William W. Cross

Periarticular raft constructs and fracture stability in split-depression tibial plateau fractures

OBJECTIVES To evaluate relative fracture stability yielded by screws placed above a lateral plate, as well as locking and non-locking screws placed through a plate in a split depression tibia plateau fracture model. METHODS Cadaver tibia specimens (mean age 74.1 years) were randomised across 3 groups: Groups 1: raft-construct outside the plate, 2: non-locking raft screws through the plate, and 3: locking raft screws through the plate. Displacement of the depressed fragment was recorded with force values from 400N to 1600N in increasing 400N increments. The force required to elicit lateral plateau fragment displacement of 5mm, 10mm, and 15mm was also recorded. RESULTS None of the mechanical testing results demonstrated statistical significance with p-values of <0.05. Cyclic testing of Groups 1, 2, and 3 at 400N revealed displacements of 0.54mm, 0.64mm, and 0.48mm, respectively. At 800N, displacements were 1.36mm, 1.4mm, and 1.4mm, respectively. At 1200N, displacements were 2.4mm, 1.9mm, and 2.1mm, respectively. At 1600N, displacements were 2.8mm, 2.5mm, and 2mm, respectively. Resistance to displacement data demonstrated the mean force required to displace the fracture 5mm in Groups 1, 2, and 3 were 250N, 330N, and 318N, respectively. For 10mm of displacement, forces required were 394N, 515N, and 556N, respectively. For 15mm of displacement, forces required were 681N, 853N, and 963N, respectively. Compared to combined groups using screws through the plate, Group 1 demonstrated lower displacement ≤800N, but demonstrated greater displacement >800N. Group 2 demonstrated greatest resistance to plateau displacement of 5mm compared to Group 1 or 3, while Group 3 was most resistant to greater displacement. The combined group using screws through the plate (Groups 2+3) was consistently more resistant than Group 1 at all levels of displacement. CONCLUSIONS Designs utilising screws through the plate trended towards statistically significant improved stability against plateau displacement relative to utilising screws outside the plate. Our study also suggests that there is no significant benefit of locking screws over non-locking screws in this unicondylar tibia plateau fracture model.

Fibular shaft allograft support of posterior joint depression in tibial plateau fractures.

Summary: Posterior depression of the lateral articular surface of the tibial plateau can be difficult to elevate and support with morselized bone graft and internal fixation. Progressive collapse after open reduction and internal fixation has been described and can lead to failure in treatment. A standard anterolateral approach to the tibia may not allow direct reduction and stabilization of posterolateral joint depression given the anatomic barriers of the fibular collateral ligament and the proximal tibiofibular articulation. Posterolateral approaches to the tibial plateau have been described and may allow direct reduction of the articular depression. These approaches, however, require dissection close to the common peroneal nerve, and some approaches also require a proximal fibular osteotomy. The use of an intraosseous fibular shaft allograft as an adjunct to open reduction and internal fixation in select cases of depressed posterolateral tibial plateau fractures allows both reduction of the joint and stabilization of the articular segment through a single approach familiar to many orthopaedic surgeons.

Reverse shoulder arthroplasty for proximal humeral fractures: outcomes comparing primary reverse arthroplasty for fracture versus reverse arthroplasty after failed osteosynthesis

