Faculty Bibliography

SUMMARY/CONCLUSIONS:Distal radius fractures are common in the geriatric population; however, treatment of these fractures remains controversial. Patients undergoing operative fixation may experience a quicker recovery with increased grip strength, which is beneficial in the active geriatric patient. Treatment options include fragment-specific fixation, volar locked plating, and dorsal bridge plating. External fixation alone leads to poor outcomes and is indicated in patients with soft tissue compromise or as a supplemental aid. Implant selection should be tailored to fracture parameters. With a thoughtful surgical algorithm and rehabilitation protocol, good outcomes can be achieved with a high rate of patient satisfaction.

SUMMARY/CONCLUSIONS:This video reviews the technique of a vascularized fibula flap for pediatric tibia reconstruction. A 4-year-old boy with a history of a left tibial infected nonunion status after multiple debridements presented with segmental bone loss and difficulty with ambulation. An ipsilateral vascularized fibula flap was used for reconstruction. The patient proceeded to union and was independently ambulatory with bracing.

SUMMARY:Treatment of periprosthetic distal femur fractures remains challenging due to assuring adequate distal fixation. Traditional treatment options include lateral locked plating and retrograde nailing, although recently dual implant constructs have been explored with promising results. Allowing immediate weight-bearing in this patient population has benefits with regards to rehabilitation and outcome. Recent literature has focused on nail-plate constructs, however plate-plate constructs are preferred at our institution as they do not require arthroplasty component compatibility, facilitate the coronal plane reduction, and allow for immediate weight-bearing.

The purpose of this study was to identify the ideal start site for a retrograde intramedullary fibular cortical screw based on its relationship to the surrounding soft tissue structures and to assess for damage to the surrounding soft tissue structures caused during placement of the screw. Four fresh frozen cadavers underwent fluoroscopic placement of a 3.5 mm cortical screw utilizing a standardized protocol. No damage to the peroneal tendons were noted in any cadaver with the foot in an inverted and plantarflexed position. The closest structure to the center of the screw head was the anterior talofibular ligament anteriorly (3.33 mm range: 3-4 mm) and the calcaneofibular ligament posteriorly (2.66 mm, range: 2-3 mm). Two screws violated the malleolar fossa medially and were noted to impinge on the lateral process of the talus. The ideal start site for a 3.5 mm intramedullary fibular screw is at the midline on the lateral radiograph and 3.0 mm lateral to the malleolar fossa on the AP radiograph. This avoids damage to the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and prevents impingement on the lateral process of the talus. (Journal of Surgical Orthopaedic Advances 30(2):078-081, 2021).

OBJECTIVES/OBJECTIVE:To compare the efficiency, radiation exposure to surgeon and patient, and accuracy of C-arm versus O-arm with navigation in the placement of transiliac-transsacral and iliosacral screws by an orthopaedic trauma fellow, for a surgeon early in practice. METHODS:Twelve fresh frozen cadavers were obtained. Preoperative computed tomography scans were reviewed to assess for safe corridors in the S1 and S2 segments. Iliosacral screws were assigned to the S1 segment in dysmorphic pelvises. Screws were randomized to modality and laterality. An orthopaedic trauma fellow placed all screws. Time of procedure and radiation exposure to the cadaver and surgeon were recorded. Three fellowship-trained orthopaedic trauma surgeons rated the safety of each screw on postoperative computed tomography scan. RESULTS:Six normal and 6 dysmorphic pelvises were identified. Eighteen transiliac-transsacral screws and 6 iliosacral screws were distributed evenly between C-arm and O-arm. Average operative duration per screw was significantly shorter using C-arm compared with O-arm (15.7 minutes ± 6.1 vs. 23.7 ± 8.5, P = 0.014). Screw placement with C-arm exposed the surgeon to a significantly greater amount of radiation (3.87 × 10 rads vs. 0.32 × 10, P < 0.001) while O-arm exposed the cadaver to a significantly greater amount of radiation (0.03 vs. 2.76 rads, P < 0.001). Two S2 transiliac-transsacral screws (1 C-arm and 1 O-arm) were categorized as unsafe based on scoring. There was no difference in screw accuracy between modalities. CONCLUSIONS:A difference in accuracy between modalities could not be elucidated, whereas efficiency was improved with utilization of C-arm, with statistical significance. A statistically significant increase in radiation exposure to the surgeon using C-arm was found, which may be clinically significant over a career. The results of this study can be extrapolated to a fellow or surgeon early in practice. The decision between use of these modalities will vary depending on surgeon preference and hospital resources.

