Arthroscopic removal of bullet fragments from the subtalar joint.

A case of arthroscopic removal of a bullet fragment from the subtalar joint and the calcaneus is presented. The bullet fragments impinged on the fibula, limiting eversion and causing pain. The fragments were removed both arthroscopically and through open incision. The patient noted complete relief of pain and improved range of motion within 1 week, and complete recovery soon thereafter.     

Treatment of Two-Part Proximal Humerus Fractures: Intramedullary Nail Compared to Locked Plating

Background

Two-part proximal humerus fractures are common orthopedic injuries for which surgical intervention is often indicated. Choosing a fixation device remains a topic of debate.

Purpose

The purpose of this study is to compare two methods of fixation for two-part proximal humerus fractures, locking plate (LP) with screws versus intramedullary nailing (IMN), with respect to alignment, healing, patient outcomes, and complications. To our knowledge, a direct comparison of these two devices in treating two-part proximal humerus fractures has never before been studied. We hope that our results will help surgeons assess the utility of LP versus IMN.

Methods

A retrospective chart review was performed on 24 cases of displaced two-part surgical neck fractures of the humerus. Twelve shoulders were treated using IMN fixation and 12 others were fixated with LP. Data collected included sociodemographic, operative details, and postoperative care and function.

Results

Radiographic comparison of fixation demonstrated an average neck-shaft angle of 124° and 120° in the IMN group and LP group, respectively. Adjusted postoperative 6-month follow-up range of motion was 134° of forward elevation in the IMN group and 141 in the LP group. The differences in range of motion and in complication rates were not found to be significant.

Conclusions

Our results suggest that either LP fixation or IMN fixation for a two-part proximal humerus fracture provides acceptable fixation and results in a similar range of shoulder motion. Although complication rates were low and insignificant between the two groups, a trend toward increased complications in the IMN group is noted.     

Surgical simulation in orthopaedic skills training

Mastering rapidly evolving orthopaedic surgical techniques requires a lengthy period of training. Current work-hour restrictions and cost pressures force trainees to face the challenge of acquiring more complex surgical skills in a shorter amount of time. As a result, alternative methods to improve the surgical skills of orthopaedic trainees outside the operating room have been developed. These methods include hands-on training in a laboratory setting using synthetic bones or cadaver models as well as software tools and computerized simulators that enable trainees to plan and simulate orthopaedic operations in a three-dimensional virtual environment. Laboratory-based training offers potential benefits in the development of basic surgical skills, such as using surgical tools and implants appropriately, achieving competency in procedures that have a steep learning curve, and assessing already acquired skills while minimizing concerns for patient safety, operating room time, and financial constraints. Current evidence supporting the educational advantages of surgical simulation in orthopaedic skills training is limited. Despite this, positive effects on the overall education of orthopaedic residents, and on maintaining the proficiency of practicing orthopaedic surgeons, are anticipated.     

Supination external rotation ankle fractures: A simpler pattern with better outcomes

Background:

Rotational injuries are the most common and usually classified as per the Lauge Hansen classification; with the most common subgroup being the supination external rotation (SER) mechanism. Isolated fractures of the distal fibula (SE2) without associated ligamentous injury are usually treated with a splint or brace and the patient may be allowed to weight bear as tolerated. This study reports the functional outcomes following a stable, low energy, rotational ankle fracture supination external rotation (SER2) when compared to unstable SER4 fractures treated operatively.

Materials and Methods:

64 patients who were diagnosed and treated nonoperatively for a stable SER2 ankle fracture were followed prospectively. In the comparison group, 93 operatively treated fibular fractures were extracted from a prospectively collected database and evaluated comparison. Baseline characteristics obtained by trained interviewers at the time of injury included: Patient demographics, short form-36, short musculoskeletal functional assessment (SMFA) and American Orthopedic Foot and Ankle Society (AOFAS) questionnaires. Patients were followed at 3, 6 and 12 months postsurgery. Additional information obtained at each followup point included any complications or evidence on fracture healing. Data were analyzed by the Student''s t-test and theFisher''s Exact Test to compare demographic and functional outcomes between the two cohorts. P < 0.05 was considered to be significant.

Results:

The average of patients’ age in the stable fracture cohort was 43 versus 45 in the SER4 group. Nearly 64% of the patient population was female when compared with 37% in the operative group. In the SER2 by 6 months all patients had returned to baseline functional status. There were 18 delayed unions (all healed by 6 months). Based on the functional outcome scores all patients had returned to preoperative level. In comparison, SE4 patients had less functional recovery at 3 and 6 months (P < 0.05) based on the SMFA scores and at 3, 6 and 12 months based on the AOFAS (P < 0.001) scores. There was no difference in pain levels between the two groups at all time points. There were three nonunions in the SE4 group and six delayed unions.

