Need For Hardware Removal Research Articles

Surgical fixation of displaced midshaft clavicular fractures with precontoured plates in adolescents

BackgroundThe use of plate fixation to treat displaced midshaft clavicular fractures in adults reduces complications and residual shoulder disability. New features of the precontoured locking plates have been shown to reduce the need for hardware removal in adults. There is a lack of studies evaluating surgical fixation of displaced clavicular fractures with precontoured plates in adolescents. We evaluate outcomes and complications of adolescents with displaced midshaft clavicular fractures treated with precontoured locking plates. Materials and Methods40 adolescents with displaced midshaft clavicular fractures were surgically treated from January 2010 to May 2017. Outcomes were evaluated using the Constant score, the 11- item version of the Disabilities of Arm, Shoulder and Hand (QuickDASH) questionnaires, and radiographs, and a visual analog scale. Return-to-sport rate, level achieved and complications were recorded. ResultsMean follow-up was 50 months (18–108 months). Constant, Quick-DASH, and visual analog scale scores were 95.6, 2.8 and 0.5 points, respectively. 100 % of adolescents returned to sports at the same level they had before injury. Mean time to return was 69 days and 95 % of patients were able to return before 12 weeks. Complication rate was 12.5 %, 3 patients (7.5 %) required hardware removal. ConclusionsAdolescents with displaced midshaft clavicular fractures treated with precontoured locking plates exhibited satisfactory outcomes and low complication rate. Compared to other reports, this study had lower rates, anatomic plates might reduce hardware-related complications.

Risk Factors Associated With Complications After Operative Treatment of Multiligament Knee Injury

Background:Many factors can affect clinical outcomes and complications after a complex multiligament knee injury (MLKI). Certain aspects of the treatment algorithm for MLKI, such as the timing of surgery, remain controversial.Purpose:To determine the risk factors for common complications after MLKI reconstruction.Study Design:Case-control study; Level of evidence, 3.Methods:A retrospective review was conducted on 134 patients with MLKI who underwent reconstruction between 2011 and 2018 at a single academic center. Patients included in the review had a planned surgical reconstruction of >1 ligament based on clinical examination and magnetic resonance imaging. Complications were categorized as (1) wound infection requiring irrigation and debridement, (2) arthrofibrosis requiring manipulation under anesthesia and/or lysis of adhesions, (3) deep venous thrombosis, (4) need for removal of hardware, and (5) revision ligament surgery. The potential risk factors for complications included patient characteristics, injury pattern categorized according to Schenck classification (knee dislocation [KD] I–KD IV), and timing of surgery. Significant risk factors for complications were analyzed by t test, chi-square test, and Fisher exact test.Results:A total of 108 patients met the inclusion criteria; of these, 29.6% experienced at least 1 complication. Smoking (odds ratio [OR], 3.20 [95% CI, 1.28-8.02]; P = .01) and planned staged surgery (OR, 2.71 [95% CI, 1.04-7.04]; P = .04) significantly increased the overall risk of complication, while increased time from injury to surgery (OR, 0.99 [95% CI, 0.98-0.998]; P < .01) significantly decreased the risk. Increasing time from injury to surgery (OR, 0.99 [95% CI, 0.97-0.998]; P = .02) also led to a slightly but significantly decreased risk for arthrofibrosis.Conclusion:The study findings suggest that smoking, decreased time from injury to initial surgery, and planned staged procedures may increase the rate of complications. Further studies are needed to determine which changes in the treatment algorithm are most effective to reduce the complication rate in patients.

Locking versus non-locking plating system in the treatment of mandibular fractures: A randomized comparative study

To evaluate fracture stability and complications such as infections, need for hardware removal, malunion, and nonunion when using 2.0-mm locking plating system in fixation of mandible fractures and to compare these to those associated with the 2.0-mm non-locking plating system.A prospective clinical study was conducted in a cohort of mandible fracture patients who were randomly assigned to two groups. Patients in the non-locking group were treated with 2.0-mm non-locking plating system, and those in locking group were treated with 2.0-mm locking plating system. Fracture stability, need for maxillomandibular fixation (MMF) and postoperative complications were assessed and compared.A total of 60 patients (30 in each group) were recruited. Significant differences were found between the two groups with respect to postoperative fracture stability (P = 0.001) and need for MMF (P = 0.005). Multivariate analysis revealed that type of fixation was not the only dependent variable which affected fracture stability. There were no significant differences in postoperative complications between the two groups.The 2.0-mm locking plating system provides greater stability and early functional restoration than the 2.0-mm non-locking plating system, with similar rates of postoperative complications. Thus, it can be used as a reliable and effective treatment modality for treating mandibular fractures.

