Yvonne M. Murtha

Complications Associated With Negative Pressure Reaming for Harvesting Autologous Bone Graft: A Case Series

A technical benefit of the reamer-irrigator-aspirator (RIA) system (Synthes, Paoli, PA) is the ability to harvest large volumes (40-90 cm3) of autogenous bone graft. Early evaluations of this technique have reported few problems, all of which were attributed to technical error. This case series reviews 6 RIA-associated complications including 4 fractures and their contributing risk factors. Cases were collected from 4 independent orthopaedic centers, and all patients underwent RIA bone graft harvesting in a lower extremity long bone injuries. In this population, 2 patients experienced acute RIA-associated events, necessitating an additional procedure or altered postoperative rehabilitation, whereas 4 patients fractured through their donor site in the early postoperative period. This series suggests that surgeons should (1) preoperatively assess cortical diameters at long bone harvest sites, (2) carefully monitor intraoperative reaming, and (3) avoid RIA bone graft harvesting in patients with a history of osteoporosis or osteopenia unless postharvest intramedullary stabilization is considered.

Surgical Timing of Treating Injured Extremities

After more than a decade of conflicting publications as well as changes in institutional resources, surgeons rightly question the ideal timing of surgical intervention for various extremity injuries. Is this fracture a true emergency? Can it wait until tomorrow morning? Is definitive management best delayed to minimize further trauma to the patient’s physiology or soft tissues? And how does the availability of protected, daytime operating-room time influence these decisions? To address these questions, we evaluated the evidence regarding the optimal or critical time for surgical intervention in treating various extremity injuries and the influence of a designated orthopaedic trauma room on management strategies. ### Compartment Syndrome Compartment syndrome of the extremities remains a true orthopaedic surgical emergency. While innovative treatments continue to be developed, little has changed in the diagnosis and management. Once the diagnosis is made, fasciotomy and evaluation of muscle viability is emergent; there are few indications for treatment delay except for a patient in extremis. #### Diagnosis Diagnosis of compartment syndrome remains clinically challenging, and despite technological developments in pressure detection instruments, physical examination and clinical history remain the mainstays of diagnosis. One of the challenges of diagnosis is physical examination in patients who cannot reliably communicate, such as those who are intubated or those with altered sensorium. In these patients, examination can be unreliable1. Additionally, the so-called classic clinical findings, such as changes on vascular examination or paralysis, occur late and are less helpful in preventing morbidity. Pain out of proportion with passive stretch of an involved muscle group is one of the earliest and most sensitive clinical signs1. Paresthesias are an early sign and likely related to nerve ischemia2. Patients can develop compartment syndromes acutely after injury, after fracture fixation, or in a delayed fashion1,3. Although a specific measured value …

Treatment of Acute Distal Femur Fractures

An emphasis on indirect reduction techniques to restore limb alignment has improved the rate of fracture healing and decreased infection rates, fixation failure, and the need for bone grafting.

The viability of cells obtained using the Reamer–Irrigator–Aspirator system and in bone graft from the iliac crest

We hypothesised that cells obtained via a Reamer-Irrigator-Aspirator (RIA) system retain substantial osteogenic potential and are at least equivalent to graft harvested from the iliac crest. Graft was harvested using the RIA in 25 patients (mean age 37.6 years (18 to 68)) and from the iliac crest in 21 patients (mean age 44.6 years (24 to 78)), after which ≥ 1 g of bony particulate graft material was processed from each. Initial cell viability was assessed using Trypan blue exclusion, and initial fluorescence-activated cell sorting (FACS) analysis for cell lineage was performed. After culturing the cells, repeat FACS analysis for cell lineage was performed and enzyme-linked immunosorbent assay (ELISA) for osteocalcin, and Alizarin red staining to determine osteogenic potential. Cells obtained via RIA or from the iliac crest were viable and matured into mesenchymal stem cells, as shown by staining for the specific mesenchymal antigens CD90 and CD105. For samples from both RIA and the iliac crest there was a statistically significant increase in bone production (both p < 0.001), as demonstrated by osteocalcin production after induction. Medullary autograft cells harvested using RIA are viable and osteogenic. Cell viability and osteogenic potential were similar between bone grafts obtained from both the RIA system and the iliac crest.

A New Technique for Removing Intramedullary Cement

Treatment of infected long bone fractures or nonunions requires stability for bony union, yet retained implants can lead to persistent infection. Antibiotic cement intramedullary nails, in addition to external fixation, are commonly used to deliver intramedullary antibiotics in infected long bone fractures and provide temporary stability. However, the retrieval of these nails can result in debonding of antibiotic cement, which can require significant time and effort to remove. A variety of methods, including intramedullary hooks, reverse curettes, flexible osteotomes, and stacked guide rods, are commonly used to remove cement fragments. When these methods fail to allow access to the entire length of the canal, the Reamer Irrigator Aspirator system (Synthes, Paoli, PA) serves as an effective method for removing retained intramedullary cement. The surgical technique is described, and three cases illustrate the successful use of the Reamer Irrigator Aspirator system for removal of an antibiotic cement intramedullary nail.

