RESUMEN
BACKGROUND: Ankle fractures associated with syndesmotic injury have a poorer prognosis than those without such an injury. Anatomic reduction of the distal tibiofibular joint restores joint congruency and minimizes contact pressures, yet operative fixation of syndesmotic ankle injuries is frequently complicated by malreduction of the syndesmosis. Current methods of assessing reduction have been shown to be inadequate. As such, additional methods to judge the accuracy of syndesmotic reduction are required. QUESTIONS/PURPOSES: The purposes of our study were (1) to determine the anatomic axis of the syndesmosis, or the trans-syndesmotic angle (TSA), and (2) to describe the intraoperative fluoroscopic appearance of syndesmotic clamp reduction oriented along the anatomic syndesmotic angle. METHODS: Computed tomography (CT) scans of 45 uninjured adult ankles were analyzed to measure the TSA, defined as the angle between the plane of a lateral ankle radiograph and a line drawn perpendicular to the fibular incisura. Three-dimensional reconstructions of CT scans were then used to demonstrate clamp placement collinear with the TSA as would be seen on an intraoperative lateral ankle radiograph. RESULTS: The average TSA measured 21±5° anterior to the plane of a lateral radiograph. When a simulated reduction clamp tine was placed on the fibular ridge and the clamp oriented along the TSA, the medial tine, as seen on a lateral radiograph, was within the anterior one-third of the tibia 93% of the time. It was, on average, 23±7% of the distance from the anterior to the posterior tibial cortex, with tine placement occurring in this range in 73% of ankles. The medial tine rested 53±17% of the distance between the anterior cortices of the tibia and fibula, with 71% of tines placed in this range. CONCLUSIONS: Reduction clamp placement oriented along the TSA has a predictable appearance on lateral ankle imaging and can guide clamp positioning during syndesmotic reduction. With one tine placed on the fibular ridge, placing the medial clamp tine in the anterior third of the tibia, or halfway between the anterior cortices of the tibia and fibula is the most accurate position for reduction in line with the TSA. LEVEL OF EVIDENCE: 2 (Retrospective diagnostic).
Asunto(s)
Fracturas de Tobillo/cirugía , Traumatismos del Tobillo/prevención & control , Articulación del Tobillo/fisiopatología , Fijación Interna de Fracturas/métodos , Reducción Abierta/métodos , Tomografía Computarizada por Rayos X , Adulto , Anciano , Anciano de 80 o más Años , Fracturas de Tobillo/complicaciones , Fracturas de Tobillo/diagnóstico por imagen , Fracturas de Tobillo/fisiopatología , Traumatismos del Tobillo/diagnóstico por imagen , Traumatismos del Tobillo/etiología , Traumatismos del Tobillo/fisiopatología , Articulación del Tobillo/diagnóstico por imagen , Femenino , Fijación Interna de Fracturas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Reducción Abierta/efectos adversos , Estudios Retrospectivos , Rotación , Instrumentos Quirúrgicos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Displaced tibial shaft fractures are common in adolescent patients, yet there is no standardized management strategy. We compared surgical fixation and closed reduction and casting (CRC) of these fractures to assess treatment outcomes and determine predictors of failure. METHODS: We retrospectively reviewed all patients aged 12 to 18 who presented with a displaced tibial shaft fracture that required reduction over an 8-year period. Exclusion criteria included open fractures and lack of follow-up to radiographic union or to 6 months from the index procedure. Fractures were initially treated based on surgeon preference either with CRC or with immediate intramedullary nailing. Seventy-four patients met inclusion criteria: 57 were initially managed with CRC and 17 with operative fixation. Radiographic healing was defined as bridging of 3 cortices and adequacy of final alignment was defined as <5 degrees of angular deformity in both planes and <1.0 cm of shortening. Outcomes were analyzed both on intent-to-treat principles and by definitive treatment method. RESULTS: Although all fractures in both groups achieved bony healing, 23 of the 57 patients who underwent CRC failed closed treatment and ultimately required surgery (40.3%). Multivariate analysis of patient and fracture characteristics revealed fracture displacement of >20% (odds ratio=7.8, P<0.05) and the presence of a fibula fracture (odds ratio=5.06, P=0.05) as predictors of closed treatment failure. Patients ultimately managed with intramedullary nailing trended toward increased adequacy of final alignment (92.5% vs. 72.4%, P=0.10) but required longer hospitalization (5.4 vs. 1.9 d, P<0.001) and had a higher incidence of anterior knee pain (20% vs. 0%, P<0.01). There was no significant difference between groups with respect to time to healing. CONCLUSIONS: Treatment outcomes between initial operative fixation and closed reduction of displaced tibia fractures in adolescents are similar, but patients must be counseled about the high failure rates with CRC. Predictors of CRC failure include initial fracture displacement and the presence of a fibula fracture-these variables should be considered when selecting a treatment method. LEVEL OF EVIDENCE: Level III-Therapeutic study.