Tratamiento de fracturas mediodiafisarias de clavícula con placas precontorneadas en adolescentes

BackgroundThe use of plate fixation to treat displaced midshaft clavicular fractures in adults reduces complications and residual shoulder disability. New features of the precontoured locking plates have been shown to reduce the need for hardware removal in adults. There is a lack of studies evaluating surgical fixation of displaced clavicular fractures with precontoured plates in adolescents. We evaluate outcomes and complications of adolescents with displaced midshaft clavicular fractures treated with precontoured locking plates. Materials and Methods40 adolescents with displaced midshaft clavicular fractures were surgically treated from January 2010 to May 2017. Outcomes were evaluated using the Constant score, the 11- item version of the Disabilities of Arm, Shoulder and Hand (QuickDASH) questionnaires, and radiographs, and a visual analog scale. Return-to-sport rate, level achieved, and complications were recorded. ResultsMean follow-up was 50 months (18 - 108 months). Constant, Quick-DASH, and visual analog scale scores were 95.6, 2.8 and 0.5 points, respectively. 100% of adolescents returned to sports at the same level they had before injury. Mean time to return was 69 days and 95% of patients were able to return before 12 weeks. Complication rate was 12.5%, 3 patients (7.5%) required hardware removal. ConclusionsAdolescents with displaced midshaft clavicular fractures treated with precontoured locking plates exhibited satisfactory outcomes and low complication rate. Compared to other reports, this study had lower rates, anatomic plates might reduce hardware-related complications.

A retrospective study to ascertain the need for hardware removal following orthognathic surgery

Background: The concept of rigid fixation following surgical interventions in the maxillofacial region is in use since the 1970s. The presence of oral native bacteria in addition to the occlusal forces acting on the plates during mastication results in few complications following rigid fixation which would eventually lead to their retrieval. Objective: The purpose of this study was to evaluate the need for hardware removal in the postoperative phase following orthognathic surgery. Methods: This retrospective study encompassed 86 patients who underwent orthognathic surgery for the correction of their dentofacial deformities in a single hospital unit between July 2009 and October 2019. A total of 314 stainless steel miniplates were used for achieving osteosynthesis in 86 patients. The primary outcome variable in this study was hardware removal. Secondary outcome variables included the reason for hardware removal and the duration between the time of placement of the hardware and its removal. The verdict on whether to postoperatively retrieve plates was based on plate exposure, infection, and patient discomfort caused by the palpability of the plate. Results: Out of the 86 patients (314 plates), 36 patients underwent Le Fort I osteotomy, harboring 144 plates; eight patients underwent anterior maxillary osteotomy, harboring 16 plates; 47 patients underwent bilateral sagittal split osteotomy, harboring 94 plates; and 30 patients underwent genioplasty, harboring 60 plates. It was observed that hardware was retrieved from 24 patients (27.90%) only due to palpability. Among the patients from whom the hardware was removed as a result of complications, 41 patients (47.67%) developed an infection in the postoperative phase, 15 patients (17.44%) had exposed hardware, and six patients (6.97%) developed an inflammatory reaction as a result of a loose screw that necessitated the removal of the hardware. Conclusion: Based on the results of this study, it can be concluded that hardware removal is essential following orthognathic surgery in the late postoperative phase. Hence, following confirmation of optimal postoperative osseous healing, patients should be educated about the need for hardware retrieval and the significance of postoperative follow-up.

True Antiglide Fixation of Weber B Ankle Fractures has Lower Rates of Removal of Hardware

Category:Trauma; AnkleIntroduction/Purpose:Plating of unstable OTA/AO 44-B1 lateral malleolus fractures has been associated with pain, peroneal irritation, and subsequent hardware removal. There has been speculation that this is due to the prominent plate and distal screw placement. Previous studies have looked at posterior vs lateral plate position but have had fairly low numbers in each group. The purpose of this study was to retrospectively compare the rates of hardware removal in unstable OTA/AO-type 44-B1 lateral malleolus fractures fixed with a posterior, true anti-glide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment thus evaluating the role of the distal screw in rates of hardware removal.Methods:Skeletally mature patients that were treated for an isolated OTA/AO 44-B1 fracture over a ten-year period (2007- 2017) were reviewed. Fractures treated with a single posterior plate were included and those fixed with a direct lateral plate were excluded. We evaluated post-op radiographs to determine application of a true anti-glide plate or a neutralization plate with screws in the distal fragment. Radiographic follow-up was used to determine bony union, malunion and need for hardware removal. Hardware removal was determined as entire plate removal; isolated syndesmotic screw removal was not included. Patients were excluded if they had less than six months of follow up. Relative risk was determined for the rate of hardware removal based on fixation technique.Results:There were 548 OTA/AO 44-B1 fractures treated over the course of ten years (2007-2017). After screening, 88 patients were included in the study. The majority of excluded patients lacked adequate follow-up. Average age of the cohort was 46 years old (range 17-84), with 47 females and 41 males included. Average length of follow up was forty months (range 6.1- 140.3). There were 28 patients in the true anti-glide plate group and sixty in the neutralization plate group. Five (18%) in the anti- glide plate group and 19 (32%) in the neutralization plate underwent a second procedure of hardware removal. Relative risk of hardware removal was 0.56 (95% CI 0.23-1.36, p=0.2). There was a 100% union rate with 0% malunion in both groups.Conclusion:Anti-glide plating has a near 50% relative risk reduction in the rate of hardware removal when compared to posterior based neutralization plating. Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. A true anti-glide plating construct should be considered as a safe and effective way of managing OTA/AO 44-B1 lateral malleolus fractures with a lower relative risk of a second operation for hardware removal.