Role of acute negative pressure wound therapy over primarily closed surgical incisions in acetabular fracture ORIF: A prospective randomized trial

BACKGROUND Negative pressure wound therapy use over closed surgical incisions (iNPWT) has proven to be effective at reducing hematoma, wound drainage and infection in high-risk wounds. The purpose of this study was to determine if iNPWT decreased the risk of infection in patients undergoing open reduction internal fixation (ORIF) for acetabular fractures. METHODS 71 patients who underwent operative intervention for an acetabular fracture between March 2008 and September 2012 consented and prospectively randomized to iNPWT or a standard postoperative (dry gauze) dressing. The primary endpoint was deep infection, i.e. necessitating surgical debridement. Patients were followed until fracture union. RESULTS 33 patients were randomized to treatment with a standard gauze dressing and 33 patients were randomized to the iNPWT cohort. There were no statistically significant differences between the groups with respect to patient demographics, clinical, or surgery characteristics. Overall, seven patients (10.6%) were diagnosed with infections; two patients (6.1%) in the placebo group and 5 (15.2%) in the treatment group. CONCLUSIONS In this randomized prospective trial, iNPWT did not decrease the incidence of deep infections when compared to gauze dressings in patients with acetabular fractures. Although not statistically significant, patients in the iNPWT cohort were 2.77 times more likely to develop a deep infection.

Removal technique for cold-welded titanium locking screws

Titanium locking plates are commonly used for periarticular fracture fixation. Early clinical results have been encouraging in their use in treating distal femur and proximal tibia fractures, particularly with the advent of instrumentation for submuscular insertion and percutaneous fixation. A unique feature of titanium locking plates is the phenomenon of cold-welded screws due to titanium being a softer metal. The removal of cold-welded screws in clinical practice can be frustrating. However, it is not commonly reported, as it is often viewed as an insignificant surgical event. Manufacturers promote a strict adherence to using a torque-limiting screwdriver to decrease the risk of cold-welding. Failure to be able to remove titanium screws can be attributed to fracturing or deforming the screw head recess, slippage of the screwdriver in the screw head, fracture of the screwdriver, or inadequate torque provided by the removal instrument. Biomechanical torque studies have shown failure of the screw head recess occurs as permanent deformation by reaming of the recess walls. If the screwdriver has slipped once, additional attempts to drive the screw in or out will produce only one-half of the original maximum torque. Consequently, once slippage has occurred, removal of the screw becomes more difficult. As the screw deforms, changing the screwdriver is futile. Previously described techniques for screw removal are documented in medical literature. First, if slippage of the screwdriver is an issue, the foil from a suture pack may be positioned between the screwdriver and the drive connection which increases the stability of the connection enough to allow for removal. Second, conical extraction screws, available in standard hardware removal sets, can be used to remove stripped screws. It can be difficult to disengage the extraction screw the locking screw

Pilon fracture complicated by compartment syndrome: a case report.

Pilon fractures associated with compartment syndrome are rare occurrences despite the relatively high-energy mechanisms that cause many pilon fractures. We report an unusual case of pilon fracture in an adult, which was complicated by development of compartment syndrome. It was successfully treated with four-compartment leg fasciotomy with good results. A high index of suspicion for compartment syndrome should be maintained in patients with intractable pain after pilon fracture.

Working length and proximal screw constructs in plate osteosynthesis of distal femur fractures

BACKGROUND The study purpose is to evaluate the working length, proximal screw density, and diaphyseal fixation mode and the correlation to fracture union after locking plate osteosynthesis of distal femoral fractures using bridge-plating technique. METHODS A four-year retrospective review was performed to identify patients undergoing operative fixation of distal femur fractures with a distal femoral locking plate using bridge-plating technique for the metadiaphyseal region. Primary variables included fracture union, secondary surgery for union, plate working length, and diaphyseal screw technique and configuration. Multiple secondary variables including plate metallurgy and coronal plane fracture alignment were also collected. RESULTS Ninety-six patients with distal femur fractures with a mean age 60 years met inclusion criteria. None of the clinical parameters were statistically significant indicators of union. Likewise, none of the following surgical technique parameters were associated with fracture union: plate metallurgy, the mean working length, screw density and number of proximal screws and screw cortices. However, diaphyseal screw technique did show statistical significance. Hybrid technique had a statistically significant higher chance of union when compared to locking (p=0.02). All proximal locking screw constructs were 2.9 times more likely to lead to nonunion. CONCLUSIONS Plating constructs with all locking screws used in the diaphysis when bridge-plating distal femur locking plates were 2.9 times more likely to incur a nonunion. However, other factors associated with more flexible fixation constructs such as increased working length, decreased proximal screw number, and decreased proximal screw density were not significantly associated with union in this study.

Parathyroid hormone: is there a role in fracture healing?

Parathyroid hormone is a well-known regulator of calcium metabolism in the body. It binds to osteoblasts and assists in the regulation of bone turnover. Changes in parathyroid hormone levels have been documented in pathologic states such as osteoporosis, and fluxes are also noted during healing of fractures. Because fracture healing requires time and is sometimes unreliable, a search for fracture-healing adjuvants that accelerate the healing rate and improve reliability of healing is compelling. Parathyroid hormone, as a systemic mediator of calcium and bone metabolism, is a good candidate. Much research has been accomplished in animal models examining the role of parathyroid hormone in fracture healing. Although further research is required, especially in human fracture patients, early indicators are that parathyroid hormone may play a role in accelerating fracture healing in healthy patients and in reducing rates of fracture nonunion in compromised patients or tissue beds.