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Fijación Intramedular de Fracturas , Tibia/diagnóstico por imagen , Adolescente , Niño , Tratamiento Conservador/métodos , Femenino , Fijación Intramedular de Fracturas/efectos adversos , Fijación Intramedular de Fracturas/métodos , Curación de Fractura , Fracturas Mal Unidas/diagnóstico , Fracturas Mal Unidas/cirugía , Humanos , Masculino , Análisis Multivariante , Selección de Paciente , Radiografía/métodos , Estudios Retrospectivos , Fracturas de la Tibia/diagnóstico , Fracturas de la Tibia/cirugía , Resultado del TratamientoRESUMEN
Traction pins are an essential tool in the orthopedic surgeon's armamentarium. Historically a definitive treatment for some fractures, they are mainly used as a temporizing measure today. Despite their frequent use and relative simplicity, traction pins can have complications, many of which can be subtle and easily overlooked. Here we report on an unusual complication that was difficult to diagnose but caused significant morbidity before being diagnosed and treated. Pseudoaneurysms can cause a range of symptoms and usually present as a painful, tender, pulsatile mass, but in this instance the popliteal artery pseudoaneurysm presented as chronic, painful lower extremity swelling. With diagnosis and treatment, the patient's symptoms resolved. We discuss the complications associated with traction-pin placement.
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Aneurisma Falso/diagnóstico , Clavos Ortopédicos/efectos adversos , Cabeza Femoral/lesiones , Fracturas de Cadera/terapia , Arteria Poplítea/lesiones , Tracción/efectos adversos , Aneurisma Falso/etiología , Aneurisma Falso/terapia , Embolización Terapéutica , Femenino , Luxación de la Cadera/terapia , Humanos , Tibia/cirugía , Tracción/instrumentación , Adulto JovenRESUMEN
OBJECTIVES: Nonunion after locked bridge plating of comminuted distal femur fractures is not uncommon. "Dynamic" locked plating may create an improved mechanical environment, thereby achieving higher union rates than standard locked plating constructs. SETTING: Academic Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Twenty-eight patients with comminuted supracondylar femur fractures treated with either dynamic or standard locked plating. INTERVENTION: Dynamic plating was achieved using an overdrilling technique of the near cortex to allow for a 0.5-mm "halo" around the screw shaft at the near cortex. Standard locked plating was done based on manufacturer's suggested technique. The patients treated with dynamic plating were matched 1:1 with those treated with standard locked plating based on OTA classification and working length. MAIN OUTCOME MEASUREMENTS: Three blinded observers made callus measurements on 6-week radiographs using a 4-point ordinal scale. The results were analyzed using a 2-tailed t test and 2-way intraclass correlations. RESULTS: The dynamic plating group had significantly greater callus (2.0; SD, 0.7) compared with the control group (1.3: SD, 0.8, P = 0.048) with substantial agreement amongst observers in both consistency (0.724) and absolute score (0.734). With dynamic plating group, 1 patient failed to unite, versus three in the control group (P = 0.59). The dynamic group had a mean change in coronal plane alignment of 0.5 degrees (SD, 2.6) compared with 0.6 (SD, 3.0) for the control group (P = 0.9) without fixation failure in either group. CONCLUSIONS: Overdrilling the near cortex in metaphyseal bridge plating can be adapted to standard implants to create a dynamic construct and increase axial motion. This technique seems to be safe and leads to increased callus formation, which may decrease nonunion rates seen with standard locked plating. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Placas Óseas , Tornillos Óseos , Fracturas del Fémur/diagnóstico por imagen , Fracturas del Fémur/cirugía , Traumatismos de la Rodilla/diagnóstico por imagen , Traumatismos de la Rodilla/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Falla de Equipo , Femenino , Fijación Interna de Fracturas/instrumentación , Fijación Interna de Fracturas/métodos , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Radiografía , Resultado del TratamientoRESUMEN