Treatment of Zone II and III Fifth Metatarsal Fractures Using a Novel Fixation Technique

Category:Sports; Lesser ToesIntroduction/Purpose:Zone II and III 5th metatarsal fractures are common injuries which can be addressed surgically with percutaneous fixation following anatomic reduction. Limited vascular supply and the specific anatomy of the 5th metatarsal causes concern for non-union of these fractures. This study evaluated a novel screw designed to optimize 5th metatarsal fixation. The titanium alloy headless screw (Jones Union System, Extremity Medical, Parsippany, NJ) provides compression across the fracture site using variable angle pitch and is designed to minimize the occurrence of painful hardware. In addition, we use an intramedullary reamer to create local autologous bone grafting in conjunction with an osteoplasty of the cuboid to obtain ideal positioning. This study represents the first to evaluate clinical outcomes following fixation with this system.Methods:Patients treated for a 5th metatarsal fracture between 2018 and 2019 by two surgeons fellowship-trained in foot and ankle orthopedics were identified. Operative notes were reviewed to ensure that patients were treated with the headless compression screw. 21 patients (22 fractures) were identified. Postoperative x-rays were reviewed to evaluate osseous bridging and time to union was determined. Retrospective chart review was performed to determine time to return to sport. Postoperative complications, including non-unions, need for revision, and need for hardware removal, were also evaluated.Results:Of the 22 total fractures, 16 were Zone II fractures and 6 were Zone III fractures. Average time to clinical follow-up was 13.60 months (range, 3.91-25.07). Average age at time of surgery was 28.82 years (range, 16 to 66). 16 males and 5 females were represented with average BMI of 27.41 kg/m2. Average time to union was 6.78 weeks (range, 5.13-12.12), and average time to return to sport was 11.38 weeks (range, 5.87-15.12). No patients experienced a non-union or painful hardware, and no other postoperative complications were observed.Conclusion:Fixation of Jones fractures using the Jones Union System produced excellent postoperative outcomes. This system, designed to address the challenges of 5th metatarsal anatomy, demonstrated effectiveness with expeditious times to union and return to sport. Union rates were high, and our cohort did not experience any postoperative complications. Although follow-up in some cases is short, no patient has experienced painful hardware. Our results suggest that this system is an effective approach for fixation of Zone II and III 5th metatarsal fractures.

P36. Operative time and learning curve between conventional fluoroscopy, fluoroscopy-based instrument navigation, and robot-assisted instrumentation in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF)

BACKGROUND CONTEXT Instrument-navigation modalities including CT-guided and robot-assisted methods claim both efficacy and accuracy when applied to spine surgery, yet often increase setup and operating times. PURPOSE The authors seek to study the impact of multitude of instrument navigational technologies on operative time and the learning curve associated with their use. STUDY DESIGN/SETTING Prospective, single-surgeon, single-institution. PATIENT SAMPLE Patients undergoing minimally invasive transforaminal lumbar interbody fusion with or without decompression, with or without previous hardware removal. OUTCOME MEASURES Total operative time, immediate surgical complications. METHODS Consecutive patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) were analyzed. Two adjunctive technologies were studied and compared with a more conventional fluoroscopic approach without navigation. Consecutive cases were done with assistance of a robot (Mazor Robotics), with the assistance of x-ray tracking (TrackX) or without navigation in three consecutive blocks of time. The cases done without assistance were used to further normalize for number of interbodies and decompressions performed as well as hardware removal if needed. Age, body mass index (BMI), sex, operative levels, laminectomy, need for hardware removal, and total operative time was recorded directly from EPIC. RESULTS A total of 120 cases (74 conventional, 14 robot-assisted, 32 Track-X) were included in analysis. There were no significant differences in age, sex, or BMI between modalities. Uncontrolled, the average operative time for conventional, robot-assisted, and TrackX was 118±36, 157±41, and 107±37 minutes, respectively, for each MIS-TLIF level (p<0.05 across each group). Once normalized for hardware removal, decompression, and number of fusion levels, the robot cases were 24% slower (added 32 minutes/case) while the x-ray tracking cases were 19% faster (subtracted 16 minutes). Operative times in no robot-assisted case were faster than the comparable control procedure, while 69% of those utilizing x-ray tracking were quicker. TrackX cases were initially slower but trended downwards through approximately 11 patients, at which point operative times were consistently quicker (R=0.63). The Mazor cases displayed no learning curve (R=0.08). None of the assisted cases were abandoned in favor of standard fluoroscopy or required hardware revision. CONCLUSIONS Enabling technology can have a significant impact to surgical efficiency. Robotic-assistance consistently negatively impacted operative times, while x-ray tracking was associated with a short learning curve and improved operative times in the vast majority of cases studied. FDA DEVICE/DRUG STATUS TrackX (Approved for this indication) Instrument-navigation modalities including CT-guided and robot-assisted methods claim both efficacy and accuracy when applied to spine surgery, yet often increase setup and operating times. The authors seek to study the impact of multitude of instrument navigational technologies on operative time and the learning curve associated with their use. Prospective, single-surgeon, single-institution. Patients undergoing minimally invasive transforaminal lumbar interbody fusion with or without decompression, with or without previous hardware removal. Total operative time, immediate surgical complications. Consecutive patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) were analyzed. Two adjunctive technologies were studied and compared with a more conventional fluoroscopic approach without navigation. Consecutive cases were done with assistance of a robot (Mazor Robotics), with the assistance of x-ray tracking (TrackX) or without navigation in three consecutive blocks of time. The cases done without assistance were used to further normalize for number of interbodies and decompressions performed as well as hardware removal if needed. Age, body mass index (BMI), sex, operative levels, laminectomy, need for hardware removal, and total operative time was recorded directly from EPIC. A total of 120 cases (74 conventional, 14 robot-assisted, 32 Track-X) were included in analysis. There were no significant differences in age, sex, or BMI between modalities. Uncontrolled, the average operative time for conventional, robot-assisted, and TrackX was 118±36, 157±41, and 107±37 minutes, respectively, for each MIS-TLIF level (p<0.05 across each group). Once normalized for hardware removal, decompression, and number of fusion levels, the robot cases were 24% slower (added 32 minutes/case) while the x-ray tracking cases were 19% faster (subtracted 16 minutes). Operative times in no robot-assisted case were faster than the comparable control procedure, while 69% of those utilizing x-ray tracking were quicker. TrackX cases were initially slower but trended downwards through approximately 11 patients, at which point operative times were consistently quicker (R=0.63). The Mazor cases displayed no learning curve (R=0.08). None of the assisted cases were abandoned in favor of standard fluoroscopy or required hardware revision. Enabling technology can have a significant impact to surgical efficiency. Robotic-assistance consistently negatively impacted operative times, while x-ray tracking was associated with a short learning curve and improved operative times in the vast majority of cases studied.

