RESUMEN

Background Proximal scaphoid fractures display high nonunion rates and increased revision cases. Waist fracture fixation involves maximizing screw length within the cortex; however, the optimal screw length for proximal scaphoid fractures remains unknown. Purpose The main purpose of this article is to compare stiffness and ultimate load for proximal scaphoid fracture fixation of various headless compression screw lengths. Methods Eighteen scaphoids underwent an osteotomy simulating a 7 mm oblique proximal fracture. Screws of three lengths (10, 18, and 24 mm) were randomly assigned for fixation. Each specimen underwent cyclic loading with stiffness calculated during the last loading cycle. Specimens that withstood cyclic loading were loaded to failure. Results No significant difference in stiffness between screw lengths was found. Ultimate load was significantly impacted by the screw length. A significant difference in ultimate load between a 10 and 24 mm screw was found; however, no significant difference occurred in ultimate load between an 18 and 24 mm screw. Conclusions No significant difference in stiffness between all groups could be due to similarities in purchase in the proximal aspect. The 10 mm screw withstanding less ultimate load compared to the 24 mm screw could be due to the 10 mm screw gaining less purchase on either side of the fracture site compared to the 24 mm screw. Lack of significant difference in ultimate load between the 18 and 24 mm screw could be occurring because the fracture site is closer to the 18 mm screw midpoint, as distal threads are engaged closer to the fracture. Clinical Relevance Maximizing screw length may not provide superior fixation biomechanically compared with fixation utilizing a 6 mm shorter screw for proximal scaphoid fractures.

RESUMEN

Background: The term black cloud for a surgeon is generally used to describe someone who is unusually busy compared with his or her counterparts, and it is a superstition that tends to pervade the medical world. The purpose of this study is to investigate whether black clouds exist in hand surgery. Methods: We examined one academic year's worth of hand surgery-specific call at a level I trauma center and tabulated the number of hand-related patient transfers and add-on cases per surgeon. Each surgeon was given a black cloud rating by the fellows who were in training that year. Correlations were made between the black cloud rating and the surgeons' call volume. Results: There were 12 surgeons who shared 365 days of hand call, and 5 of them are hand surgery fellowship trained. Those 5 surgeons tended to be busier on their call days, with more cases added on overnight and the next day, and also had worse black cloud ratings than the 7 non-hand fellowship trained surgeons. Conclusions: In regard to hand surgery, while true emergencies occur and require emergent intervention, how busy hand surgeons may be during call may be influenced by a variety of factors not related to their patients' problems but rather their daily schedules, their hospitals' ability to facilitate add-on cases, and their rapport with their fellow surgeons to share case loads.

Asunto(s)

Mano/cirugía , Ortopedia/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Cirujanos/estadística & datos numéricos , Carga de Trabajo/estadística & datos numéricos , Femenino , Humanos , Masculino , Centros Traumatológicos/provisión & distribución

RESUMEN

BACKGROUND: The objective of this study was to determine the interfragmentary compression forces generated in a foam model as a function of headless compression screw type (fully threaded and central threadless) and fracture location. METHODS: Eighty-eight polyurethane foam models were fixed across a simulated transverse fracture with either a fully threaded screw or a central threadless screw. The location of the transverse fracture varied along the length of the foam model in 2 mm increments for 11 fracture locations. The force generated at the fracture site upon fixation was utilized to determine the interfragmentary compression. Interfragmentary compression was compared using a paired t test and 2-way analysis of variance, with significance set at P < .05. RESULTS: Interfragmentary compression was found to vary based on fracture location and screw type. The fully threaded screw generated significantly greater compression for fracture locations at 12 mm and 18 mm from the top edge of the foam model, while the central threadless screw generated significantly greater compression for fractures located 2 mm from the top edge of the foam model. CONCLUSIONS: The central threadless screw and the fully threaded screw had different fracture locations where maximum compression force occurred. The fully threaded screw generated greater compression force toward the screw center due to greater thread purchase. However, the central threadless screw generated greater compression at the most proximal fracture location due to its greater thread pitch toward the screw head. Maximizing interfragmentary compression may aid in reducing nonunion rates associated with the internal fixation of proximal scaphoid fractures.