OBJECTIVES: Total elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures. METHODS: Seven patients (mean 74 years; range 56-86 years) with open (two Grade I and five Grade 2) distal humerus fractures (OTA 13C) who were treated between 2001 and 2007 with a standard staged protocol that included TEA were studied. Baseline Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained during the initial hospitalization, and the 6- and 12-month follow-up visits. Elbow range of motion (ROM) measurements were obtained at each follow-up visit. RESULTS: Follow-up averaged 43 (range 4-138) months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with joint contracture, one olecranon fracture unrelated to the TEA, and two loose humeral stems. The average final ROM was from 21° (range 5-30°) to 113° flexion (range 90-130°). DASH scores averaged 25 at pre-injury baseline and 48 at the most recent follow-up visits. CONCLUSIONS: TEA has become a mainstream option for the treatment of distal humerus fractures which are on occasion open. There is hesitation in using arthroplasty in an open fracture setting due to a potential increased infection risk. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus.
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Artroplastia de Reemplazo de Codo , Desbridamiento/métodos , Articulación del Codo/cirugía , Fijación Interna de Fracturas/métodos , Fracturas Abiertas/cirugía , Fracturas del Húmero/cirugía , Fracturas Intraarticulares/cirugía , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Codo/métodos , Articulación del Codo/fisiopatología , Estudios de Seguimiento , Fracturas Abiertas/fisiopatología , Humanos , Fracturas del Húmero/fisiopatología , Fracturas Intraarticulares/fisiopatología , Persona de Mediana Edad , Rango del Movimiento Articular , Resultado del Tratamiento , Lesiones de CodoRESUMEN
BACKGROUND: Butyric acid (BA) has been shown to be angiogenic and to enhance transcriptional activity in tissue. These properties of BA have the potential to augment biological healing of a repaired tendon. PURPOSE: To evaluate this possibility both biomechanically and histologically in an animal tendon repair model. STUDY DESIGN: Controlled laboratory study. METHODS: A rabbit Achilles tendon healing model was used to evaluate the biomechanical strength and histological properties at 6 and 12 weeks after repair. Unilateral tendon defects were created in the middle bundle of the Achilles tendon of each rabbit, which were repaired equivalently with either Ultrabraid BA-impregnated sutures or control Ultrabraid sutures. RESULTS: After 6 weeks, BA-impregnated suture repairs had a significantly increased (P < .0001) Young's modulus and ultimate tensile strength relative to the control suture repairs. At 12 weeks, no statistical difference was observed between these measures. The histological data at 6 weeks demonstrated significantly increased (P < .005) vessel density within 0.25 mm of the repair suture in the BA-impregnated group. There was also an associated 42% increase in the local number of myofibroblasts in the BA samples relative to the controls at this time. By 12 weeks, these differences were not observed. CONCLUSION: Tendons repaired with BA-impregnated sutures demonstrated improved biomechanical properties at 6 weeks relative to control sutures, suggesting a neoangiogenic mechanism of enhanced healing through an increased myofibroblast presence. CLINICAL RELEVANCE: These findings demonstrate that a relatively simple alteration of suture material may augment early tendon healing to create a stronger repair construct during this time.