Total knee arthroplasty following intramedullary tibial nailing

Introduction/purposeTotal knee arthroplasty (TKA) in the setting of previous periarticular hardware increases resource utilization, readmissions, complications, and revision rates. Despite the frequency of intramedullary nail (IMN) fixation for tibial fractures, little guidance exists on the management of these patients and no series have reported on outcomes of patients undergoing TKA in the setting of a retained or removed IMN.MethodsThis is a retrospective case series of patients who underwent TKA after IMN fixation of tibial fractures. Patient and case data, including need for hardware removal, staged vs non-staged procedures, operative time, and need for revision implants, were recorded. Postoperative data, including complications and revision, were recorded. Oxford Knee Score (OKS) was performed at follow-up.ResultsNine patients were identified consisting of eight women and one man. Follow-up ranged from 0.8–13 years. Non-staged removal of the intramedullary hardware occurred in three cases that had increased operative lengths recorded. There were no complications related to wound healing or infection. No patients required revision. Two of the three patients who underwent non-staged TKA developed arthrofibrosis requiring manipulation. OKS scores in patients who underwent non-staged surgery were consistently low.ConclusionsConversion TKA after tibial IMN fixation can result in satisfying outcomes in many patients. However, intramedullary hardware presents challenges to TKA similar to more extensively studied conversion TKA scenarios. Removing hardware in either a staged or non-staged fashion results in increased resource utilization and imparts perioperative challenges with only theoretical benefits of one approach compared to the other. Increased stiffness may be associated with a non-staged approach to hardware removal and TKA. Several technical factors may permit component positioning without removal of hardware. Despite limitations, this is the first series to discuss this challenging clinical scenario and provides surgeons with technical guidance and data on operative outcomes.

A Prospective, Randomized Investigation of Syndesmosis Injury Fixation

Category:Ankle; TraumaIntroduction/Purpose:Syndesmotic disruption occurs in 10 to 13% of all ankle fractures. It is present in 15 cases per 100,000 of the general population. There has been debate on the best treatment for syndesmotic injuries. The typical surgical treatments include fixation with either screws or suture button devices. The purpose of this study is to compare clinical outcomes of syndesmotic injuries treated surgically with either screws or suture button devices. It was hypothesized that suture button fixation would provide equal clinical results with less need for hardware removal.Methods:This was a multi-center, randomized, prospective clinical trial comparing two surgical interventions for treatment of acute syndesmotic injury. Subjects were placed into either screw fixation or the Suture-button device group. Subjects with clinical signs or radiographic evidence of syndesmotic injury were asked to participate in this study. Inclusion criteria was ages 18 to 65 years old with confirmed syndesmotic instability. The primary outcomes of the study were VAS scores (activity, pain, satisfaction) and FFI scores (pain, disability, activity) which were collected at preoperative state, 6 weeks, and 12 months postoperatively.Results:Sixty-five subjects were enrolled in this study. Thirty-two subjects received Suture-button fixation (49%) and 33 received screw fixation (51%). VAS scores and FFI scores for subjects treated with the Suture-button device or screw fixation comparing preoperative, six-week, and 12-month scores all showed clinical improvement. There was no significant difference between the two treatment groups (p >0.05).Nine subjects (27%) in the syndesmotic screw fixation group experienced adverse events, and only one subject (3%) in the suture-button group had adverse event.Conclusion:The short-term clinical outcomes suggest that both syndesmotic screws and suture-button devices are effective treatment options to address acute syndesmotic injuries. In the short-term (12-months), suture-button fixation resulted in significantly less adverse events compared to syndesmotic screw fixation group.

