Weight-bearing protocols should optimize fracture healing while avoiding fracture displacement or implant failure. Biomechanical and animal studies indicate that early loading is beneficial, but ...high-quality clinical studies comparing weight-bearing protocols after lower extremity fractures are not universally available. For certain fracture patterns, well-designed trials suggest that patients with normal protective sensation can safely bear weight sooner than most protocols permit. Several randomized, controlled trials of surgically treated ankle fractures have shown no difference in outcomes between immediate and delayed (≥ 6 weeks) weight bearing. Retrospective series have reported low complication rates with immediate weight bearing following intra-medullary nailing of femoral shaft fractures and following surgical management of femoral neck and intertrochanteric femur fractures in elderly patients. For other fracture patterns, particularly periarticular fractures, the evidence in favor of early weight bearing is less compelling. Most surgeons recommend a period of protected weight bearing for patients with calcaneal, tibial plafond, tibial plateau, and acetabular fractures. Further studies are warranted to better define optimal postoperative weight-bearing protocols.
Patient-reported outcomes are important to assess effectiveness of clinical interventions. For orthopaedic trauma patients, the short Musculoskeletal Function Assessment (sMFA) is a commonly used ...questionnaire. Recently, the Patient-Reported Outcome Measurement Information System (PROMIS) PF Function Computer Adaptive Test (PF CAT) was developed using item response theory to efficiently administer questions from a calibrated bank of 124 PF questions using computerized adaptive testing. In this study, we compared the sMFA versus the PROMIS PF CAT for trauma patients.
Orthopaedic trauma patients completed the sMFA and the PROMIS PF CAT on a tablet wirelessly connected to the PROMIS Assessment Center. The time for each test administration was recorded. A 1-parameter item response theory model was used to examine the psychometric properties of the instruments, including precision and floor/ceiling effects.
One hundred fifty-three orthopaedic trauma patients participated in the study. Mean test administration time for PROMIS PF CAT was 44 seconds versus 599 seconds for sMFA (P < 0.05). Both instruments showed extremely high item reliability (Cronbach alpha = 0.98). In terms of instrument coverage, neither instrument showed any floor effect; however, the sMFA revealed 14.4% ceiling effect, whereas the PROMIS PF CAT had no appreciable ceiling effect.
Administered by electronic means, the PROMIS PF CAT required less than one-tenth the amount of time for patients to complete than the sMFA while achieving equally high reliability and less ceiling effects. The PROMIS PF CAT is a very attractive and innovative method for assessing patient-reported outcomes with minimal burden to patients.
OBJECTIVES:To compare orthopaedic trauma volume and mechanism of injury before and during statewide social distancing and stay-at-home directives.
DESIGN:Retrospective.
SETTING:Level 1 trauma center.
...PATIENTS/PARTICIPANTS:One thousand one hundred thirteen patients sustaining orthopaedic trauma injuries between March 17 and April 30 of years 2018, 2019, and 2020.
INTERVENTION:Statewide social distancing and stay-at-home directives.
MAIN OUTCOME MEASUREMENTS:Number of consults, mechanism of injury frequency, and type of injury frequency.
RESULTS:During the COVID-19 pandemic, orthopaedic trauma consult number decreased. Injuries due to gunshot wounds increased and those due to automobile versus pedestrian accidents decreased. Time-to-presentation increased and length of stay decreased. Operative consults remained unchanged.
CONCLUSIONS:Orthopaedic trauma injuries continued to occur during the COVID-19 pandemic at an overall decreased rate, however, with a different distribution in mechanism and type of injury.
LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
•Historical methods of cutaneous traction use adhesive tape and plaster in immediate contact with the skin, resulting in a complication rate of 11%.•Cutaneous traction with modern foam boots has an ...overall complication rate of 0.7%.•Modern foam boot traction has a similar complication rate as skeletal traction.
Cutaneous traction is used to temporize lower extremity fractures and relies on friction between the skin and surrounding material to apply a longitudinal force. This circumferential compressive force can lead to pressure sores, skin sloughing, or compressive neuropathies. These complications have been reported in up to 11% of patients when the cutaneous traction relies on adhesive tapes, plaster, and rubber bandages being in immediate contact with the skin. The rates of these complications are not well documented when using modern foam boots.
A retrospective chart review was performed on all orthopedic trauma patients who suffered pelvic or lower extremity injuries between March 1st, 2020 and April 30th, 2021 at a single Level-1 trauma center. We included all patients with femoral fractures, axially unstable pelvic ring and/or acetabular fractures, and unstable hip dislocations temporized with the use of cutaneous traction. All patients had intact skin and lower extremity nerve function prior to application.
