Peter A. Siska

New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.

Prolonged operative time increases infection rate in tibial plateau fractures

BACKGROUND Fractures of the tibial plateau present a treatment challenge and are susceptible to both prolonged operative times and high postoperative infection rates. For those fractures treated with open plating, we sought to identify the relationship between surgical site infection and prolonged operative time as well as to identify other surgical risk factors. METHODS We performed a retrospective controlled analysis of 309 consecutive unicondylar and bicondylar tibial plateau fractures treated with open plate osteosynthesis at our institutions level I trauma centre during a recent 5-year period. We recorded operative times, injury characteristics, surgical treatment, and need for operative debridement due to infection. Operative times of infected cases were compared to uncomplicated surgical cases. Multivariable logistic regression analysis was performed to identify independent risk factors for postoperative infection. RESULTS Mean operative time in the infection group was 2.8h vs. 2.2h in the non-infected group (p=0.005). 15 fractures (4.9%) underwent four compartment fasciotomies as part of their treatment, with a significantly higher infection rate than those not undergoing fasciotomy (26.7% vs. 6.8%, p=0.01). Open fracture grade was also significantly related to infection rate (closed fractures: 5.3%, grade 1: 14.3%, grade 2: 40%, grade 3: 50%, p<0.0001). In the bicolumnar fracture group, use of dual-incision medial and lateral plating as compared to single incision lateral locked plating had statistically similar infection rates (13.9% vs. 8.7%, p=0.36). Multivariable logistic regression analysis of the entire study group identified longer operative times (OR 1.78, p=0.013) and open fractures (OR 7.02, p<0.001) as independent predictors of surgical site infection. CONCLUSIONS Operative times approaching 3h and open fractures are related to an increased overall risk for surgical site infection after open plating of the tibial plateau. Dual incision approaches with bicolumnar plating do not appear to expose the patient to increased risk compared to single incision approaches.

Efficacy of intraoperative cell saver in decreasing postoperative blood transfusions in instrumented posterior lumbar fusion patients.

Study Design. A retrospective study. Objective. To determine the efficacy of using intraoperative cell saver in decreasing the need for blood transfusion. Summary of Background Data. Lumbar spine surgery is associated with potential large intraoperative blood loss, which may put patients at risk for blood transfusions. Preoperative autologous blood donation mitigates the need for allogenic blood transfusion, but does not eliminate it. Cell-saver use has been advocated to further reduce the need for transfusion, but recent reports have called its efficacy into question. Methods. Data were collected from 188 patients undergoing consecutive instrumented lumbar laminectomy and fusion. One hundred and forty-one of these patients had cell saver used during their procedures, whereas 47 did not. In addition, previously published data from similarly treated patients were used for analysis. Operative blood loss, autologous and allogenic blood transfusions, discharge hematocrit, and patient factors were analyzed. Results. A significant increase in the number of blood transfusions was found in the cell-saver group. The cell-saver group also had a significantly increased blood loss compared with the non–cell-saver group. Using analysis of covariance, we determined the effect of blood loss on the need for transfusion. The results showed that correcting for blood loss eliminated the significance in the transfusion difference, but cell saver still was not able to decrease the transfusion need. Comparing our current results with our previously published results also demonstrated no benefit of cell saver use. Conclusion. Use of cell saver in instrumented lumbar fusion cases was not able to decrease the need for blood transfusion. Cell-saver use was associated with a significantly higher blood loss.

Dysphagia after anterior cervical spine surgery: a prospective study using the swallowing-quality of life questionnaire and analysis of patient comorbidities.

Study Design. Prospective study of 29 patients who underwent anterior cervical (AC) or posterior lumbar (PL) spinal surgery. A validated measure of dysphagia, the Swallowing–Quality of Life (SWAL-QOL) survey, was used to assess the degree of postoperative dysphagia. Objective. To determine the degree of dysphagia preoperatively and postoperatively in patients undergoing AC surgery compared with a control group that underwent PL surgery. Summary of Background Data. Dysphagia is a well-known complication of AC spine surgery and has been shown to persist for up to 24 months or longer. Methods. A total of 18 AC patients and a control group of 11 PL patients were prospectively enrolled in this study and were assessed preoperatively and at 3 weeks and 1.5 years postoperatively using a 14-item questionnaire from the SWAL-QOL survey to determine degree of dysphagia. Other patient factors and anesthesia records were examined to evaluate their relationship to dysphagia. Results. There were no significant differences between the AC and PL groups with respect to age, sex, body mass index, or length of surgery. The SWAL-QOL scores at 3 weeks were significantly lower for the AC group than for the PL group (76 vs. 96; P = 0.001), but there were no differences between the groups preoperatively or at final follow-up. Smokers, patients with chronic obstructive pulmonary disease, and women had lower SWAL-QOL scores at one or more time point. Conclusion. Patients undergoing AC surgery had a significant increase in the degree of dysphagia 3 weeks after surgery compared with patients undergoing PL surgery. By final follow-up, swallowing in the AC group recovered to a level similar to preoperative and comparable to that in patients undergoing lumbar surgery at 1.5 years. Smoking, chronic obstructive pulmonary disease, and female sex are possible factors in the development of postoperative dysphagia.

Treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty implant: span the whole bone

IntroductionPeriprosthetic femur fractures are a growing problem in the geriatric population. This study examines Vancouver B1 periprosthetic femur fractures treated with open reduction internal fixation using a laterally based plate. Outcomes using plates which spanned the length of the femur to the level of the femoral condyles were compared to those which did not. The hypothesis was that spanning internal fixation would result in a decreased rate of refracture and subsequent reoperation.Materials and methodsPatients admitted to three affiliated academic hospitals treated with open reduction internal fixation for a periprosthetic femur fracture in the setting of a preexisting total hip arthroplasty or hemiarthroplasty stem were identified. Patient data were reviewed for age, gender, fracture classification, operative intervention, time to union, as well as complications related to treatment and need for further surgery.ResultsOver a 5-year period, 58 patients were treated with open reduction internal fixation using a laterally based plate for Vancouver B1 femur fractures. Twenty-one patients were treated with plates that extended to the level of the femoral condyles. In that group there were no nonunions or subsequent periprosthetic fractures reported. Of 36 patients treated with short plates, 3 went on to nonunion resulting in plate failure and refracture and 2 sustained a subsequent fracture distal to the existing fixation.ConclusionsIn this series, fixation for periprosthetic femur fractures around a well-fixed arthroplasty stem which spans the length of the femur to the level of the femoral condyles is associated with a decreased rate of nonunion and refracture. By decreasing the rate of refracture and nonunion, spanning fixation decreases the morbidity and mortality associated with additional surgery in a fragile geriatric population.

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

OBJECTIVES To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach. DESIGN Retrospective review. SETTING Two level one trauma centres. PATIENTS Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up. INTERVENTION Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients). MAIN OUTCOME MEASUREMENTS Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p=0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p<0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p=0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p=0.333). CONCLUSIONS A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome. LEVEL OF EVIDENCE Level III.

Staged Treatment of High Energy Midfoot Fracture Dislocations

Background: Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious. Methods: One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed. Results: The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred. Conclusion: Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients. Level of Evidence: Level III, retrospective comparative study.

Open supracondylar femur fractures with bone loss in the polytraumatized patient – Timing is everything!

INTRODUCTION Open supracondylar femur fractures are rare, complex injuries which occur in polytrauma patients and are complicated by bone loss, contamination, compromised soft tissues, and poor host condition. The purpose of this study is to demonstrate a successful treatment protocol for these challenging injuries. METHODS A consecutive series of 15 open supracondylar femur fractures in 14 polytrauma patients (ages 16-75, mean 41) were treated at one Level I trauma centre by a single surgeon. Fracture patterns included seven AO/OTA Type C2 and eight Type C3 fractures. All fractures were open and classified by Gustillo/Anderson as type IIIA (10 fractures) and type IIIB (five fractures). Stage I was performed within 24h and included thorough open fracture care and early definitive fixation with a laterally based locking device and antibiotic bead placement. Stage II was performed several months later (average 3.6 months) when the soft tissue envelope had revascularized and the polytrauma patient had recovered from their other injuries. Stage II consisted of either an anterior incision or subvastus approach to the distal femur, bone grafting, BMP application, and addition of medial column support to create rigid fixation. RESULTS All fractures (15/15) healed uneventfully. Union was determined by absence of pain and radiographic union in 3/4 cortices. Mean time to union was 4 months. There were no deep infections and alignment was maintained (average tibiofemoral angel of 5° of valgus) although several limbs were complicated by knee stiffness. CONCLUSIONS Healing of open supracondylar femur fractures with critical sized bone defects requires diligent surgical timing in order to optimise the host and wound bed. Thorough initial debridement and early definitive fixation halt ongoing soft tissue injury, restores length and alignment, and allow for sterilisation of the wound. After patients have recovered from their other injuries and the soft tissue sleeve has revascularized, bone grafting with BMP supplementation and medial column plating allows for rigid fixation of the femur and offers the biology these fracture patterns require for successful union without infection.

Soft Tissue and Biomechanical Challenges Encountered with the Management of Distal Tibia Nonunions

A thoughtful treatment algorithm is required to optimally treat distal tibia nonunion. A healthy respect for the tenuous soft tissue envelope, compromised vascularity, and challenging mechanical environment is advisable. Achieving osseous union and improved functionality requires an individualized plan of care based on the personality of the nonunion and host. Attention must be focused on providing mechanical stability at the site of nonunion and providing biologic supplementation.

Plate augmentation for femoral nonunion: more than just a salvage tool?

ObjectiveThe aim of the current study was to determine whether plate augmentation was a successful treatment algorithm for selected femoral nonunions initially managed with intramedullary nailing.Materials and methodsA total of 30 femoral nonunion cases were managed using the plate augmentation strategy with 13 primary cases and 17 multi-operated femurs (avg 2.8 ineffective procedures). Adjunctive strategies included autologous bone grafting and/or BMP for atrophic/oligotrophic and bone defect cases. Deformity correction was performed when required.ResultsOsseous union occurred in 29 of 30 cases. One multi-operated case with bone defect and prior infection required repeat autologous grafting prior to union.ConclusionPlate augmentation should be added to the armamentarium for management of selected femoral nonunion that have failed initial intramedullary nailing.