Procedure-Specific Hardware Removal After Evans Osteotomy.

The Evans osteotomy is a widely used procedure for the correction of adult and pediatric flexible flatfoot deformity. Locking plates are commonly used to stabilize the osteotomy and the allograft. However, there have been incidences of soft-tissue irritation caused by the hardware, requiring subsequent hardware removal. Therefore, we sought to review whether age, sex, or laterality of the procedure had any correlation with the rate of hardware removal. A retrospective review was performed of 47 consecutive patients who underwent an Evans calcaneal osteotomy between October 1, 2013, and October 1, 2016. Data were collected and analyzed based on age, sex, laterality, and the need for hardware removal. All of the 47 patients met the inclusion criteria. Seventy procedures were performed, and hardware removal was required in 16 patients and 21 feet (30%). The only statistically significant finding was that 11 females and only five males required either unilateral or bilateral hardware removal (P = .039). All 16 patients reported complete pain relief after hardware removal. Females are twice as likely as males to develop symptoms after locking plate application over an Evans osteotomy and may require hardware removal. Despite the low-profile nature of the locking plate to fixate the Evans osteotomy, the hardware can be a source of significant pain. Patients, especially females, should be cautioned about potential hardware-related pain and a possible follow-up procedure to remove the hardware.

Pediatric tibial eminence fracture treatment: A case series using a bioabsorbable screw

BackgroundPediatric tibial eminence fractures constitute a complex injury with multiple treatment options. We have described a technique that combines direct visualization through an open approach and stable fixation using a bioabsorbable screw. The purpose of this study is to describe our surgical technique for tibial eminence fractures and to compare the radiographic and functional outcomes to previous open or arthroscopic methods. MethodsWe retrospectively reviewed a series of five pediatric patients who underwent open reduction and internal fixation of a tibial eminence fracture with a headless, bioabsorbable poly-L lactic acid (PLLA) screw (Bio-Compression screw, Arthrex Inc, Naples, FL) from 2016 to 2017. The surgical technique involves an open approach, direct fracture reduction, and fixation with a PLLA screw without violating the epiphyseal plate. Postoperative assessment was quantified using the Lysholm knee score (LKS), knee arc of motion (AOM), presence of a pivot shift or Lachman, and knee radiographs with an average of 18.4 months of follow-up. ResultsFive patients (average age of 11.3 years) were treated with a biobsorbable screw and followed for an average of 18.4 months. Average LKS was 99.6, AOM was 98.4%, all patients had negative pivot shift and Lachman exams, and all patients went on to radiographic union. No patients required re-operation or implant removal. ConclusionsThe goals of tibial eminence fracture management are fracture union, restoring knee stability, and regaining normal knee motion and kinematics. Our study demonstrates that open treatment with a bioabsorbable screw is an excellent alternative surgical method as it reliably results in rigid fixation, fracture union, excellent knee function scores, and it mitigates the possible need for hardware removal. Level of evidenceTherapeutic Level IV – Case series.

Washers do not affect the rate of implant removal or elbow motion in medial epicondyle fractures.

The use of a washer to supplement screw fixation can prevent fragmentation and penetration during the surgical treatment of pediatric medial epicondyle fractures. However, concerns may arise regarding screw prominence and the need for subsequent implant removal. The purpose of this study is to evaluate the impact of washer utilization on the need for hardware removal and elbow range of motion (ROM). All pediatric medial epicondyle fractures treated with a single screw over a 7-year period were queried for this retrospective case-control study. Hardware removal was performed only if the patient experienced a complication or implant-related symptoms that were refractory to non-operative management. Of the 137 patients included in the study, a washer was utilized in 90 (66%). Thirty-one patients (23%) ultimately underwent hardware removal. There was not an increased need for implant removal in those with a washer (P = 0.11). When analyzing a subgroup of 102 athletes only, there was similarly no difference in the rate of implant removal if a washer was used (P = 0.64). Overall, 107 (78%) patients regained full ROM at a mean of 13.9 ± 9.7 weeks after surgery with no significant difference along the lines of washer use. Use of a washer did not affect the need for subsequent implant removal or elbow ROM after fixation of medial epicondyle fractures, even in athletes. If there is concern for fracture fragmentation or penetration, a washer can be included without concern that future unplanned surgeries may be required.