There were 138 patients identified with 141 lower extremities. The average patient age was 50.7 (6–100) years. Mean traction weight of 9.8 (5–20) pounds. Average traction duration was 20.9 (2.3–243.5) hours. At the time of traction removal, there was 1 (0.7%) new skin wound and 0 nerve palsies. The new skin wound was a stage one heel pressure sore and did not require further treatment.
Cutaneous traction with a modern foam boot was found to have a skin complication rate of 0.7% and a nerve palsy complication rate of 0% for an overall complication rate of 0.7%, which has not been previously established and is lower than historically reported complication rates of 11% when utilizing adhesive and plaster directly on skin. Foam boot Cutaneous traction may be considered a safe option for traction placement.
Background
Stabilization after a pelvic fracture can be accomplished with an anterior external fixator. These devices are uncomfortable for patients and are at risk for infection and loosening, ...especially in obese patients. As an alternative, we recently developed an anterior subcutaneous pelvic internal fixation technique (ASPIF).
Questions/purposes
We asked if the ASPIF (1) allows for definitive anterior pelvic stabilization of unstable pelvic injuries; (2) is well tolerated by patients for mobility and comfort; and (3) has an acceptable complication rate.
Methods
We retrospectively reviewed 91 patients who incurred an unstable pelvic injury treated with an anterior internal fixator and posterior fixation at four Level I trauma centers. We assessed (1) healing by callous formation on radiographs and the ability to weightbear comfortably; (2) patient function by their ability to sit, stand, lie on their sides, and how well they tolerated the implants; and (3) complications during the observation period. The minimum followup was 6 months (mean, 15 months; range, 6–40 months).
Results
All 91 patients were able to sit, stand, and lie on their sides. Injuries healed without loss of reduction in 89 of 91 patients. Complications included six early revisions resulting from technical error and three infections. Irritation of the lateral femoral cutaneous nerve was reported in 27 of 91 patients and resolved in all but one. Heterotopic ossification around the implants, which was asymptomatic in all cases, occurred in 32 of 91 patients.
Conclusions
The anterior internal fixator provided high rates of union for the anterior injury in unstable pelvic fractures. Patients were able to sit, stand and ambulate without difficulty. Infections and aseptic loosening were reduced but heterotopic ossification and irritation of the LFCN are common.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Biomechanics of Locked Plates and Screws Egol, Kenneth A; Kubiak, Erik N; Fulkerson, Eric ...
Journal of orthopaedic trauma,
2004-September, Letnik:
18, Številka:
8
Journal Article
Recenzirano
OBJECTIVE:To review the biomechanical principles that guide fracture fixation with plates and screws; specifically to compare and contrast the function and roles of conventional unlocked plates to ...locked plates in fracture fixation. We review basic plate and screw function, discuss the design rationale for the new implants, and examine the biomechanical evidence that supports the use of such implants.
DATA SOURCES:Systematic review of the per reviewed English language orthopaedic literature listed on PubMed (National Library of Medicine online service).
STUDY SELECTION:Papers selected for this review were drawn from peer review orthopaedic journals. All selected papers specifically discussed plate and screw biomechanics with regard to fracture fixation. PubMed search terms wereplates and screws, biomechanics, locked plates, PC-Fix, LISS, LCP, MIPO, and fracture fixation.
DATA SYNTHESIS:The following topics are discussedplate and screw function—neutralization plates and buttress plates, bridge plates; fracture stability—specifically how this effects gap strain and fracture union, conventional plate biomechanics, and locking plate biomechanics.
CONCLUSIONS:Locked plates and conventional plates rely on completely different mechanical principles to provide fracture fixation and in so doing they provide different biological environments for healing. Locked plates may increasingly be indicated for indirect fracture reduction, diaphyseal/metaphyseal fractures in osteoporotic bone, bridging severely comminuted fractures, and the plating of fractures where anatomical constraints prevent plating on the tension side of the bone. Conventional plates may continue to be the fixation method of choice for periarticular fractures which demand perfect anatomical reduction and to certain types of nonunions which require increased stability for union.
