Paul M. Lafferty

Operative Treatment of Chest Wall Injuries: Indications, Technique, and Outcomes

Most injuries to the chest wall with residual deformity do not result in long-term respiratory dysfunction unless they are associated with pulmonary contusion. Indications for operative fixation include flail chest, reduction of pain and disability, a chest wall deformity or defect, symptomatic nonunion, thoracotomy for other indications, and open fractures. Operative indications for chest wall injuries are rare.

Injuries to the ankle syndesmosis

➤ Despite being common, syndesmotic injuries are challenging to diagnose and treat.➤ Anatomic reduction of the ankle syndesmosis is critical for good clinical outcomes.➤ Intraoperative three-dimensional radiography and direct syndesmotic visualization can improve rates of anatomic reduction.➤ The so-called gold-standard syndesmotic screw fixation is being brought increasingly into question as new fixation techniques emerge.➤ Syndesmotic screw removal remains controversial, but may allow spontaneous correction of malreductions.

Surgical Coaching from Head-Mounted Video in the Training of Fluoroscopically Guided Articular Fracture Surgery.

BACKGROUNDnThe evolving surgical skills education paradigm in orthopaedics has generated a strong demand for validated educational tools and methodologies. This study aimed to confirm that a one-on-one faculty coaching review of the head-mounted video recording of a residents surgical performance on a validated articular fracture simulation trainer would substantially improve subsequent performance.nnnMETHODSnFifteen first-year or second-year orthopaedic surgery residents reduced and fixed a standardized intra-articular tibial plafond fracture model under fluoroscopic guidance. Their performances were recorded by a head-mounted video camera. Prior to repeating the procedure six weeks later, eight subjects (the intervention group) reviewed the video of their performance with an orthopaedic traumatologist, and seven subjects (the control group) did not. Cohort performance was compared with respect to task duration, number of fluoroscopic images, and scores on the Objective Structured Assessment of Technical Skills (OSATS) as evaluated by fellowship-trained orthopaedic traumatologists blinded to the residents year in training and prior surgical experience.nnnRESULTSnThe initial performance OSATS scores were not significantly different (p ≥ 0.05) between the control and intervention groups. Assessments of their repeat performance showed a significant net interval improvement (p < 0.05) in OSATS scores in the intervention group (mean [and standard deviation], 21 ± 8 points) compared with the control group (6 ± 3 points). The mean fluoroscopy utilization had a significant net decrease (p < 0.05) in the intervention group (-5.4 ± 11.7 points) compared with the control group (5.3 ± 7.0 points). Task duration in the repeat performance was similar between both groups.nnnCONCLUSIONSnPersonalized video-based feedback improved performance on a standardized articular fracture trainer for first-year and second-year residents. The described technique may further enhance resident surgical skills education.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Outcomes after operative management of symptomatic rib nonunion.

Objective: To report the outcomes of rib reconstruction after painful nonunion. Design: Retrospective case series. Setting: Level I trauma center. Patients/Participants: Between November 2007 and May 2013, 10 patients who presented with 16 rib nonunions and disabling pain were treated with reconstruction of their nonunited rib fractures. Intervention: Rib nonunion reconstruction predominately with iliac crest bone graft and a tension band plate with a locked precontoured plating system for ribs. Main Outcome Measurements: Demographic data, mechanism of injury, and number of rib nonunions were recorded. Operative procedure, length of follow-up, complications, Short Form Survey 36, and a patient questionnaire were also captured and documented. Results: Eight of the 10 patients sustained their original fractures from a fall. Outcomes were available for the 10 patients at a mean follow-up of up of 18.6 months (range, 3–46 months). All 16 ribs went on to union with a mean time from reconstruction to union of 14.7 weeks (range, 12–24 weeks). At final follow-up, the mean mental and physical component Short Form Survey 36 scores were 54.4 and 43.5, respectively. Eight of the 10 patients were able to return to work and/or previous activities without limitations. Complications included 1 wound infection that resolved after irrigation and debridement with adjunctive antibiotics. One symptomatic implant was removed. Conclusions: Ten patients with 16 symptomatic rib nonunions were reconstructed using autologous bone graft and implant/mesh fixation manifesting in successful union with improved patient function and a low rate of complications. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medical Clearance Risk Rating as a Predictor of Perioperative Complications After Total Hip Arthroplasty

Hip arthroplasty has become the standard treatment of end-stage osteoarthritis. However, postoperative complications are the risks associated with joint arthroplasty, which most significantly impact patient results and the total cost of care. Currently, no predictive system has been developed for categorizing levels of risk for the development of postoperative complications in patients undergoing total hip arthroplasty. We examined the association between the medical clearance risk rating by the physician performing the preoperative clearance examination and postoperative complications after total hip arthroplasty. We have demonstrated a significant association between the medical clearance risk rating and postoperative urinary track infection, and the American Society of Anesthesiologist score but no significant association to other complications. This study presents a predictive patient characteristic that may help us identify among our patients the ones that may benefit from a personally tailored preoperative planning and evaluation but demonstrates further work is necessary to better predict the risk of complications after total hip arthroplasty.