A Novel and Safe Fibular Osteotomy for Total Ankle Replacement through Lateral Transfibular Approach

Category:Ankle ArthritisIntroduction/Purpose:The lateral transfibular total ankle arthroplasty (TAA) has been reported on with good short term outcomes. One key downside to the lateral TAA is the rate of symptomatic hardware and wound issues requiring hardware removal seen with the short oblique fibular osteotomy. Therefore, we report on a comparative cohort study of lateral TAA using the traditional short oblique fibular osteotomy to a long oblique fibular osteotomy, termed Foot and Ankle Reconstruction Group Osteotomy (FARG).Methods:Retrospective identification of primary lateral transfibular TAA performed by a single surgeon from May 2013 to October 2016 with minimum 2 years follow-up. Clinical assessment included patient demographics, wound complications, need for hardware removal, visual analogue scale, American Orthopaedic Foot & Ankle Society score, Short Form-12 Mental Composite Score, and Short Form-12 Physical Composite Score. Radiographic assessment included weight bearing x-rays to assess tibiotalar alignment, implant alignment, and fibular osteotomy healing.Results:A total of 159 primary lateral TAA were identified. The short oblique fibular osteotomy was used in 50 cases and the FARG osteotomy in 109 cases. Implant survival was 100% and there were no fibular osteotomy nonunions in both groups. There was improvement in all clinical parameters in both groups with no significant difference between groups in any of these parameters. The radiographic measures showed excellent alignment at all time points in both groups with no significant difference between groups. There was a significant difference between groups in the rate of wound dehiscence and rate of hardware removal for any reason with the FARG osteotomy having a lower rate of both compared to the short oblique fibular osteotomy.Conclusion:Modification of the traditional fibular osteotomy to the long oblique Foot & Ankle Reconstruction Group fibular osteotomy has excellent 2-year survival with good clinical and radiographic outcomes yet provides decreased rates of wound complications and decreased rates of symptomatic fibular hardware compared to the traditional short oblique fibular osteotomy.

A Prospective, Randomized Suture-button vs Screw Syndesmotic Fixation

Category:Ankle, Arthroscopy, SportsIntroduction/Purpose:Syndesmotic disruption occurs in 10 to 13% of all ankle fractures. It is present in 15 cases per 100,000 of the general population. There has been debate on the best treatment for syndesmotic injuries. The typical surgical treatments include fixation with either screws or suture button devices. The purpose of this study is to compare clinical outcomes of syndesmotic injuries treated surgically with either screws or suture button devices. It was hypothesized that suture button fixation would provide equal clinical results with less need for hardware removal.Methods:This was a multi-center, randomized, prospective clinical trial comparing two surgical interventions for treatment of acute syndesmotic injury. At the time of surgical intervention, subjects were placed into either the screw fixation or the Suture-button device group by opening a randomized envelope in the operating room. Subjects with clinical signs or radiographic evidence of syndesmotic injury were asked to participate in this study. Inclusion criteria was ages 18 to 65 years old with confirmed syndesmotic instability. The primary outcomes of thestudy were VAS scores (activity, pain, satisfaction) and FFI scores (pain, disability, activity) which were collected at preoperative state, 6 weeks, and 12 months postoperatively.Results:Sixty-five subjects were enrolled in this study. Thirty-two subjects received Suture-button fixation (49%) and 33 received screw fixation (51%). VAS scores and FFI scores for subjects treated with the Suture-button device or screw fixation comparing preoperative, six-week, and 12-month scores all showed clinical improvement. There was no significant difference between the two treatment groups (p >0.05). Nine subjects (27%) in the syndesmotic screw fixation group experienced adverse events; four required repeat surgery for symptomatic syndesmotic screw removal, one for revision fixation, and four did not return to surgery despite hardware failure. One subject(3%) in the suture-button group required hardware removal.Conclusion:The short-term clinical outcomes suggest that both syndesmotic screws and suture-button devices are effective treatment options to address acute syndesmotic injuries. In the short-term (12-months), suture-button fixation resulted in significantly less adverse events compared to syndesmotic screw fixation group.

Extended Drain Dwell Duration Following Muscle Flap Closure for Complex Spine Surgery Does Not Increase the Risk of Surgical Site Infections