BACKGROUND Surgical treatment of proximal humeral fractures in the elderly pose challenges in decision making. Reverse total shoulder arthroplasty (RTSA) has been established as a reliable option for salvage of failed hemiarthroplasty, although few studies have analyzed RTSA after failed open reduction with internal fixation (ORIF). This study evaluated the outcomes of patients with failed osteosynthesis who undergo salvage RTSA compared with patients undergoing primary RTSA for proximal humeral fractures. METHODS We retrospectively reviewed 18 patients who underwent primary RTSA for acute proximal humeral fractures and 26 patients who underwent arthroplasty after failed ORIF at our institution between 2003 and 2013. Minimum follow-up was 2 years, with a mean follow-up 3 years (range, 2.0-6.0 years). RESULTS There are no statistically significant differences in clinical outcomes between the two cohorts in the American Shoulder and Elbow Surgeons scores and in the most recent forward flexion or external rotation. The salvage RTSA cohort experienced a higher complication rate (8%), including dislocation and aseptic loosening. The primary RTSA cohort had a 5% complication rate, with 1 late prosthetic joint infection requiring reoperation. CONCLUSION Although RTSA after failed ORIF has a higher rate of complications compared with acute RTSA, the revision and reoperation rate as well as clinical outcomes and shoulder function remained comparable. When a surgeon approaches these complex fractures in patients with poor underlying bone stock, this study supports acute arthroplasty or ORIF with the knowledge that salvage RTSA still has the potential to achieve good outcomes if osteosynthesis fails.

Tranexamic Acid Safely Reduced Blood Loss in Hemi- and Total Hip Arthroplasty for Acute Femoral Neck Fracture: A Randomized Clinical Trial

Objectives: We aimed to determine whether (1) tranexamic acid (TXA) reduces the incidence of transfusion (2) TXA reduces the calculated blood loss, and (3) there are any observable differences in 30- and 90-day complications with TXA administration during arthroplasty for femoral neck fracture (FNF). Design: Prospective, double-blinded, randomized controlled trial. Setting: Level 1 Academic Trauma Center. Patients/Participants: One hundred thirty-eight patients who presented with a low-energy, isolated, FNF (AO 31B) treated with either hemi- or total hip arthroplasty within 72 hours of injury were randomized to either the TXA group (69 patients) or placebo group (69 patients). Intervention: In the TXA group, patients received 2 doses of 15 mg/kg intravenous TXA dissolved in 100 mL of saline, each administered over 10 minutes; 1 dose just before incision, and the second at wound closure. In the placebo group, 100 mL of saline solution was administered in a similar fashion. Perioperative care was otherwise standardized including conservative transfusion criteria. Main Outcome Measurements: Our primary outcome was to determine the proportion of patients who underwent blood transfusion during hospitalization. Secondary outcomes were calculated blood loss, number of units transfused during hospitalization, and incidence of adverse events at 30 and 90 days including thromboembolic event, wound complications, reoperation, hospital readmission, and all-cause mortality. Results: TXA reduced mean incidence of transfusion by 305 mL (P = 0.0005). There was a trend toward decreased transfusion rate in the TXA group (17% vs. 26%, P = 0.22). TXA was safe with no differences in adverse events at 30 and 90 days. Conclusions: This randomized clinical trial found that TXA administration safely reduced blood loss with a tendency for decreased transfusion rate and total blood product consumption for patients undergoing hip arthroplasty for acute FNF. More studies are needed to further ascertain the role of TXA in the management of patients with FNF. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Antegrade Femoral Nailing in Acetabular Fractures Requiring a Kocher-Langenbeck Approach

Ipsilateral displaced acetabular and femoral shaft fractures represent a dilemma for orthopedic surgeons because antegrade femoral nailing may complicate a Kocher-Langenbeck acetabular exposure. The goals of this study were to review the results of ipsilateral femoral and acetabular fractures treated with antegrade femoral nailing and a Kocher-Langenbeck approach and to evaluate the assertion that this treatment strategy is associated with increased morbidity. This was a retrospective cohort study at a regional Level I trauma center. Sixteen patients with a femoral fracture treated with antegrade nailing and an ipsilateral acetabular fracture treated with a Kocher-Langenbeck approach were identified. One patient died as a result of his injuries, and 2 were not available for long-term follow-up. One had a deep infection requiring irrigation, debridement, and intraveonous antibiotics. One patient developed a hematoma requiring irrigation and debridement. At final follow-up, 2 patients had no heterotopic ossification about the hip, 4 had Brooker class I heterotopic ossification, 3 had Brooker class II heterotopic ossification, 2 had Brooker class III heterotopic ossification, and 2 patients had Brooker class IV heterotopic ossification requiring excision. Ipsilateral femoral and acetabular fractures represent a rare and severe injury constellation. Antegrade nailing of the femur with ipsilateral Kocher-Langenbeck exposure for fixation of the acetabulum was not associated with excessive rates of wound-healing complications, but the incidence of heterotopic ossification was increased.

