Patients Underwent Hardware Removal Research Articles

Clinical and Radiographic Outcomes After Hindfoot and Ankle Arthrodesis Using Cellular Bone Allograft Augmentation: A Short Report.

Nonunion after ankle or hindfoot arthrodesis is associated with poor outcomes. Cellular bone allograft is an alternative to autograft for use in these procedures. The purpose of this study was to prospectively evaluate the early efficacy and safety of cellular bone allograft use in hindfoot and ankle arthrodesis procedures. Fourteen patients undergoing hindfoot or ankle arthrodesis supplemented with cellular bone allograft were prospectively enrolled. Computed tomography (CT) scans were obtained postoperatively at set time points and reviewed by 3 fellowship-trained foot and ankle surgeons as well as 1 musculoskeletal radiologist. Primary outcome was CT-verified union, defined as >25% of joint surface. Complications were recorded and revision procedures offered as indicated. CT-verified union rate during the study period was 76.7% (23 of 30 joints). Union was 100% for the ankle joint (2 of 2), 50% for the talonavicular joint (5 of 10), 100% for the calcaneocuboid joint (8 of 8), and 80.0% for the subtalar joint (8 of 10). One patient underwent revision fusion procedure, and 1 patient underwent hardware removal during the study period. Our initial experience suggests that use of cellular bone allograft augmentation in hindfoot and ankle arthrodesis may offer an alternative to autograft without potential of donor site morbidity. Level IV, case series.

Navigated Simultaneous Lateral Minimally Invasive Tubular and Posterior Mini-Open Access for Removal and Revision of Triangular Sacroiliac Joint Implants: A Technical Note

Sacroiliac joint (SIJ) fusion, to treat back pain caused by SIJ dysfunction, can employ open or minimally invasive surgery (MIS) techniques and either cylindrical (screw-shaped) or triangular (wedge-shaped) implants. Fusion nonunion sometimes explains recurrent SIJ pain following fusion and occasionally requires hardware revision. MIS revision minimizes patient pain, infection, and disability, but due to the triangular implant size and form factor, implant removal can present challenges for MIS access during the explantation and achieving good bony purchase for reinstrumentation. Here, we report a prone single-position lateral MIS/posterior mini-open procedure for triangular-implant SIJ fusion revision. The patient is a 72-year-old female who underwent right SIJ fusion for lower back and leg pain sustained after a fall 2 years prior but experienced recurrent pain over the subsequent 2 years, with imaging findings of right SIJ peri-hardware lucencies and diagnostic injections confirming persistent right-sided sacroiliitis. The patient underwent hardware removal using the lateral MIS incision with table-mounted tubular access and image-guided navigation to maintain exposure, plus simultaneous reinstrumentation using a navigated S2-alar-iliac screw and iliac bolt construct with connecting rod through the posterior mini-open incision made for the navigation reference frame spinous process clamp. The use of navigation and MIS access can significantly decrease the complexity of lateral hardware removal, and mini-open navigated screw-and-rod constructs offer reinstrumentation options accessible to surgeons unfamiliar with specialized posterior SIJ systems.

Arthrex Mini Tightrope Fixation for Chronic Distal Radioulnar Joint Instability.

Chronic distal radioulnar joint (DRUJ) instability is a complex clinical condition that is difficult to treat. Currently, there is no gold standard treatment. We present a novel technique using Arthrex Mini Tightrope for DRUJ stabilization. In this case series, a 1.6 mm K-wire was passed transversely through the distal ulna and radius. The Mini Tightrope was inserted into the end of the K-wire and pulled through the bone tunnels. Appropriate tension was achieved to stabilize the joint according to individual laxity comparable to the contralateral side. Five patients (3 males and 2 females) comprised this pilot series, with a mean age of 27.1 years. All sustained a traumatic injury at an average of 12.4 months before surgery (range: 5 to 32 mo). In addition, 3 patients had central triangular fibrocartilage complex tears treated with arthroscopy at the time of Mini Tightrope placement. While one patient was lost to follow-up after 7 weeks postoperative due to incarceration, 4 patients demonstrated coronal and sagittal stability in the context of DRUJ motion and a satisfactory range of motion. The mean time for the return to work for the two patients who were laborers or normal activity postoperatively was 5.2 weeks (range: 1 to 16.4 wk). Unrestricted activity was generally allowed 8 weeks postoperatively but varied by patient. The same 4 patients underwent hardware removal at an average of 31 weeks (range: 15 to 44 wk). Although this is only a pilot series, this suggests that temporary Mini Tightrope stabilization of the DRUJ may be a viable solution while upholding the benefits of minimally invasive surgery.

Patient-Reported Outcomes of Surgically Treated Lisfranc Injuries with Isolated Longitudinal Instability