PURPOSE: Surgical drains are routinely used to prevent the accumulation of fluid at the operative site, an effect known to decrease the risk of seroma and theoretically lower the chance of abscess or small hematoma formation. Despite these potential benefits, significant debate exists in the literature regarding the risk that such drains might be imparting on the development of surgical site infections (SSIs), and the use of prophylactic antibiotics to “cover the drain” remains a common practice despite scant evidence that closed suction drains increase the risk for SSI. The purpose of the present study is to examine our database of over 12 years of muscle flap closure following complex spinal surgery to determine the effect of drain dwell duration on postoperative wound complications including SSI. METHODS: For this retrospective review, 301 consecutive index cases of complex spine surgery with immediate muscle flap closure (paraspinous, trapezius, latissimus dorsi, and/or thoracolumbar fascia) by the senior author from 2006 to 2018 were identified. The electronic medical record was reviewed for patient characteristics, perioperative details, and outcomes. Examination of the effect of median drain dwell duration on the primary endpoint, SSI, was first conducted via the Mann-Whitney test followed by univariable logistic regression analysis for both the primary endpoint and secondary endpoints including wound complication requiring reoperation and the need for hardware removal due to infection. RESULTS: The cohort was 50.8% male and with an average age of 59.0 ± 18.0 years and body mass index of 27.8 ± 6.7 kg/m2. In 85% of cases, ≥1 drain was in intimate contact with the hardware and/or bone graft, and patients received no >24 hours of postoperative intravenous cefazolin (or other appropriate perioperative coverage in case of documented allergy) unless further antibiotics were indicated. There were 15 cases of SSI, overall, making for an incidence of 4.9%. Drain durations were clearly documented in 271 cases. Median drain dwell duration among these cases was 19 days (interquartile range [IQR], 14–27 days), overall, 19 days (IQR, 14–27 days) among cases which did not develop SSI, and 22 days (IQR, 15–30 days) among cases which did develop SSI (P = 0.231). Univariable logistic regression analysis also demonstrated no increased risk with longer drain dwell times for the development of SSI (odds ratio [OR], 1.03; 95% confidence interval [CI], 0.98–1.08; P = 0.282), wound complication requiring reoperation (OR, 1.02; 95% CI, 0.96–1.09; P = 0.559), or subsequent removal of hardware due to infection (OR, 1.03; 95% CI, 0.95–1.11; P = 0.528). CONCLUSIONS: In this large retrospective series of 301 cases spanning over 12 years, we demonstrate that increased drain dwell duration is not associated with SSI, wound complication requiring reoperation, or need for hardware removal due to infection. These findings, particularly in light of the high-risk nature of the cohort in which 85% of patients had drains placed adjacent to hardware and/or bone graft, contribute to the evidence that increased drain dwell times do not place patients at greater risk of SSI and that such patients do not need prophylactic antibiotics for drain coverage.

Rigid Internal Fixation of Proximal Crescentic Metatarsal Osteotomy in Hallux Valgus Correction.

The purpose of this study was to evaluate outcomes utilizing a low-profile titanium plate and screw construct for rigid fixation of first ray proximal crescentic osteotomies in the treatment of hallux valgus. Forty-eight patients (53 feet) with mild to severe hallux valgus were prospectively enrolled and completed 12-month follow-up. All were treated with a proximal crescentic osteotomy, fixed with a low-profile titanium plate, distal soft tissue correction, with or without an Akin osteotomy. Recorded outcomes included change in first ray dorsiflexion angles, need for hardware removal, radiographic and clinical evaluation, pain, and American Orthopaedic Foot & Ankle Society (AOFAS) scores. All patients achieved radiographic union of their osteotomy. An Akin osteotomy was performed in 83% of patients. Seventeen feet (32%) had hardware removed. First ray dorsiflexion angles increased from a mean of 1.6 degrees preoperatively to 5.0 degrees postoperatively (P < .001). Dorsal malunion, defined as change in dorsiflexion angle greater than 1 standard deviation above the mean, occurred in 7 feet. The mean hallux valgus angle improved from 29 to 9 degrees (P < .001). The mean 1-2 intermetatarsal angle decreased from 14 to 6 degrees (P < .001). The first metatarsophalangeal joint range of motion decreased from 77 to 59 degrees (P < .001). The mean visual analog scale score improved from 4 to 0.7 (P < .0001). The mean AOFAS score improved from 55 to 89 points (P < .001). Proximal crescentic metatarsal osteotomy, fixed with a low-profile titanium plate and screw construct, with distal soft tissue repair, and Akin osteotomy as indicated, was a safe and reliable method for operative treatment of hallux valgus. Level IV, retrospective case series.

Single- vs 2-Screw Lag Fixation of the Medial Malleolus in Unstable Ankle Fractures.

The purpose of this study was to determine the efficacy of medial malleolar fixation with 1 vs 2 screws. Between April 2013 and February 2017, 196 patients who presented at 2 hospitals within one academic institution with an unstable rotational ankle fracture with a medial fracture and were treated operatively by a trained orthopedic surgeon were identified. These patients' charts were reviewed and their injury, radiographic, surgical, and follow-up data recorded. Medial malleolus fragment size was assessed on the anteroposterior (AP) and lateral views of the initial injury radiograph. Functional outcome was assessed using Maryland Foot Score (MFS). Patients were grouped based upon the number of screws utilized to fox the medial malleolar fragment. Data were assessed using Fisher exact tests and independent t tests with SPSS, version 23. Out of the 196 patients who met inclusion criteria, 47 patients (24%) were fixed with 1 medial malleolar screw and 149 patients (76%) were fixed with 2 screws. There were no differences among patients who received 1 vs 2 screws with regard to age, gender, body mass index, American Society of Anesthesiologists grade, or smoking status. The average malleolar fragment size was smaller in those treated with 1 screw on both the AP and lateral radiographic views than those with 2 screws (P = .009, P = .001, respectively). There was no difference between groups in ankle dorsiflexion or plantarflexion at 1 year postoperation (P = .451, P = .581). Patients who received 1 screw did not differ from those who received 2 screws with respect to Maryland Foot Scores (P = .924). There was no difference in rate of revision surgery or need for hardware removal between groups (P = .093). Furthermore, time to healing and postoperative complication rate did not differ between groups. The use of a single screw for medial malleolar fixation provided stable fixation to allow ankle fracture healing, without an increase in complications. This information is especially important in situations when the fragment is too small to accommodate multiple fixation points. Level III, retrospective case-control study.