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Tendón Calcáneo/efectos de los fármacos , Ácido Butírico/farmacología , Materiales Biocompatibles Revestidos , Neovascularización Fisiológica/efectos de los fármacos , Suturas , Cicatrización de Heridas/efectos de los fármacos , Tendón Calcáneo/fisiología , Animales , Fenómenos Biomecánicos , Modelos Animales , Conejos , Cicatrización de Heridas/fisiologíaRESUMEN
After acute tendon injury, rapid mobilization prevents adhesions and improves the ultimate strength of the repair. Radiofrequency (RF) ablation is proposed to enhance angiogenesis in the early stages of healing. The mechanism and effect of RF have not yet been described in an animal model of tendon injury. To investigate the biomechanical effect of bipolar RF on acute injury in a rabbit model of partial Achilles tendon transection and suture repair, RF-treated tendon repairs were compared to untreated tendons. Cross-sectional area, Young's modulus, and ultimate tensile strength were determined. At 6 and 12 weeks after repair, RF-treated tendons had significant increases in cross-sectional area (P<.001; P< .0001) and ultimate tensile strength (P<.0001; P<.01). Young modulus of RF-treated tendons was increased at 6 weeks but not at 12 weeks (P<.01) Compared with untreated tendons, RF-treated tendons showed faster return to mechanical integrity. This may allow earlier rehabilitation.
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Tendón Calcáneo/fisiopatología , Tratamiento de Radiofrecuencia Pulsada , Traumatismos de los Tendones/terapia , Tendón Calcáneo/lesiones , Animales , Fenómenos Biomecánicos , Neovascularización Fisiológica , Conejos , Traumatismos de los Tendones/fisiopatología , Traumatismos de los Tendones/cirugía , Cicatrización de HeridasRESUMEN
BACKGROUND: Osteochondral allografts are an increasingly popular treatment for the repair of articular cartilage lesions. Current tissue bank protocols require bacteriological testing that takes from 21 to 28 days to process. During this time, tumor necrosis factor-alpha (TNF-α, a proapoptotic cytokine) is upregulated, resulting in loss of chondrocyte viability. To date, etanercept (a cytokine inhibitor) has not been studied in the current storage paradigm with the intention of preserving cell viability. PURPOSE: This study was undertaken to assess whether the addition of etanercept can improve the chondrocyte viability ofosteochondral allograft during storage. STUDY DESIGN: Controlled laboratory study. METHODS: Osteochondral allografts were harvested from 8 Boer goat femurs and placed into storage media and stored at 4°C for 28 days. The experimental group was supplemented with 10 µg/mL of etanercept. After storage, cell viability was assessed by live/dead staining and confocal microscopy. Specimens were also analyzed histologically and underwent histomorphologic analysis. TNF-α expression was measured with semiquantitative polymerase chain reaction. RESULTS: At 28 days, the percentage viability of the superficial zone in etanercept-treated allografts was maintained at significantly higher levels than those measured in the untreated group (69.3 ± 9.4 compared with 47.8 ± 19.1, P = .01). No difference was found histologically between the etanercept and the untreated group (ie, safranin O staining for glycosaminoglycan expression). Histomorphologic assessment showed no difference in indentation stiffness or roughness between groups. TNF-α expression was significantly decreased in the etanercept group compared to the untreated group. CONCLUSION: Etanercept was able to maintain cell viability of osteochondral allografts significantly better than the current storage paradigm after 28 days of storage. CLINICAL RELEVANCE: Maintaining the viability of the superficial zone will benefit outcomes by facilitating joint articulation via improved lubrication. Additionally, maintaining the cellular viability for increased periods of time may allow a greater window of time in which a suitable recipient may be found.