Walter W. Virkus

High-energy tibial plateau fractures.

Abstract The severity of a tibial plateau fracture and the complexity of its treatment depend on the energy imparted to the limb. Low‐energy injuries typically cause unilateral depression‐type fractures, whereas high‐energy injuries can lead to comminuted fractures with significant osseous, soft‐tissue, and neurovascular injury. Evaluation includes appropriate radiographs and careful clinical assessment of the soft‐tissue envelope. Treatment is directed at safeguarding tissue vascularity and emphasizes restoration of joint congruity and the mechanical axis of the limb. Temporary joint‐spanning external fixation facilitates soft‐tissue recovery, whereas minimally invasive techniques and anatomically contoured plates can limit damage to the soft tissues and provide stable fixation. Alternatively, the use of limited internal fixation and definitive external fixation can minimize soft‐tissue disruption, avoid complications, and allow fracture union. Complications, including infection, loss of fixation, and malalignment, are best avoided by following these biologically respectful treatment principles.

Locking plates for extremity fractures.

Thirty-three peer-reviewed studies met the inclusion criteria for the Overview. Criteria were framed by three key questions regarding indications for the use of locking plates, their effectiveness in comparison with traditional nonlocking plates, and their cost-effectiveness. The studies were divided into seven applications: distal radius, proximal humerus, distal femur, periprosthetic femur, tibial plateau (AO/OTA type C), proximal tibia (AO/OTA type A or C), and distal tibia. Patient enrollment criteria were recorded to determine indications for use of locking plates, but the published studies do not consistently report the same enrollment criteria. Regarding effectiveness, there were no statistically significant differences between locking plates and nonlocking plates for patient-oriented outcomes, adverse events, or complications. The literature search did not identify any peer-reviewed studies that address the cost-effectiveness or cost-utility of locking plates.

Femoral Fracture Through a Previous Pin Site After Computer-Assisted Total Knee Arthroplasty

Computer-assisted total knee arthroplasty has been gaining popularity given the proposed benefits of increased accuracy of the femoral and tibial cuts, quantitative feedback on soft tissue balancing, and the potential for performing the procedure through smaller incisions with decreased soft tissue trauma. Most navigation systems require femoral and tibial threaded pin insertion for placement of guidance trackers, which when removed leave behind defects in the bone that may act as stress risers. We present 2 cases of a femoral fracture through a previous pin site where a guidance tracker had been placed for computer-assisted total knee arthroplasty. Both patients were informed that data concerning the cases would be submitted for publication. To our knowledge, this complication has not previously been reported for this procedure.

Preoperative radiotherapy in the treatment of soft tissue sarcomas.

The goal of the current study was to analyze the oncologic results and wound complications in patients with soft tissue sarcomas treated with preoperative radiation therapy and en bloc resection. A standard protocol of preoperative radiotherapy was administered followed by en bloc resection in 209 patients. The protocol included needle or incisional biopsy, prospective staging, a consistent dose of radiotherapy, standardized prospective evaluation of surgical margins, and long-term followup. The target radiotherapy dose was 50.4 cGy. Twenty-nine patients had low-grade lesions, and 180 had high-grade lesions. The mean followup was 55 months. The significant wound complication rate was 22% (moderate 14%, major 7%, and amputation 1%). Wound complications were significantly higher in patients with lower extremity lesions when compared with patients with upper extremity or axial lesions, and in patients with lesions larger than 5 cm. The local recurrence rate was 11% in patients who did not have prior surgery, and 37% in patients who had prior surgery at an outside institution (17% overall). Local recurrence was increased significantly in patients who had prior surgery. At latest followup, 78 patients (47%) were continuously disease-free, six (4%) were alive with no evidence of disease, nine (5%) were alive with disease, 63 (38%) died of disease, and 11 (7%) died of another cause. The 2- and 5-year disease-specific survival rates were 77% and 67%, respectively. Overall survival was 56%. A significant decrease in survival was seen in patients who had a local recurrence, and in patients with high-grade lesions. Preoperative radiotherapy can be given safely with a wound complication rate not significantly higher than that reported for other forms of radiotherapy delivery. Local recurrence tends to be higher if surgical intervention is done before tertiary center referral. Distant disease continues to be the cause of the high mortality in these patients.

Blastomycosis of long bones.

The presentation of blastomycosis clinically and radiographically is nonspecific and often mistaken for a neoplasm. Delay in diagnosis is common. Patients with osseous blastomycosis present with pain and swelling. Radiographs usually show an eccentric lucency in the distal ends of long bones. These patients frequently are referred for a neoplastic workup and a diagnosis is made only after biopsy. We review the cases of five patients diagnosed with a bone tumor who had blastomycosis osteomyelitis. The time to diagnosis from original symptoms was 4.7 months (range, 3–8 months). The average age of the patients was 45.6 years (range, 20–59 years). A Musculoskeletal Tumor Society functional assessment was done. Early radiographs of the current patients ranged from normal to showing faint osteopenia in the involved location. As the disease progressed, the area of lucency appeared with either diffuse or well-marginated borders. Treatment included surgical debridement with antifungals. The mean functional score was 93.3%. All patients are disease-free. Blastomycosis, similar to tuberculosis, often is mistaken for a neoplasm. Blastomycosis osteomyelitis can be treated with excellent results. The key is diagnosis and including endemic fungal infections in the differential diagnosis of bone tumors. In addition, every potential neoplasm should include cultures of specimens obtained at biopsy.