Purpose To determine the effect of insertion angle, from 45° to 135° in 15° increments, on the number of cycles withstood, the ultimate pullout strength, and the stiffness of threaded suture anchors ...subjected to load. Methods Threaded anchors were inserted into polyurethane foam at angles from 45° to 135°, in 15° increments, relative to the direction of pull. Five anchors were tested at each angle. The anchors were first cycled for 30 cycles (10 each at 100 N, 150 N, and 200 N). The surviving specimens were then tensioned to failure. The McNemar test was used to compare cyclic failure rates. Paired-samples t tests were used to compare load-to-failure (LTF) and stiffness data. All P values are multiplicity adjusted by the Hommel procedure. Results Four of 5 anchors inserted at 45° failed during cyclic testing at a mean of 27 cycles ( P = .13). One of 5 anchors placed at 60° failed after 29 cycles ( P = .99). All other anchors survived cyclic testing. Mean LTF was 234 N, 243 N, 297 N, 373 N, 409 N, 439 N, and 417 N at insertion angles of 45°, 60°, 75°, 90°, 105°, 120°, and 135°, respectively. LTF was significantly less for the 60° group when compared with the 90°, 105°, 120°, and 135° groups ( P < .05). LTF was significantly less for the 75° group when compared with the 105°, 120°, and 135° groups ( P < .05). For the 90° group, LTF was only significantly less when compared with the 135° group ( P = .022). The differences in LTF between the 105°, 120°, and 135° groups were not significant. Stiffness increased from 28.13 N/mm at 90° to 43.4 N/mm at 105° ( P = .03), 61.48 N/mm at 120° ( P = .003), and 86.83 N/mm at 135° ( P = .008). Conclusions Anchors placed at more acute angles, that is, anchors placed closer to the so-called deadman's angle, failed at lower loads and provided less construct stiffness than anchors placed at angles greater than 90°. Stiffness also increased sequentially from an angle of insertion of 90° up to our maximum angle tested of 135°. For threaded metallic suture anchors, an obtuse insertion angle of 90° to 135° in relation to the line of pull of the suture and rotator cuff withstands a greater LTF and provides a stiffer construct than the more acute insertion angle advocated by the “deadman theory.” Clinical Relevance This study offers a biomechanical validation for optimal placement of threaded suture anchors at an angle of 90° or more, as anatomic restraints allow, from the vector of pull of the attached suture and rotator cuff, rather than the 45° angle recommended by the deadman theory.
BACKGROUND:The objective of the present study was to evaluate human synovial fluid for inflammatory cytokine concentrations following acute tibial plateau fracture. Our hypothesis was that there ...would be an elevated inflammatory response following intra-articular fracture, and that the inflammatory response would be greater after high-energy compared with low-energy injuries.
METHODS:Between December 2011 and June 2013, we prospectively enrolled forty-five patients with an acute tibial plateau fracture. Synovial fluid aspirations were performed on the injured and uninjured knees. Twenty patients who required an external fixator followed by delayed fixation underwent aspiration at both surgical procedures. The concentrations of interferon-gamma (IFN-γ), interleukin-1 beta (IL-1β), interleukin-1 receptor antagonist (IL-1RA), IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12(p70), IL-13, IL-17A, tumor necrosis factor-alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), and macrophage inflammatory protein-1 beta (MIP-1β) were quantified with use of multiplex assays.
RESULTS:The forty-five patients had an average age of forty-two years (range, twenty to sixty years). There were twenty-four low-energy and twenty-one high-energy tibial plateau injuries. There was a significant difference between injured and uninjured knees (p < 0.001) with regard to concentrations of IL-1β, IL-6, IL-8, IL-10, IL-1RA, and MCP-1. There was not a detectable difference in synovial fluid cytokine concentrations between high and low-energy injuries. The concentrations of IL-10 (p < 0.001), IL-1RA (p = 0.002), IL-6 (p < 0.001), IL-8 (p < 0.001), and MCP-1 (p = 0.002) were significantly greater in the injured knee than in the uninjured knee at the second aspiration, at a mean of 9.5 days (range, three to twenty-one days) after the initial injury.
CONCLUSIONS:There was a significant local inflammatory response following acute tibial plateau fracture. There was not a detectable difference in inflammatory cytokine concentration between high and low-energy injuries. Synovial fluid concentrations of IL-10, IL-8, IL-6, IL-1RA, and MCP-1 remained elevated at the second aspiration.
CLINICAL RELEVANCE:The articular surface is exposed to acute and sustained concentrations of multiple inflammatory cytokines following intra-articular fracture. Inflammatory cytokines have been associated with the development of primary and inflammatory arthritis, and this research indicates that these factors could also play a role in the development of posttraumatic osteoarthritis.