Asunto(s)

Fenómenos Biomecánicos/fisiología , Tornillos Óseos/efectos adversos , Fracturas Óseas/cirugía , Presión/efectos adversos , Hueso Escafoides/patología , Diseño de Equipo , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/métodos , Fracturas por Compresión , Humanos , Hueso Escafoides/fisiopatología

RESUMEN

BACKGROUND: Since the start of the conflict in the Middle East in 2001, military orthopedic surgeons have faced complex orthopedic injuries including high-energy soft tissue wounds, traumatic amputations, and open fractures. Although orthopedic surgeons are well trained in the management of osseous injuries, the treatment of soft tissue injuries can be technically challenging and unfamiliar. Early washout, debridement of devitalized tissue, external fixation of bony injuries, and antibiotic therapy remain the foundation of early wound management. However, these unique extremity injuries have no standard plan of care, and definitive treatment options continue to evolve. The following report highlights the typical cases seen in the wartime setting and offers possible solutions for the associated soft tissue injuries. METHODS: A single orthopedic surgeon at a Role 3 combat support hospital performed all cases in this series. This study is a report of the cases that the orthopedic surgeon encountered while deployed and the various techniques that can be used to manage the complex wounds seen in a deployed setting. FINDINGS: Twelve patients were included in this report and the data are shown. Of the 12 patients, 6 were injured by an improvised explosive device (IED), 4 were injured by a high-velocity gunshot wound (HVGSW), 1 was injured by a gunshot wound (GSW), and 1 was injured in an auto versus pedestrian motor vehicle crash. The wound sizes ranged from 10 to 300 cm2. All patients required more than one irrigation and debridement before wound closure. There was a successful outcome in 11 of the 12 patients. The only patient without a known successful outcome was lost to follow up. Six patients were treated with split thickness skin graft (STSG) alone. Four patients were treated with STSG plus an additional means of coverage. One patient was treated with a random flap and one patient was treated with a full thickness skin graft. Integra was used in two of the patients. Each of the patients in whom integra was used had exposed bone and had a successful outcome with respect to tissue coverage. DISCUSSION: This study details different soft tissue coverage techniques that must be learned and possibly employed by the deployed surgeon. Limitations of this study include its retrospective nature and the selected sampling of cases. At initial presentation, the management of war wounds secondary to high-velocity gunshot wounds and improvised explosive devices can be quite daunting. Adhering to firm surgical principles of thorough and meticulous debridement is the foundation of later soft tissue reconstructive options. Once the tissue is deemed clear of infection and contamination, there are myriad treatment options utilizing flaps, synthetic materials, and skin grafting. These are relatively straightforward techniques that the general orthopedic surgeon can utilize while deployed in a combat setting. In the end, it is critical for deployed surgeons to learn multiple techniques to provide definitive soft tissue coverage in a wartime theater.

Asunto(s)

Procedimientos Ortopédicos/instrumentación , Traumatismos de los Tejidos Blandos/cirugía , Adulto , Campaña Afgana 2001- , Afganistán , Femenino , Fracturas Abiertas/complicaciones , Fracturas Abiertas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Personal Militar , Procedimientos Ortopédicos/métodos , Cirujanos Ortopédicos/tendencias , Trasplante de Piel/métodos , Trasplante de Piel/tendencias , Traumatismos de los Tejidos Blandos/complicaciones , Heridas y Lesiones/cirugía