Arthroscopic Latarjet: Suture-Button Fixation Is a Safe and Reliable Alternative to Screw Fixation

To evaluate mid-term clinical outcomes, complications, bone-block healing, and positioning using suture-button fixation for an arthroscopic Latarjet procedure. Patients with traumatic recurrent anterior instability and glenoid bone loss underwent guided arthroscopic Latarjet with suture-button fixation. We included patients with anterior shoulder instability, glenoid bone loss >20%, and radiographic and clinical follow-up minimum of 24months. Patients with glenoid bone loss <20% or those that refused computed tomography imaging were excluded. Bone-block fixation was accomplished with 2 cortical buttons connected with a looped suture (4 strands). The looped suture was tied posteriorly with a sliding-locking knot. After transfer of the bone block on the anterior neck of the scapula, compression (100N) was obtained with the help of a tensioning device. Clinical assessment was performed at 2 weeks, 3 months, 6 months, and then yearly with computed tomography completed at 2 weeks and 6 months to confirm bony union. A consecutive series of 136 patients underwent arthroscopic Latarjet with 121 patients (89%; mean age 27 years) available at final follow-up (mean follow-up, 26months; range, 24-47months). No neurologic complications or hardware failures were observed; no patients had secondary surgery for implant removal. The transferred coracoid process healed to the scapular neck in 95% of the cases (115/121). The bone block did not heal in 4 patients; it was fractured in 1 and lysed in another. Smoking was a risk factor associated with nonunion (P < .001). The coracoid graft was positioned flush to the glenoid face in 95% (115/121) and below the equator in 92.5% (112/121). At final follow-up, 93% had returned to sports, whereas 4 patients (3%) had a recurrence of shoulder instability. The subjective shoulder value for sports was 94 ± 3.7%. Mean Rowe and Walch-Duplay scores were 90 (range, 40-100) and 91 (range, 55-100), respectively. Suture-button fixation is an alternative to screw fixation for the Latarjet procedure, obtaining predictable healing with excellent graft positioning, and avoiding hardware-related complications. There was no need for hardware removal after suture-button fixation. The systematic identification of the axillary and musculocutaneous nerves reduced risk of neurologic injury. A low instability recurrence rate and excellent return to pre-injury activity level was found. Suture-button fixation is simple, safe, and may be used for both open and arthroscopic Latarjet procedure. Level IV, therapeutic case series.

USE OF A WASHER DOES NOT AFFECT THE RATE OF IMPLANT REMOVAL OR ELBOW MOTION AFTER FIXATION OF MEDIAL EPICONDYLE FRACTURES

Background: The use of a washer to supplement screw fixation can prevent fragmentation and penetration during the surgical treatment of medial epicondyle fractures. However, concerns may arise regarding screw prominence and the need for subsequent implant removal. The purpose of this study is to evaluate the impact of washer utilization on the need for hardware removal and elbow range of motion (ROM). Methods: All surgically-treated pediatric medial epicondyle fractures over a 7-year period were queried for this retrospective case-control study. Patients were only included if their fracture was fixed with a single screw with or without a washer. Per institutional protocol, implants were not routinely removed after fracture healing. Hardware removal was performed only if the patient experienced a complication or implant-related symptoms that were refractory to non-operative management. Full ROM was considered flexion beyond 130 degrees and less than a 10-degree loss of extension. Univariate analysis was followed by creation of Kaplan-Meier (one minus survival) curves in order to analyze the time until full ROM was regained after surgery. Curves between patients with and without a washer were compared with a log rank test. Results: Of the 137 patients included in the study, the mean age was 12.2±2.3 years and 85 (62%) were male. A total of 31 (23%) patients ultimately underwent hardware removal. A washer was utilized in 90 (66%) cases overall. There was not an increased need for subsequent implant removal in these patients compared to those that underwent screw fixation alone (p=0.11). The mean BMI of patients that underwent hardware removal (19.1±2.5) was similar to that of children who did not (20.4±3.5, p=0.06). When analyzing a subgroup of 102 athletes only, there was similarly no difference in the rate of implant removal if a washer was used (p=0.64). Overall, 107 (78%) patients regained full ROM at a mean of 13.9±9.7 weeks after surgery (Figure 1). There was no statistically significant difference in the proportions of patients with and without a washer that achieved full ROM (p=0.46). Full ROM was achieved at a mean of 14.1±11.0 weeks in those with a washer compared to 13.6±6.2 weeks in those without one (p=0.21). Conclusions: Use of a washer did not affect the need for subsequent implant removal or elbow ROM after fixation of pediatric medial epicondyle fractures, even in thinner patients or competitive athletes. If there is concern for fracture fragmentation or penetration, a washer can be included without concern that future unplanned surgeries may be required.