Open reduction and percutaneous fixation of a rare hamstring avulsion fracture

Surgical treatment has been advocated for ischial tuberosity avulsion fractures in athletes. This article presents the case of an elite rower with a large avulsion fracture involving the entire inferior obturator ring with a novel technique for open reduction using a limited Kocher-Langenbeck approach and percutaneous fixation using posterior column lag screws. The fracture healed anatomically, and at 1 year follow-up the patient had full range of motion, normal gait and had returned to high-level sporting activities.

In Vitro Biomechanical Evaluation of a Novel, Minimally Invasive, Sacroiliac Joint Fixation Device

ABSTRACT Background: Sacroiliac (SI) joint pathology may result in low-back pain, which causes substantial disability. Treatment failure with operative management of SI pain may be related to incomplete fusion of the joint and to fixation failure. The objective of this study was to evaluate the initial biomechanical stability of SI joint fixation with a novel implantable device in an in vitro human cadaveric model. Methods: The right and left sides of 3 cadaveric L4-pelvis specimens were tested (1) intact, (2) destabilized, and (3) instrumented with an implantable SI joint fixation device using a simulated single-stance load condition. Right-leg and left-leg stance data were grouped together for a sample size of 6, and angular range of motion (ROM) was determined during application of flexion-extension, lateral bending, and axial rotation bending moments to a limit of 7.5 Nm. Results: Following intact testing, destabilization by severing the posterior SI joint capsule and ligaments and the pubic symphysis reliably produced a significantly destabilized joint with the mean angular ROM more than doubling in flexion-extension and lateral bending and more than tripling in axial rotation (P ≤ .003) compared to the intact condition. Instrumentation with the SI screw fixation device significantly reduced mean joint ROM compared to the destabilized condition in all 3 anatomic planes tested (P < .001). When compared to the intact condition, the SI-instrumented condition significantly reduced lateral bending (P = .01) and had a similar ROM in flexion-extension (P = .14) and axial rotation (P = .85). Conclusions: Instrumentation with the SI screw fixation device significantly reduced mean joint ROM compared to the destabilized condition, with similar ROM in flexion-extension and axial rotation, and it significantly reduced ROM in lateral bending compared to that for the intact joint. The ROM values observed with the instrumented condition were comparable to levels of mobility considered favorable for spinal fusion.

Allgöwer–Donati Versus Vertical Mattress Suture Technique Impact on Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography

