calcaneal fractures after falling from a height. A staged protocol was used for the bilateral pilon fractures, with external fixation until operative fixation on day 9. Nonoperative management of the calcaneal fractures resulted in a successful functional outcome at 10 months of follow-up. Treatment of this fracture pattern must incorporate the condition of the soft tissues, an understanding of the fractures, and minimize patient risk factors to optimize the functional and surgical outcomes.

Stockinette Application Over a Non-Prepped Foot Risks Proximal Contamination

This study sought to determine if there was an increased risk for surgical site contamination during stockinette application for a lower extremity surgery draping technique. Utilizing a simulated, sterile surgical field, stockinettes were applied over 10 cadaver lower extremities that were contaminated with non-pathogenic Escherichia coli on the foot. Of those, five specimens were then disinfected with Chloroprep and another 5 did not undergo any disinfection. All the specimens in which the stockinette was applied over a non-prepped foot showed proximal contamination. No contamination occurred in any of the specimens where the foot was disinfected. Stockinette can be a source of surgical site contamination when placed over a non-prepared foot.

Open Tibial Pilon Fracture With Wound Botulism Exacerbated by Aminoglycoside Antibiotic Beads: Case Report.

Wound botulism is a rare but potentially fatal complication of open fractures. Botulinum toxin is a potent neurotoxin produced by Clostridium botulinum. This anaerobic, grampositive, spore-forming bacterium is ubiquitously found in soil and can cause neuroparalytic syndrome in association with open fractures. The toxin binds irreversibly to the distal synaptic cell membrane of cholinergic nerves, blocking the release of acetylcholine into the synaptic cleft. This blockage of acetylcholine can lead to progressive, generalized weakness, with the most severe complication being respiratory failure and death. Excluding intravenous drug use as the cause, approximately 1 case each year is reported in the United States. The incidence of open fractures infected with C. botulinum is approximately 0.29 per every 10 000 open fractures. Diagnosis of wound botulism is usually delayed, and many cases are believed to go unreported due to mild symptoms and unfamiliarity with the disease. Clinical presentation of wound botulism may not manifest until 4 to 18 days following injury, which further contributes to a delayed diagnosis. Patients with wound botulism initially present with diplopia, ptosis, and blurred vision. Dysarthria, dysphagia, and decreased reflexes appear as the disease progresses. The hallmark presentation of botulism is a progressive, descending, symmetric paralysis in the setting of a normal sensory and cognitive exam. Prior to 1950, the mortality rate for wound botulism was above 60%. However, with early recognition and treatment mortality is now less than 5%. While anaerobic wound cultures are routinely done, they can take weeks or even months to finalize, and results can be misleading as only 65% of wound botulism cases demonstrate growth of C. botulinum. The most reliable method for botulism diagnosis is the mouse inoculation test, where 2 mice are inoculated with the infectious sample in question. One mouse is pretreated with botulism antitoxin and the other mouse is the control. If the control mouse dies, the diagnosis of botulism is confirmed. Treatment of an infected open fracture presents a complex problem to the orthopaedic surgeon. Antibiotic impregnated cement beads are gaining popularity in open fractures complicated by infection This antibiotic delivery method provides a high dose direct elution of antibiotics at the infected site and decreased harmful side effects due to low systemic levels. Aminoglycosides are generally the most commonly used antibiotics for this purpose, as they are effective against gram negative bacilli, staphylococci, streptocococi, enterococci, and anaerobes. In addition to ototoxicity and nephrotoxicity, aminoglycosides interact at the presynaptic membrane to potentiate the neuromuscular blockade. Previous reports have documented worsening of botulism symptoms with systemic therapeutic levels of aminoglycosides, but we present the first case of wound botulism exacerbated through the use of tobramycin eluding cement beads.

Biomechanical analysis of four external fixation pin insertion techniques

Having multiple external fixation pin designs and insertion techniques has led to debate as to which combination creates the stiffest construct. This study sought to biomechanically evaluate construct strength using self-drilling (SD) and self-tapping (ST) pins inserted with either bicortical or unicortical fixation. SD and ST 5.0 mm stainless steel pins were used in combination with bicortical self-drilling (BCSD), bicortical self-tapping (BCST), unicortical self-drilling (UCSD), and unicortical selftapping (UCST) techniques. Pre-drilling for the self-tapping pins was completed with a 4.0 mm drill bit using ¾ inch polyvinyl chloride (PVC) pipe as the insertional medium. The PVC pin constructs were then loaded to failure in a cantilever bending method using a mechanical testing system. Ten trials of each technique were analyzed. BCSD insertion technique had the highest maximum failure force and stiffness of all tested techniques (P<0.0001). SD pins were significantly stronger to bending forces than ST pins in both the unicortical and bicortical setting (P<0.0001). Three point bending tests of the 5.0 mm SD and ST threaded area showed that threaded portion of the SD pins had a 300 N greater maximum failure force than the ST pins. Biomechanical analysis of external fixation pin insertion techniques demonstrates that bicortical fixation with SD pins achieved the greatest resistance to bending load. Despite both pins being 5.0 mm and constructed from stainless steel, ST and SD behaved differently with regard to maximum failure force and stiffness. This study demonstrates that insertion technique and pin selection are both important variables when attempting to achieve a stiff external fixation construct.

Bilateral Hemiarthroplasty in a Patient with Below-Knee and Above-Knee Amputations

Case:This case involved a sixty-two-year-old male patient with bilateral femoral neck fractures that occurred six months apart in the setting of bilateral lower-extremity amputation. Hemiarthroplasty was performed at each presentation, with the use of a standard femoral stem on the right side and a short stem on the left. At the time of follow-up, the patient had returned to his preoperative ambulatory status. Conclusion:This case report illustrates successful bilateral hemiarthroplasty in a patient who had previously undergone bilateral lower-extremity amputation, with use of an implant with a short stem for the limb with above-knee amputation.