Intramedullary Nailing of Proximal and Distal One-Third Tibial Shaft Fractures With Intraoperative Two-Pin External Fixation

BACKGROUND Fractures of the proximal and distal one thirds of the tibial shaft have historically higher malunion rates than those of the midshaft. This retrospective case series evaluates the postoperative radiographic outcome of intramedullary nailing of proximal and distal one-third tibial shaft fractures using intraoperative two-pin external fixation, often referred to as traveling traction. MATERIALS AND METHODS Between 2000 and 2005, 15 consecutive patients with proximal third and 27 consecutive patients with distal third displaced extra-articular fractures of the tibia were treated with statically locked intramedullary nailing and supplementary intraoperative two-pin rectangular frame external fixation. The external fixation was removed once the proximal and distal locking screws were in place. The alignment of the fractures was determined using standard postoperative anteroposterior and lateral radiographs. RESULTS Postoperatively, 14 of 15 patients with proximal fractures and 25 of 27 patients with distal fractures had less than 5 degrees of angular deformity in both the coronal and sagittal planes and less than 1 cm shortening. CONCLUSIONS Statically locked intramedullary nailing with simultaneous intraoperative traveling traction external fixation as treatment for proximal and distal one-third extra-articular tibial shaft fractures is successful in achieving a high rate of acceptable postoperative alignment.

Lateral hip pain in an athletic population: differential diagnosis and treatment options.

Context: Posterior hip pain is a relatively uncommon but increasingly recognized complaint in the orthopaedic community. Patient complaints and presentations are often vague or nonspecific, making diagnosis and subsequent treatment decisions difficult. The purposes of this article are to review the anatomy and pathophysiology related to posterior hip pain in the athletic patient population. Evidence Acquisition: Data were collected through a thorough review of the literature via a MEDLINE search of all relevant articles between 1980 and 2010. Results: Many patients who complain of posterior hip pain actually have pain referred from another part of the body—notably, the lumbar spine or sacroiliac joint. Treatment options for posterior hip pain are typically nonoperative; however, surgery is warranted in some cases. Conclusions: Recent advancements in the understanding of hip anatomy, pathophysiology, and treatment options have enabled physicians to better diagnosis athletic hip injuries and select patients for appropriate treatment.

Arthroscopically assisted minimally invasive intraarticular bullet extraction: technique, indications, and results.

BACKGROUND We describe a new arthroscopically assisted, minimally invasive approach to intraarticular bullet extraction limited in its surgical dissection to the bullet tract itself. This procedure accomplishes intraarticular irrigation and removal of the retained missile without the need for a formal open approach. Additionally, we report on a novel extension of this technique to include bullet removal from the sacroiliac joint. METHODS During a 5-year period (April 2001 to April 2006), 11 patients with retained intraarticular missiles as a result of low-velocity gunshot wounds were treated at our institution with attempted arthroscopically assisted minimally invasive bullet extraction. All patients were male with a mean age of 22.3 years (range, 17-45). Anatomic location of the retained bullets included the knee (6), hip (4), and sacroiliac joint (1). RESULTS We report a 90.9% success rate of arthroscopically assisted intraarticular bullet extraction from the hip, knee, and sacroiliac joint. One case involving the knee required conversion to an open approach to avoid iatrogenic osseous damage to the posterior aspect of the femoral condyle. CONCLUSIONS Surgical extraction of retained intraarticular missiles from low-velocity handguns should be performed to minimize the risk of mechanical arthritis, synovitis, and lead toxicity. Arthroscopically assisted bullet extraction using the bullet tract with a minimally invasive approach should be considered when it can be safely accomplished without iatrogenic damage associated.

The effect of contaminated surgical margins revisited

The current study was done to assess the oncologic outcomes after inadvertent intraoperative contamination in the treatment of musculoskeletal sarcomas, to determine the prognostic significance of these events. Forty-three patients with malignant lesions and either positive margins or intraoperative tumor penetration are included in the study. There were 12 bone lesions and 31 soft tissue lesions. The final margin was intracapsular in 11 patients, contaminated marginal in 13 patients, and contaminated wide in 19 patients. Thirty-two patients received radiation therapy with doses from 4560 to 7000 cGy. The mean followup was 69 months (range, 24–179 months). In patients in whom the surgical margin was contaminated, additional tissue was removed with the goal being to obtain tumor-free surgical margins. Local recurrence occurred in four of 32 patients (12.5%) with no gross residual tumor. There was a significant difference in the recurrence rate between a wide (0 of 19) versus a marginal or intracapsular margin (nine of 24) based on the final surgical margin. High-grade lesions were more likely to recur than low-grade lesions, and soft tissue lesions were more likely to recur than bone lesions. Similar to previous reports, treatment of inadvertent contamination with reexcision and irrigation of the wound results in a similar recurrence rate to cases without contamination. Efforts should be made to achieve a wide final margin. Adjuvant therapies should be used whenever feasible.

Stage Ie Primary Nonhodgkin’s Lymphoma of Bone

The results of treatment of 28 patients with Stage IE primary lymphoma of bone were evaluated. Nine patients were treated with curative intent with irradiation alone and 19 patients received radiotherapy combined with adjuvant chemotherapy. Local control was 100%. The 10-year freedom-from-relapse rate was 53%; all relapses were distant metastases, and the median time to failure was 1 year. All patients with relapses succumbed to their disease. The 10-year cause-specific survival rate was 48%. The 10-year survival rate was 53%. Multivariate analysis of survival suggested that pathologic fracture before treatment, age greater than 60 years, no aggressive chemotherapy, and lesions that were not in long bones may influence these end points. Two patients (7%) sustained moderate or severe late toxicity. Although the likelihood of local control after treatment of Stage IE primary lymphoma of bone is very high with radiotherapy, more effective systemic regimens are needed. A significant proportion of patients with this disease die of distant metastases, despite the use of what are considered standard doxorubicin-based chemotherapy regimens.