Background
High-energy tibial plateau and tibial plafond fractures have a high complication rate and are frequently treated with a staged approach of spanning external fixation followed by definitive ...internal fixation after resolution of soft tissue swelling. A theoretical advantage to early spanning external fixation is that earlier fracture stabilization could prevent further soft tissue damage and potentially reduce the occurrence of subsequent infection. However, the relative urgency of applying the external fixator after injury is unknown, and whether delay in this intervention is correlated to subsequent treatment complications has not been examined.
Questions/purposes
Is delay of more than 12 hours to spanning external fixation of high-energy tibial plateau and plafond fractures associated with increased (1) infection risk; (2) compartment syndrome risk; and (3) time to definitive fixation, length of hospitalization, or risk of secondary surgeries? We further stratified our results based on injury site: plateau and plafond. In practical clinical terms, many of these high-energy C-type articular fractures will arrive at the regional trauma center in the evening and this investigation attempted to explore if these injuries need to be placed in temporizing fixators that evening or if they may be safely addressed in a dedicated trauma room the next morning.
Methods
We performed a retrospective review of all patients at a Level I university trauma center with high-energy tibial plateau and plafond fractures who underwent staged treatment with a spanning external fixation followed by subsequent definitive internal fixation between 2006 and 2012. Patients who received a fixator within 12 hours of recorded injury time were classified as early external fixation; those who received a fixator greater than 12 hours from injury were classified as delayed external fixation. There were 80 patients (42 plateaus and 38 plafonds) in the early external fixation cohort and 79 patients (45 plateaus and 34 plafonds) in the delayed external fixation cohort. Deep infection rate was 13% in plateau fractures and 18% in plafond fractures. Rates of infection, compartment syndrome, secondary surgeries, time to definitive fixation, and length of hospitalization were recorded.
Results
Controlling for differences in open fracture severity between groups, there was no difference in infection for plafond (early fixation: 12 of 38 32%; delayed fixation: seven of 34 21%; adjusted relative risk = 1.39 95% confidence interval {CI}, 0.45–4.31, p = 0.573) and plateau (early fixation: eight of 42 19%; delayed fixation: nine of 45 20%; adjusted relative risk: 0.93 95% CI, 0.31–2.78, p = 0.861) groups. For compartment syndrome risk, there was no difference between early and delayed groups for plateau fractures (early fixation: six of 42 14%; delayed fixation: three of 45 7%; relative risk = 0.47 0.12–1.75, p = 0.304) and plafond fractures (early fixation: two of 38 5%; delayed fixation: three of 34 9%; relative risk = 1.67 0.30–9.44, p = 0.662). There was no difference for length of hospitalization for early (9 ± 7 days) versus delayed fixation (9 ± 6 days) (mean difference = 0.24 95% CI, −2.9 to 3.4, p = 0.878) for patients with plafond fracture. Similarly, there was no difference in length of hospitalization for early (10 ± 6 days) versus delayed fixation (8 ± 4 days) (mean difference = 1.6 95% CI, −3.9 to 0.7, p = 0.170) for patients with plateau fracture. Time to definitive fixation for plateau fractures in the early external fixation group was 8 ± 6 days compared with 11 ± 7 days for the delayed external fixation group (mean difference = 2.9 95% CI, 0.13–5.7, p = 0.040); there was no difference in time to definitive fixation for early (12 ± 7 days) versus delayed (12 ± 6 days) for patients with plafond fractures (mean difference = 0.39 95% CI, −2.7 to 3.4, p = 0.801). There was no difference in risk of secondary surgeries between early external fixation (21 of 38 55%) and delayed external fixation (13 if 34 38%) for plafond fractures (adjusted relative risk = 0.69 95% CI, 0.41–1.16, p = 0.165) and no difference between early fixation (24 of 42 57%) and delayed fixation (26 of 45 58%) for plateau fractures (adjusted relative risk = 1.0 95% CI, 0.70–1.45, p = 1.00).
Conclusions
We were unable to detect a difference in infection, compartment syndrome, secondary procedures, or length of hospitalization for patients who undergo early versus delayed external fixation for high-energy tibial plateau or plafond fractures. This may affect decisions for resource use at trauma centers such as whether high-energy periarticular lower extremity fractures need to be spanned on the evening of presentation or whether this procedure may wait until the morning trauma room. Given the high complication rate of these injuries and clinical relevance of this question, this may also need to be examined in a prospective manner.
Level of Evidence
Level IV, therapeutic study.
The evolution of locked plates Kubiak, Erik N; Fulkerson, Eric; Strauss, Eric ...
Journal of bone and joint surgery. American volume
88 Suppl 4
Journal Article
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