RESUMEN

The use of intraoperative fluoroscopy has become a routine and useful adjunct within orthopaedic surgery. However, the fluoroscopy machine may become an additional source of contamination in the operating room, particularly when maneuvering from the anterior-posterior position to the lateral position. Consequently, draping techniques were developed to maintain sterility of the operative field and surgeon. Despite a variety of methods, no studies exist to compare the sterility of these techniques specifically when the fluoroscopy machine is in the lateral imaging position. We evaluated the sterility of 3 c-arm draping techniques in a simulated operative environment. The 3 techniques consisted of a traditional 3-quarter sterile sheet attached to the side of the operative table, a modified clip-drape method, and a commercially available sterile pouch. Our study demonstrated that the traditional method poses a high risk for sterile field contamination, whereas the modified clip-drape method and commercially available sterile pouch kept floor contamination furthest from the surgical field. With the current data, we urge surgeons to use modified techniques rather than the traditional draping method.

Asunto(s)

Fluoroscopía/efectos adversos , Control de Infecciones/métodos , Procedimientos Ortopédicos/efectos adversos , Procedimientos Ortopédicos/métodos , Paños Quirúrgicos , Infección de la Herida Quirúrgica/prevención & control , Contaminación de Equipos , Humanos , Cuidados Intraoperatorios , Quirófanos/normas , Procedimientos Ortopédicos/instrumentación , Procedimientos Ortopédicos/normas , Vestimenta Quirúrgica/microbiología , Paños Quirúrgicos/microbiología , Infección de la Herida Quirúrgica/etiología

RESUMEN

INTRODUCTION: There is a paucity of information on management of forearm fractures through pre-existing ischemic contractures. The prevention of a Volkmann's contracture in forearm compartment syndrome requires vigilant clinical evaluation and emergent fasciotomy, but many of the patients who develop these contractures often do so as a result of delayed presentation due to substance abuse and intoxication. This case describes the first report and management of a severely displaced both bone (BB) forearm fracture through a chronic forearm Volkmann's contracture. CASE REPORT: A 39 year old female presented with an acute both bone forearm fracture in the setting of a Volkmann's contracture. Although very limited in use, the arm was functional for holding objects and was determined to be important in her activities of daily living. The surgical management involved open reduction internal fixation with radial and ulnar shortening osteotomies to restore cortical alignment secondary to the extensive overlying soft tissue contractures. CONCLUSION: Restoration of the radial bow and other standard principles of open reduction and internal fixation of BB fractures may not be as important as obtaining fracture union in patients with these complicated injuries due to the pre-existing functional limitations of the limb. The soft tissue envelope in a contracted forearm is commonly fibrotic and provides an abnormal fracture healing environment. Careful attention to osseous and soft tissue healing in the postoperative period is recommended. This report details the first case, technical difficulties, and subsequent management of a BB fracture in the setting of subsequent management of a both bone fracture in the setting of a chronic Volkmann's contracture.

RESUMEN

CASE: This case involved a sixty-two-year-old male patient with bilateral femoral neck fractures that occurred six months apart in the setting of bilateral lower-extremity amputation. Hemiarthroplasty was performed at each presentation, with the use of a standard femoral stem on the right side and a short stem on the left. At the time of follow-up, the patient had returned to his preoperative ambulatory status. CONCLUSION: This case report illustrates successful bilateral hemiarthroplasty in a patient who had previously undergone bilateral lower-extremity amputation, with use of an implant with a short stem for the limb with above-knee amputation.

RESUMEN

We conducted a study to identify complications associated with open treatment of ankle fractures in patients who tested positive for illicit drugs on urine drug screen (UDS). We hypothesized that patients who had a history of positive UDS and underwent open reduction and internal fixation of an ankle fracture would have a higher incidence of major and minor complications. We retrospectively reviewed the cases of 142 patients who had surgical stabilization of an ankle fracture during a 3-year period. Patients with a history of positive UDS were compared with matched controls with negative UDS. Outcomes measures included nonunion, malunion, and superficial or deep infection. Fisher exact test, Wilcoxon rank sum test, and univariate logistic regression were used to determine statistical significance. There were no significant differences in age, sex, fracture type, incidence of diabetes, or incidence of open fracture between the groups. Incidence of nonunion was higher in patients with positive UDS (P = .01), as was incidence of deep infection (P = .05). Incidence of pooled major complications was also higher in positive UDS patients (P = .03). Patients with a history of illicit drug use, as evidenced by positive UDS, are at increased risk for perioperative complications during treatment for ankle fracture.