Bleeding disorders in orthopedic surgery.

With increasing recognition of the complications related to coagulopathies, it is of paramount importance for all orthopedic surgeons to possess a basic knowledge of common bleeding disorders. The evaluation of the coagulopathic patient requires a careful history, physical examination, and laboratory evaluation. Bleeding disorders commonly include quantitative and qualitative platelet and coagulation factor disorders and coagulation inhibitors. The management of these coagulopathies that can be encountered in elective and nonelective practice is often ignored. With appropriate knowledge and a multidisciplinary approach with hematologists and cardiologists, surgeons can perform minor and major orthopedic procedures safely and effectively.

Stress radiographs in orthopaedic surgery

&NA; Stress radiographs are useful in determining the amount of ligamentous laxity present following trauma. The results may be helpful in determining diagnosis, surgical indications, and the type and timing of rehabilitation. Some techniques for obtaining stress radiographs involve specific patient positioning or manually applied force; others require use of a particular testing device. Stress radiographs may be obtained for a variety of anatomic areas and joints. The parameters that define abnormality on stress radiographs should be compared with those of clinical findings. The use of common and novel methods to obtain stress radiographs has led to improved identification and diagnosis of many orthopaedic pathologies. Some of these techniques have been developed with the aim of reducing patient discomfort or minimizing the clinicians exposure to radiation.

The Effect of Articular Reduction After Fractures on Posttraumatic Degenerative Arthritis: A Critical Analysis Review.

The current literature describes many factors that contribute to the outcome after an articular fracture. Many of these factors, such as social and environmental influences, medical comorbidities, secondary gain, and premorbid conditions, are beyond the surgeon’s control. Variables that the orthopaedic surgeon has at least modest influence on include the quality of reduction and rehabilitation1-4. It is vital that the surgeon maximize this influence through a better understanding of the importance of articular reduction and fixation after fractures.nnA large body of basic science research supports the concept that malreduction leads to posttraumatic arthritis5-21. In addition, there is a growing understanding of how biological and genetic mechanisms come into play after articular trauma in the process of chondrocyte apoptosis, which results in cartilage degeneration22-28. With that being said, the present report is not meant to be a comprehensive review of articular injury but will focus clinically on the importance of articular fracture reduction on the basis of radiographic evidence and clinical outcomes.nnFor certain anatomic regions, such as the glenoid fossa, distal part of the femur, humeral head, femoral head, and talus, little to no information is available with regard to how much articular step-off or gap is acceptable. These injuries provide an opportunity to investigate the …

The effect of early operative stabilization on late displacement of zone I and II sacral fractures

INTRODUCTIONnThis study was designed to evaluate the effect on displacement of early operative stabilization on unstable fractures when compared to stable fractures of the sacrum.nnnMETHODSnPatient consisted of those sustaining traumatic pelvic fractures that also included sacral fractures of Denis type I and type II classification, who were over 18 at the time of the study. Patients were managed emergently, as judged appropriate at the time and then subsequently divided into two cohorts, comprising those who were either treated operatively or non-operatively. The operative group comprised those treated with either internal fixation or external fixation.nnnRESULTSnTwenty-eight patients had zone II fractures, and 20 had zone I fractures. Zone II fractures showed average displacements of 6.5mm and 6.9mm in the rostral-caudal and anteroposterior directions, respectively, at final follow up. Zone I fractures had average displacements of 6.6mm and 6.1mm in both directions. There were no significant differences between zone I and II sacral fractures (rostral-caudal P=0.74, anteroposterior P=0.24). Average changes in fracture displacement in patients with zone I fractures were 0.6-1.0mm in both directions. Average changes in zone II fractures were 1.8-1.5mm in both directions. There were no significant differences between the average changes in zone I and II fractures in any direction (rostral-caudal P=0.64, anteroposterior P=0.68) or in average displacements at final follow up in any of zone or the entire cohort. Statistically significant differences were noted in average changes in displacement in zone II fractures in the anteroposterior plane (P=0.03) and the overall cohort in the anteroposterior plane (P=0.02).nnnCONCLUSIONnOperative fixation for unstable sacral fractures ensures displacement at follow up is comparable with stable fractures treated non operatively.