Conclusions:

An SER2 ankle fracture is a relatively benign injury with functional limitations resolving by 3 months while the need for surgical fixation in SER ankle fractures appears to affect lower extremity function to a greater degree for a longer time period. Patients should be counseled as to these expected outcomes.     

Operative repair of anterior instability and rotator cuff tears in athletes

Rotator cuff tears in individuals under age 40 are uncommon; especially rare is the younger patient with acombination of full thickness rotator cuff tear and a Bankart lesion. Operative management of this challenging patient must provide for a “stable” repair of both lesions to allow for optimal rehabilitation. Our surgical preference includes arthroscopic subacromial decompression, rotator cuff repair, and a formal open capsulolabral reconstruction. Based on surgeon preference and skill, a mini-open or arthroscopic repair can be performed. This approach allows for a more aggressive rehabilitation to facilitate a full return to activity levels.     

Regional anesthesia for nonunion surgery with iliac crest bone grafting results in an increase in same day discharge

European Journal of Orthopaedic Surgery & Traumatology - The purpose of this study was to evaluate the outcomes of fracture nonunion repair with autogenous iliac crest bone graft (ICBG) under...     

Split depression tibial plateau fractures: a biomechanical study

OBJECTIVE: To determine the biomechanical characteristics of four different fixation constructs for split depression fractures of the lateral tibial plateau (OTA classification 41B3.1). DESIGN: Laboratory investigation using a cadaveric simulated split depression tibial plateau fracture model. SETTING: Split depression tibial plateau fractures were created, reduced, and instrumented in a matched pair design. Specimens were tested for stiffness using a materials testing machine. INTERVENTION: Tibias were instrumented with an L-buttress plate, four 3.5-millimeter subchondral raft screws with an antiglide plate, an L-buttress plate with cancellous allograft, or four 3.5-millimeter subchondral raft screws placed through a periarticular plate. MAIN OUTCOME MEASUREMENTS: Vertical subsidence of the lateral tibial plateau was measured for the entire construct and for the local depression. The relative medial and lateral condylar tilt with central loading was also measured. RESULTS: There was no significant difference between the four fixation methods for overall longitudinal stiffness of the proximal tibial fracture fixation construct (range, 2,026 to 2,666 newtons per millimeter). The local depression stiffness for the raft-periarticular plate and raft-antiglide plate were 425 newtons per millimeter and 342 newtons per millimeter, respectively, versus 243 newtons per millimeter and 210 newtons per millimeter for the two large fragment buttress constructs. There was no significant difference between the local depression stiffness for the two raft constructs. There was no significant difference between the local depression stiffness for the two buttress plate constructs. Local depression stiffness was found to be significantly greater for the raft-periarticular plate construct when compared with the large fragment buttress plate construct without bone graft (p = 0.0314). Condylar tilt data showed a significant difference between the medial tilt observed in the prefracture specimen and the lateral tilt observed after fixation (p less-than-or-equal 0.017) for all constructs. CONCLUSIONS: There was no significant difference in the overall construct stiffness between the four fixation constructs. Fixation constructs with a raft of subchondral screws were more resistant to local depression loads. This supports the use of a raft construct when a central depression is a significant component of the overall fracture pattern. Condylar tilt data showed a persistent weakness in the postfixation lateral plateau regardless of fixation construct when compared with the intact specimen. This supports the current clinical practice of delayed weight-bearing for ten to twelve weeks.     

Fat embolism syndrome

Fat embolization and the clinical syndrome associated with this pathology are poorly understood complications of skeletal trauma. Fat embolization is characterized by release of fat droplets into systemic circulation after a traumatic event. Fat embolism syndrome (FES) is an infrequent clinical consequence of fat embolization. Classically, FES presents with the triad of pulmonary distress, mental status changes, and petechial rash 24 to 48 hours after pelvic or long-bone fracture. FES incidence increases with the number of fractures sustained by an individual. Many clinicians believe that FES incidence has decreased over the past several decades secondary to advances in resuscitative measures. FES pathophysiology remains unclear. Current theories involve common mechanical and biochemical mechanisms that explain how fat emboli manifest as FES. Much controversy surrounds the question of whether there is a causal relation between intramedullary nailing and FES onset. Clinical diagnosis is essential, as laboratory and radiographic findings are nonspecific. Early supportive pulmonary therapy and other resuscitative measures may halt the pathophysiologic cascade and prevent clinical deterioration. Fortunately, if FES is diagnosed early, and pulmonary and cardiac functions are optimally supported, prognosis is very good.