Robert J. Gaines

Comparison of Insertional Trauma Between Suprapatellar and Infrapatellar Portals for Tibial Nailing

The purpose of this study was to determine differences in insertional articular trauma in infrapatellar tibial portal and suprapatellar portal intramedullary tibial nail insertion techniques. A cadaveric study was performed on 10 matched pairs of fresh-frozen adult cadaver lower extremities with intact extensor mechanisms. Two study groups with 10 limbs each were created: left lower limbs were treated with a standard medial parapatellar nailing portal and right lower limbs were treated with a suprapatellar tibial nailing portal. Start points were created under fluoroscopic guidance in anteroposterior and mediolateral planes. A start wire was placed and opening reaming was performed on the specimens using instrumentation specific to the nailing portal. Specimens were then dissected by medial parapatellar arthrotomy, revealing the intra-articular condition of the knee structures. The border of the tibial entry reamer hole was measured to the anterior horns of the menisci, anterior cruciate ligament root, and intermeniscal ligament using a digital caliper accurate to 0.02 mm. The structure was considered damaged if the structure was obviously damaged on visual inspection or if a measurement was less than 1 mm. Impact to intra-articular structures was numerically lower in the suprapatellar group (2/10) compared with the infrapatellar group (4/10), but the difference was not statistically significant between the 2 groups (P=.629). The suprapatellar portal approach to the tibial start point demonstrated a lower overall incidence of damage to intra-articular structures, but no significant statistical difference existed between the 2 treatment groups.

The use of surgical drains in orthopedics.

The use of postsurgical drains have a long history in thoracic and abdominal surgery. In orthopedics these devices have been used to decrease local edema, lessen the potential for hematoma or seroma formation, and to aid in the efflux of infection. However, the role of postoperative surgical drains in clean, elective cases has not been firmly established. In fact, most studies fail to show a statistical difference in outcome between drained and undrained patients. Despite the paucity of clinical evidence demonstrating any benefit supporting their use, drains continue to be placed after elective orthopedic procedures.

Patellar tendon repair with suture anchors using a combined suture technique of a Krackow-Bunnell weave.

Suture repair of the ruptured patellar tendon is the treatment of choice for patients requiring operative management. This standard technique includes fixation through transosseous tunnels in the patella. The use of suture anchor fixation has several advantages over the standard approach, including less dissection, decreased surgical time, more accurate suture placement, and a low-profile construct. Additionally, the pullout strength of suture anchors warrants consideration of this technique in these repairs. This article describes using suture anchors for repair of the acute ruptured patellar tendon with a combination of Krackow and Bunnell sutures.

Treatment of atrophic diaphyseal humeral nonunions with compressive locked plating and augmented with an intramedullary strut allograft.

Objective: The aim of this study was to evaluate the effectiveness of thorough debridement and locked compression plating augmented with an intramedullary fibular allograft for the treatment of atrophic diaphyseal humeral nonunions. Design: The study involved a level 4 retrospective case series. Setting: This study was conducted at a level 1 university trauma center. Patients: Twenty patients with painful atrophic nonunions of the humeral diaphysis were examined. Intervention: This involved a thorough debridement and locked compression plating augmented with an intramedullary fibular allograft. Main Outcome Measures: These were union rate, shoulder range of motion, visual analog scale (VAS) pain, VAS function, patient satisfaction, and American Shoulder and Elbow Surgeons score at latest follow-up. Methods: Clinical and radiographic examinations were performed preoperatively and postoperatively. VAS pain and function scores were collected preoperatively and postoperatively. Patient satisfaction and ASES scores were recorded at the time of the most recent follow-up. Results: Bony union was achieved in 19 of 20 patients (95%). The patients demonstrated an average improvement in forward elevation from 65 to 144° (P = 0.001), abduction from 48 to 133° (P < 0.001), external rotation from 34 to 70° (P = 0.05), and internal rotation from S1 to T12 (P = 0.025). VAS pain scores improved from 6.05 to 1.88 (P = 0.032). VAS function scores improved from 2.06 to 7.75 (P = 0.003). The average postoperative ASES score was 76, and the average patient satisfaction was rated 9.3/10. Conclusions: Atrophic nonunions of the humerus can be successfully treated with debridement of the nonunion, coupled with the use of a fibular allograft and locked compression plating. This technique leads to predictable healing without the morbidity associated with autograft. Level of Evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evolution of orthopaedic reconstructive care.

&NA; The patterns and severity of injury sustained by service members have continuously evolved over the past 10 years of combat in Iraq and Afghanistan. The 2010 surge of combat troops into Afghanistan, combined with a transition to counterinsurgency tactics with an emphasis on dismounted operations, resulted in increased exposure of US service members to improvised explosive devices and a new pattern of injury termed dismounted complex blast injury. This constellation of injuries typically includes multiple extremity injuries, high bilateral transfemoral amputations, amputated or mangled upper extremities, open pelvis fractures, and injury to the perineal and/or genital regions. These polytraumatized patients frequently present with head, abdominal, and genitourinary injuries, as well. Traditional methods of reconstruction must be optimized because tissue availability may be limited.

Reprioritization of research for combat casualty care

&NA; Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.

Single-Stage Total Hip Arthroplasty and Fracture Fixation for a Both Column Acetabular Fracture in Type I Osteogenesis Imperfecta

Frank A. Liporace *, Richard S. Yoon , Matthew A. Frank , James P. Maurer , Robert J. Gaines b a Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Medicine and Dentistry of New Jersey (UMDNJ) – New Jersey Medical School, 90 Bergen Street, Newark, NJ 07103, United States b Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23701, United States

A Novel Technique for Ligamentous Reconstruction of the Sternoclavicular Joint

SUMMARY The technique presented is a departure from previous attempts to standardize the treatment of sternoclavicular dislocations. It offers stability without requiring extra dissection around vital intrathoracic structures and greatly decreases the risk of migration of the implant used for fixation.

Delayed presentation of bladder entrapment secondary to nonoperative treatment of a lateral compression pelvic fracture.

Entrapment of the bladder secondary to pelvic fracture is infrequently described in the literature. Entrapment has most commonly been found to occur through the actions of internal or external fixation. This case report presents bladder entrapment that was not detected until the patient developed genitourinary symptoms and dyspareunia 8 months after nonoperative treatment of a stable lateral compression pelvic fracture.

Dead Space Management After Orthopaedic Trauma: Tips, Tricks, and Pitfalls.

Dead space is defined as the residual tissue void after tissue loss. This may occur due to tissue necrosis after high-energy trauma, infection, or surgical debridement of nonviable tissue. This review provides an update on the state of the art and recent advances in the management of osseous and soft tissue defects. Specifically, our focus will be on the initial dead space assessment, provisional management of osseous and soft tissue defects, techniques for definitive reconstruction, and dead space management in the setting of infection. Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.