Multiple surgeries are often required to manage segmental bone loss because of the complex mechanics and biology involved in reconstruction. These procedures can lead to prolonged recovery times, ...poor patient outcomes, and even delayed amputation. A two-stage technique uses induced biologic membranes with delayed placement of bone graft to manage this clinical challenge. In the first stage, a polymethyl methacrylate spacer is placed in the defect to produce a bioactive membrane, which appears to mature biochemically and physically 4 to 8 weeks after spacer placement. In the second, cancellous autograft is placed within this membrane and, via elution of several growth factors, the membrane appears to prevent graft resorption and promote revascularization and consolidation of new bone. Excellent clinical results have been reported, with successful reconstruction of segmental bone defects >20 cm.
OBJECTIVES:To define the incidence of sacral U-type insufficiency fracture and describe management of a consecutive series of patients with this injury.
DESIGN:Retrospective analysis.
SETTING:Single ...Level II trauma center.
PATIENTS/PARTICIPANTS:Sixteen adult patients with sacral U-type insufficiency fractures treated over a 36-month period.
INTERVENTION:Patients were indicated for percutaneous screw fixation of the posterior pelvis if they had posterior pelvic pain that prohibited mobilization.
MAIN OUTCOME MEASUREMENTS:Visual analog scale for pain, distance ambulated on postoperative day 1, and change in sacral kyphosis.
RESULTS:The sacral U-type insufficiency fracture incidence was 16.7% (19/114); average patient age was 75 years. Delayed surgery was performed after primary nonoperative treatment had failed in 62.5% (10/16) at an average 83 days postinjury. Acute surgery was performed in 37.5% (6/16) at an average 5 days postinjury. Distance ambulated on postoperative day 1 was 114.4 feet 95% confidence interval (CI) (50.6, 178.2) and 88.7 feet 95% CI (2.8, 174.6) in the delayed and acute surgery groups, respectively, P = 0.18. Change in visual analog scale for pain was −3.2 95% CI (−5.0, −1.4) and −3.7 95% CI (−7.0, −0.4) in the delayed and acute surgery groups, respectively, P = 0.15. Change in sacral kyphosis from presentation to surgery was 12.3 degrees 95% CI (6.7, 17.9) and 0.3 degrees 95% CI (−0.2, 0.9) in the delayed and acute surgery groups, respectively, P < 0.01. Minimum follow-up was 12 months.
CONCLUSIONS:Treatment of sacral U-type insufficiency fractures by percutaneous screw fixation permits early mobilization, provides rapid pain relief, and prevents progressive deformity.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Purpose We conducted this study to determine if preoperative magnetic resonance imaging (MRI) cross-sectional area measurements would correlate with intraoperative graft size in hamstring anterior ...cruciate ligament (ACL) reconstructions. Methods We retrospectively reviewed ACL reconstructions performed by a single surgeon using a quadruple-looped hamstring allograft. Preoperative MRI axial images were used to determine the combined cross-sectional area of the semitendinosis and gracilis tendons. These cross-sectional areas were correlated to the intraoperative graft size. Results We found a strong correlation between the MRI cross-sectional areas and graft size. If the combined cross-sectional areas were ≥18mm2 , there was an 88% probability of obtaining a graft of sufficient size at the time of surgery. Conclusions We conclude that our technique is a reliable option to assist the surgeon with preoperative determination of graft size. This is valuable to the orthopaedist to more accurately discuss graft options with the patient and improve preoperative preparation with respect to graft choice. Level of Evidence: Level II, development of diagnostic criteria on the basis of consecutive patients with universally applied gold standard.
Clinical Outcomes of Surgical Stabilization of Flail Chest Injury Taylor, Benjamin C; Fowler, T Ty; French, Bruce G ...
Journal of the American Academy of Orthopaedic Surgeons,
2016-August, 2016-Aug, 2016-08-00, 20160801, Letnik:
24, Številka:
8
Journal Article
Recenzirano
IntroductionRecent reported success in surgical stabilization of flail chest has been described in small series, but scant evidence exists for this procedure in the orthopaedic literature.MethodsWe ...reviewed 88 consecutive patients who underwent surgical stabilization of flail chest, along with 88 consecutive patients with flail chest who underwent traditional closed management before initiation of our algorithm change to surgical management.ResultsSurgical stabilization of flail chest injuries led to statistically significant decreases in hospital length of stay, ventilator-dependency time, pneumonia, tracheostomy, and mortality rate. In addition, the presence of pulmonary contusion did not eliminate the significant improvements in the aforementioned variables.DiscussionSurgical stabilization of flail chest with modern techniques and implants provides significant improvements in both mortality and short-term outcomes. Although pulmonary contusion decreased overall outcomes across both cohorts, this factor did not alter the ability of rib fixation to improve outcomes.
Abstract Surgical techniques and fixation strategies for the treatment of unstable posterior pelvic ring injuries continue to evolve. The safety of the posterior surgical approach in particular has ...been questioned due to historically high rates of wound related complications. More contemporary studies have shown lower infection rates, however concern still persists. These concerns for infection and wound necrosis have led, in part, to increased interest in closed reduction and percutaneous fixation for treatment of these injuries but an open posterior approach remains the optimal strategy in some injury patterns. We describe herein a modified posterior approach to the pelvis designed to minimize wound related complications and present our clinical results demonstrating wound complication rates consistent with contemporary publications.