CASE:An open obturator dislocation with associated pelvic ring injury and perineal wound underwent fixation and aggressive debridement. Despite this, the patient proceeded to infection requiring additional debridements and prolonged intravenous antibiotics. At 18 months postinjury, the patient developed avascular necrosis and significant heterotopic ossification; however, she was able to ambulate. CONCLUSIONS:Open obturator dislocations of the hip require a multidisciplinary team. Despite prompt antibiotic therapy and aggressive debridement, patients are at high risk of infection because of the microbial environment in this region. Open obturator hip dislocations are at significant risk of avascular necrosis despite timely reduction.

This study investigated differences between patients <65 and ≥65 years of age following lumbar microdecompression. Differences between age groups were investigated with univariate analyses. A linear mixed effects model was fit to the study outcomes. 144 patients were studied. There was no difference in two-year outcomes between the age groups. Outcome measures showed improvement compared to baseline at one- and two-years (p < 0.001). Age group had a significant effect on back pain (p = 0.016). Patients ≥65 years of age may experience greater relief in back pain following microdecompression. Nonetheless, significant improvement is observed in both age groups at two-years.

Vancouver B1 periprosthetic fractures undergoing operative fixation remain difficult to treat due to a short proximal segment that offers limited options for fixation. The trochanteric hook plate addresses this issue by maximizing proximal purchase and utilizing the entire lateral surface area of the greater trochanter. A surgical technique that prioritizes proximal fixation and adheres to basic principles resulted in all fractures healing in a small case series. (Journal of Surgical Orthopaedic Advances 29(4):199-201, 2020).

OBJECTIVE:To assess factors that may predict failure to improve at 12 and 24 months after unilateral laminotomy with bilateral decompression (ULBD) for the management of lumbar spinal stenosis. METHODS:A database of 255 patients who underwent microdecompression surgery by a single orthopedic spine surgeon between 2014 and 2018 was queried. Patients who underwent primary single-level ULBD of the lumbar spine were included. Visual analog scale (VAS) for back pain and leg pain and Oswestry Disability Index (ODI) results were collected preoperatively and at 12 and 24 months postoperatively. Demographic, radiographic, and operative factors were assessed for associations with failure to improve. Clinically important improvement was defined as reaching or surpassing the previously established minimum clinically important difference for ODI (12.8) and not requiring revision. RESULTS:A total of 68 patients were included. Compared with preoperative values for back pain, leg pain, and ODI (7.32, 7.53, and 51.22, respectively), there were significant improvements on follow-up at 12 months (2.89, 2.23, and 22.40, respectively; P < 0.001) and 24 months (2.80, 2.11, 20.32, respectively; P < 0.001). Based on the defined criteria, 50 patients showed clinically important improvement after ULBD. Of the 18 patients who failed to improve, 12 required revision. Independent predictors of failure to improve included female sex (adjusted odds ratio, 5.06; 95% confidence interval, 1.49-21.12; P = 0.014) and current smoker status (adjusted odds ratio, 5.39; 95% confidence interval, 1.39-23.97; P = 0.018). CONCLUSIONS:ULBD for the management of lumbar spinal stenosis leads to clinically important improvement that is maintained over a 24-month follow-up period. Female sex and tobacco smoking are associated with poorer outcomes.

Treatment of periprosthetic fractures above total knee arthroplasty remains challenging because of assessment of implant stability and the short segment of often osteoporotic bone available for distal fixation. Fractures with significant medial comminution should undergo retrograde intramedullary nailing or dual-implant fixation, as isolated lateral locked plating is not indicated. There are a multitude of objective and subjective factors incorporated into the decision to proceed with retrograde nailing including assessment of the patient's functional status, fracture morphology, implant stability, and compatibility of the prosthesis with retrograde nailing. Here, we review the steps to success in using retrograde intramedullary nailing in the treatment of specific periprosthetic fractures about total knee arthroplasty.