OBJECTIVE The purpose of this study was to evaluate which primary wound closure technique for ankle fractures affords the most robust perfusion as measured by laser-assisted indocyanine green angiography (LA-ICGA): Allgöwer-Donati or vertical mattress. DESIGN Prospective, randomized. SETTING Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS Thirty patients undergoing open reduction internal fixation (ORIF) for ankle fractures were prospectively randomized to Allgöwer-Donati (n=15) or vertical mattress (n=15) closure. Demographics were similar for both cohorts with respect to age, sex, BMI, surgical timing and AO/OTA fracture classification. MAIN OUTCOME MEASUREMENTS Skin perfusion (mean incision perfusion & mean perfusion impairment) was quantified in fluorescence units with LA-ICGA along the lateral incision as well as anterior and posterior to the incision at 30 separate locations. Minimum follow-up was 3 months with a mean follow up 4.7 months. RESULTS Allgöwer-Donati enabled superior perfusion compared to the vertical mattress suture technique. Mean incision perfusion for Allgöwer-Donati was 51 (SD=13) and for vertical mattress was 28 (SD=10; P<0.0001). Mean perfusion impairment was less in the Allgöwer-Donati cohort (12.8, SD=9) compared to the vertical mattress cohort (23.4, SD=14; P=0.03). One patient in each cohort experienced a wound complication. CONCLUSION The Allgöwer-Donati suture technique offers improved incision perfusion compared to vertical mattress closure following ORIF of ankle fractures. Theoretically this may enhance soft tissue healing and decrease the risk of wound complications. Surgeons may take this into consideration when deciding closure techniques for ankle fractures. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.OBJECTIVE The purpose of this study was to evaluate which primary wound closure technique for ankle fractures affords the most robust perfusion as measured by laser-assisted indocyanine green angiography: Allgöwer-Donati or vertical mattress. DESIGN Prospective, randomized. SETTING Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS Thirty patients undergoing open reduction internal fixation for ankle fractures were prospectively randomized to Allgöwer-Donati (n = 15) or vertical mattress (n = 15) closure. Demographics were similar for both cohorts with respect to age, sex, body mass index, surgical timing, and OTA/AO fracture classification. MAIN OUTCOME MEASUREMENTS Skin perfusion (mean incision perfusion and mean perfusion impairment) was quantified in fluorescence units with laser-assisted indocyanine green angiography along the lateral incision as well as anterior and posterior to the incision at 30 separate locations. Minimum follow-up was 3 months with a mean follow-up 4.7 months. RESULTS Allgöwer-Donati enabled superior perfusion compared with the vertical mattress suture technique. Mean incision perfusion for Allgöwer-Donati was 51 (SD = 13) and for vertical mattress was 28 (SD = 10, P < 0.0001). Mean perfusion impairment was less in the Allgöwer-Donati cohort (12.8, SD = 9) compared with that in the vertical mattress cohort (23.4, SD = 14; P = 0.03). One patient in each cohort experienced a wound complication. CONCLUSIONS The Allgöwer-Donati suture technique offers improved incision perfusion compared with vertical mattress closure after open reduction internal fixation of ankle fractures. Theoretically, this may enhance soft tissue healing and decrease the risk of wound complications. Surgeons may take this into consideration when deciding closure techniques for ankle fractures. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Outcome and Management of Primary Amputations, Subtotal Amputation Injuries, and Severe Open Fractures with Nerve Injuries

Patients with severe lower-extremity trauma present multiple challenges to surgeons, physiatrists, rehabilitation specialists, and family members. Often there is considerable debate surrounding limb salvage or to proceed with early amputation. Prior to the LEAP study (Lower Extremity Assessment Project), high-level evidence assisting the clinician in this decision was lacking. This chapter details the findings of the LEAP study and other studies examining combat-related injuries and provides the surgeon and other members of the treatment team valuable information and guidance in the management and counseling of the trauma patient with severe limb-threatening trauma.

Does ankle aspiration for acute ankle fractures result in pain relief? A prospective randomized double-blinded placebo controlled trial

Objectives: Does ankle aspiration help with pain control in patients with ankle fractures? Design: Prospective, double-blind, randomized, placebo-controlled trial. Setting: Level 1 Academic Medical Center. Patients/Participants: Consecutive skeletally mature patients with ankle fractures. Intervention: Randomized between ankle aspiration and sham procedure. Main Outcome Measurements: Pain scores for 72 hours after injury and pain medicine usage. Results: Comparison between study subjects receiving ankle aspiration and sham procedure showed no significant differences in pain scores acutely in the emergency department or within 3 days after injury. There were also no statistically significant differences in pain medicine usage within 3 days after injury. Secondary outcomes, including lower leg volume, 6-month functional outcome scores, and complication rate, also showed no significant differences between subjects receiving aspiration and the sham procedure. Conclusions: Aspiration of acute ankle fractures does not result in decreased pain scores or opioid usage after aspiration. Aspiration of acute ankle fractures does not provide measurable clinical benefit. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.