Asunto(s)

Fracturas de Tobillo/cirugía , Fijación Interna de Fracturas/efectos adversos , Drogas Ilícitas/orina , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Adulto , Fracturas de Tobillo/orina , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Detección de Abuso de Sustancias , Infección de la Herida Quirúrgica/orina , Resultado del Tratamiento , Cicatrización de Heridas

RESUMEN

BACKGROUND: Bone cements are used as adjuncts to fracture fixation methods and can also function as a local drug delivery system. The ability to elute drugs makes bone cement a promising and powerful chemotherapy treatment modality for osseous tumors. However, because of poor elution rates, the clinical application of this drug delivery mode remains challenging. Soluble fillers, such as sugars, salts, or biocompatible polymers, offer a solution to improve elution rates. This study quantified the effect of polyethylene glycol (PEG) on the elution properties of three commercially available bone cements. METHODS: Two grams of Vertebroplastic, Palacos, and Confidence bone cement powder containing three concentrations (0%, 20%, or 50%) of PEG filler were hand mixed with 10 mg of methotrexate. This powder mixture was then polymerized with 1.0 mL of the cement specific liquid monomer. The cylindrical elution samples were placed in saline solution and methotrexate elution was recorded for 720 h. RESULTS: The cumulative and daily elution rate increased as the concentration of PEG increased for each bone cement. However, the percent of increase depended on the bone cement used. Cumulative methotrexate elution increased by 40%-54% in case of the highest PEG filler concentration when compared with controls. CONCLUSIONS: PEG soluble filler offers a promising method for improving methotrexate drug elution in bone cement. Future studies need to optimize the PEG and bone cement ratio that produces the greatest drug elution profile without sacrificing the biomechanical properties of bone cement.

Asunto(s)

Cementos para Huesos , Sistemas de Liberación de Medicamentos , Metotrexato/administración & dosificación , Polietilenglicoles/farmacología , Polimetil Metacrilato/química

RESUMEN

Congenital thumb contractures are a well described but complex deformity to manage. Thumb contractures are common in patients with arthrogryposis. Many patients with arthrogryposis develop a supination, adduction, and flexion contracture at the thumb carpometacarpal join. Despite some thumb function, their thumb position and contracted first webspace precludes effective pinch or grasp, with the thumb opposing only to the palmar space. An extension, reorientation metacarpal osteotomy that places thumb in an efficient position has the potential to improve function in of these patients. This report provides a new classification system for congenital thumb deformities that can dictate management based upon thumb joint positions. We describe a previously unreported, arthrogrypotic thumb contracture that can be managed with an extension/pronation metacarpal osteotomy with simultaneous widening of the first webspace.

Asunto(s)

Artrogriposis/cirugía , Osteotomía/métodos , Pulgar/anomalías , Pulgar/cirugía , Artrogriposis/fisiopatología , Niño , Femenino , Humanos , Masculino , Pulgar/fisiopatología

RESUMEN

This study sought to determine if there was an increased risk for surgical site contamination during stockinette application for a lower extremity surgery draping technique. Utilizing a simulated, sterile surgical field, stockinettes were applied over 10 cadaver lower extremities that were contaminated with non-pathogenic Escherichia coli on the foot. Of those, five specimens were then disinfected with Chloroprep and another 5 did not undergo any disinfection. All the specimens in which the stockinette was applied over a non-prepped foot showed proximal contamination. No contamination occurred in any of the specimens where the foot was disinfected. Stockinette can be a source of surgical site contamination when placed over a non-prepared foot.