The direct anterior approach has recently gained popularity for patients undergoing elective total hip arthroplasty. It is unknown whether the reported benefits of the direct anterior approach to ...elective total hip arthroplasty can be extrapolated to patients undergoing hemiarthroplasty after femoral neck fracture. A retrospective review of 101 patients was performed to compare the outcomes of patients treated with hemiarthroplasty using the direct anterior approach (group 1) with those of patients undergoing the procedure with the posterior, anterolateral, or lateral approach (group 2). No differences in age, American Society of Anesthesiologists classification, and preinjury ambulatory status were identified between treatment groups. No difference in operative time was found between those undergoing the anterior approach (98.7 minutes) and those undergoing other surgical approaches (96.5 minutes) (P=.76). No difference in either the need for transfusion or the number of blood products transfused was seen (P=.21) postoperatively. Patients undergoing the direct anterior approach were more likely to be discharged by postoperative day 3 (P=.004) despite no difference in the recorded number of feet ambulated in the hospital. At a mean clinical follow-up of 16 weeks, there was no difference in the rate of return to baseline ambulatory status between groups (P=.07). The overall rates of major and minor complications for all patients were 23% and 26%, respectively, with no statistically significant differences between groups. The overall dislocation rate of all patients was found to be 3%. All dislocations were observed in group 2. Larger prospective studies are needed to further define the benefits of the direct anterior approach in this patient population.
Surgical Treatment of Flail Chest and Rib Fractures Fowler, T Ty; Taylor, Benjamin C; Bellino, Michael J ...
Journal of the American Academy of Orthopaedic Surgeons,
2014-December, Letnik:
22, Številka:
12
Journal Article
Recenzirano
Despite significant advances in critical care management, flail chest remains a clinically significant finding, with a mortality rate of up to 33%. Nonsurgical management is associated with prolonged ...ventilator support, pneumonia, respiratory difficulties, and lengthy stays in the intensive care unit, as well as chronic pain from nonunion and malunion of the bony thorax. Treatment with aggressive pulmonary toilet, ventilator support, and different modalities of pain control remains the benchmark of care. However, several recent randomized controlled studies of surgical intervention of flail chest have demonstrated an improvement in the number of ventilator days, intensive care unit and hospital stays, incidence of pneumonia, and respiratory function and hospital costs, as well as faster return to work. The success of these surgical constructs compared with those of historical attempts at open fixation is largely the result of modern plating technology and improvement in surgical approaches. Clinical evidence continues to grow regarding proper indications and techniques for surgical stabilization of flail chest.
Operative management of thoracic injuries is an increasingly accepted technique, with multiple reports of improved patient outcomes as compared with nonoperative treatment. Despite the evolving ...support of rib fracture fixation, descriptions of surgical approaches and tactics remain limited. We present this information to allow surgeons to begin or improve treatment of these injuries. In addition, we present the initial treatment results of a series of 21 patients treated with the approaches described within.
Fracture fixation of the medial malleolus in rotationally unstable ankle fractures typically results in healing with current fixation methods. However, when failure occurs, pullout of the screws from ...tension, compression, and rotational forces is predictable. We sought to biomechanically test a relatively new technique of bicortical screw fixation for medial malleoli fractures. Also, the AO group recommends tension-band fixation of small avulsion type fractures of the medial malleolus that are unacceptable for screw fixation. A well-documented complication of this technique is prominent symptomatic implants and secondary surgery for implant removal. Replacing stainless steel 18-gauge wire with FiberWire suture could theoretically decrease symptomatic implants. Therefore, a second goal was to biomechanically compare these 2 tension-band constructs. Using a tibial Sawbones model, 2 bicortical screws were compared with 2 unicortical cancellous screws on a servohydraulic test frame in offset axial, transverse, and tension loading. Second, tension-band fixation using stainless steel wire was compared with FiberWire under tensile loads. Bicortical screw fixation was statistically the stiffest construct under tension loading conditions compared to unicortical screw fixation and tension-band techniques with FiberWire or stainless steel wire. In fact, unicortical screw fixation had only 10% of the stiffness as demonstrated in the bicortical technique. In a direct comparison, tension-band fixation using stainless steel wire was statistically stiffer than the FiberWire construct.
Although biomechanical and clinical evidence exists regarding smaller compression screws, biomechanical data regarding the larger headless screws are not currently available. Headed and headless ...6.5-mm cannulated compression screws were examined, with analysis of interfragmentary compression, insertion torque, and resistance of the construct to a shear force. No significant differences were seen between the maximum insertion torque of the headless or headed screws. Maximum and steady-state compression forces were also not significantly different between groups. Countersinking the headless model 2 mm led to a 77.01% decrease in steady-state compression levels. Shear testing did not reveal any significant differences in peak load at ultimate failure, specimen stiffness, or final block displacement, although a trend to increased peak load and stiffness was seen with the headless specimens.