Asunto(s)

Vendajes/microbiología , Desinfección/métodos , Contaminación de Equipos/prevención & control , Infecciones por Escherichia coli/prevención & control , Paños Quirúrgicos/microbiología , Infección de la Herida Quirúrgica/prevención & control , Articulación del Tobillo/microbiología , Articulación del Tobillo/cirugía , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Vendajes/efectos adversos , Cadáver , Pie/microbiología , Pie/cirugía , Humanos , Articulación de la Rodilla/microbiología , Articulación de la Rodilla/cirugía , Paños Quirúrgicos/efectos adversos

RESUMEN

High energy fractures of the distal tibial plafond and calcaneus have been associated with high functional morbidity and wound complications. Although both of these fractures result from a similar mechanism, they have rarely been reported to occur on an ipsilateral extremity. The combination of these 2 injuries on the same extremity would increase the likelihood of an adverse surgical or functional outcome. We present the case and management strategy of a 43-year-old male with bilateral open pilon fractures and closed calcaneal fractures after falling from a height. A staged protocol was used for the bilateral pilon fractures, with external fixation until operative fixation on day 9. Nonoperative management of the calcaneal fractures resulted in a successful functional outcome at 10 months of follow-up. Treatment of this fracture pattern must incorporate the condition of the soft tissues, an understanding of the fractures, and minimize patient risk factors to optimize the functional and surgical outcomes.

Asunto(s)

Traumatismos del Tobillo/cirugía , Calcáneo/lesiones , Fracturas Abiertas/cirugía , Traumatismos de los Tejidos Blandos/cirugía , Fracturas de la Tibia/cirugía , Accidentes por Caídas , Adulto , Traumatismos del Tobillo/diagnóstico por imagen , Traumatismos del Tobillo/terapia , Placas Óseas , Trasplante Óseo , Calcáneo/diagnóstico por imagen , Protocolos Clínicos , Fijadores Externos , Traumatismos de los Pies/diagnóstico por imagen , Traumatismos de los Pies/terapia , Fijación de Fractura , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Fracturas Óseas/terapia , Fracturas Abiertas/diagnóstico por imagen , Fracturas Abiertas/terapia , Humanos , Masculino , Radiografía , Traumatismos de los Tejidos Blandos/diagnóstico por imagen , Traumatismos de los Tejidos Blandos/terapia , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/terapia , Trasplante Homólogo

RESUMEN

Perilunate dislocations are a devastating injury to the carpus that carry a guarded long-term prognosis. Mayfield type 4 perilunate dislocations are rare, high-energy injuries that carry a risk for avascular necrosis (AVN) of the lunate. When AVN ensues and the carpus collapses, primary treatment with a proximal row carpectomy or arthrodesis has been advocated. This case reports a successful clinical result and revascularization of an extruded lunate with open reduction and internal fixation. This type 4, Gustilo grade 1 open perilunate dislocation exhibited complete avulsion of all lunate ligamentous attachments. Management included open reduction and internal fixation as well as carpal tunnel release through a combined dorsal and volar approach. Despite concerns for lunate AVN due to complete disruption of lunate vascularity, a 10-month postoperative clinical and radiographic examination demonstrated no pain with activities of daily living as well as a revascularized lunate.

RESUMEN

A floating hip injury occurs in the setting of poly-trauma and is a rare and difficult problem to manage. Floating hip injuries require vigilant attention not only to the osseous injuries but also the surrounding compartments and soft tissue envelope. We report the case of a 35-year-old male with a lower extremity posterior wall acetabular fracture, ipsilateral femoral shaft fracture and a postero-superior hip dislocation. Closed reduction failed, necessitating an open reduction internal fixation of his hip dislocation and acetabular fracture. The patient then developed a thigh compartment syndrome requiring a fasciotomy. Despite the obvious bony injuries, orthopedic surgeons must be vigilant of the neurovascular structures and soft tissues that have absorbed a great amount of force. A treatment plan should be formulated based on the status of the overlying soft tissue, fracture pattern and the patient's physiologic stability.