Category: Midfoot/Forefoot; Other Introduction/Purpose: A longitudinal Lisfranc variant injury occurs from a longitudinal force on the midfoot directed through the first ray and medial cuneiform. This is unique in that other Lisfranc injury patterns typically result from an axial-directed force or a rotational force that externally rotates the midfoot. More common Lisfranc injury patterns can have instability longitudinally, but usually it is accompanied by coronal instability and even axial instability. To date, there has been no study with a cohort of Lisfranc injuries with isolated longitudinal instability. The purpose of this study was to report patient-reported outcome measures (PROMs) for those undergoing surgical treatment for longitudinal Lisfranc injuries. Methods: Retrospective chart review was completed to identify patients with surgically treated longitudinal Lisfranc injuries by a single surgeon between April 2018 and February 2022. Intraoperative fluoroscopy was used to confirm Lisfranc injuries positive for only longitudinal instability and negative for coronal and axial instability. Surgical technique consisted of open reduction internal fixation (ORIF) with a compression screw from the medial to middle cuneiform and a “homerun” compression screw from the medial cuneiform to the base of the second metatarsal. PROMs, collected preoperatively and postoperatively, included the Foot and Ankle Ability Measure (FAAM), Veterans RAND 12-Item Health Survey (VR-12), and visual analog scale (VAS) pain scale. Patient satisfaction was assessed through a survey consisting of a 0-100 rating scale with “least satisfied” being 0 and “most satisfied” being 100. Statistical analyses to determine significance were completed through sample t-tests assuming unequal variance with significance set at P<.05. Results: Fourteen patients (14 feet) with an average age of 25.2±15.7 years sustained longitudinal Lisfranc injuries. Eleven of 14 patients competed in competitive sports when injured with football (n=5) being the most prevalent sport. Eleven patients underwent hardware removal an average of 3.6 months following their primary surgery. There were three cases of broken hardware, and one revision in which ORIF was converted to fusion. The average latest follow-up time for PROMs were 25.9 (range, 12-44) months. Results demonstrate a significant improvement in FAAM Total, FAAM ADL, and FAAM Sports scores at latest follow-up (Figure 1). There was also improvement in VR-12 Mental, VR-12 Physical, and VAS scores, though not statistically significant. Mean patient satisfaction at latest follow-up was 99/100. Conclusion: This study is the first to present data from a cohort of isolated longitudinal Lisfranc injuries. There is significant debate about surgical management of Lisfranc injuries. The improvement in PROMs at latest follow-up and high patient satisfaction suggests that ORIF may be an optimal surgical approach for management of longitudinal Lisfranc injuries.

Outcomes of Early Weightbearing Following Open Reduction and Internal Fixation in the Geriatric Population

Category: Ankle; Trauma Introduction/Purpose: Ankle fractures are the third most common extremity fracture, and its incidence is increasing in the elderly [1,2]. While the operative indications in ankle fractures have been established, there is no consensus regarding timing of weightbearing. There has been a growing trend towards early weightbearing due to its advantages in rehabilitation and return to function [3,4,5]. Even so, a survey study revealed that physicians tend to increase the non-weightbearing period for their geriatric population [6]. Expanding on our prior data which advocated for early weightbearing in ankle ORIF patients with syndesmotic injuries, we investigated the effects of early weightbearing after ankle ORIF in the geriatric population [7]. We hypothesized that there would not be an increased complication rate in this study cohort. Methods: A retrospective review was performed of patients over the age of 60 that underwent ankle ORIF at a level 1 trauma center and three neighboring community hospitals from 2015 to 2023. One of three senior surgeons were involved in all cases. Patient demographics, medical comorbidities, concomitant injuries, fixation method and complications were recorded. Maisonneuve injuries, fractures with articular surface involvement greater than 25%, open fractures, and revision cases were excluded. Patients with neuropathy were also excluded. All patients underwent an ORIF with possible syndesmotic fixation depending on intraoperative findings. Postoperatively, patients were 50% partial weightbearing for 2-3 weeks for a period of soft tissue and wound healing. After that, all patients were permitted to bear as much weight as tolerable. Results: 113 patients were identified that met our criteria. The average age was 72.6 years old. 25 were male and 88 were female. The average BMI was 26.8%. 60.2% of patients reported one or more medical comorbidities. The average follow-up time was seven months. We had zero major postoperative complications to report. We considered major complications to include: hardware failure, gross loss of reduction, need for revision ORIF, and accelerated post traumatic arthritis. Four patients were noted to have delayed wound healing. An additional four patients had minor surgical site infections that resolved with oral antibiotics. Six patients underwent hardware removal for various reasons. 65/113 (57%) patients received syndesmotic fixation of some form. Conclusion: This is the largest study to date reporting on effects of early weightbearing in the geriatric ankle ORIF population. In our study of 113 patients, all patients were allowed to weight bear as tolerated after short period of soft tissue rest, indiscriminate of syndesmotic injury or osteoporosis. We report no major complications and a limited number of soft tissues related complications. In a patient population with a known morbidity from prolonged immobility, as evidenced from the hip fracture literature, we hope our data helps to build confidence in early postoperative weightbearing [8].

Metal hypersensitivity in foot & ankle orthopaedic surgery: A systematic review

IntroductionMetal hypersensitivity affects 10–15% of individuals. Orthopaedic implants contain various metals and, therefore, metal hypersensitivity may impact patient outcomes. PurposeWe report a systematic review of the literature on metal hypersensitivity in patients undergoing foot and ankle (F&A) surgery. Our goal is to provide an overview presenting symptoms, diagnostic methods, treatment, and clinical outcomes. MethodsA comprehensive literature search of Ovid MEDLINE and EMBASE was performed from its inception (01-Jan 1966) to 23-Nov 2021. MeSH search terms on F&A were used including orthopaedic surgeries, metal types, and hypersensitivity. All full-text, English, experimental and observational studies reporting on metal hypersensitivity in the context of foot and/or ankle surgeries using metallic orthopaedic devices were included. Article screening, critical appraisal, and data extraction was performed by two reviewers. Disagreements were resolved by a third reviewer. ResultsFifteen studies were identified, reporting on 45 patients (18 male and 27 female). Median age was 58 years and mean follow-up was 20.8 months. 42 static and three arthroplasty implants were included. In total, 19 patients (42.2%) were diagnosed with metal hypersensitivity to a constituent of their implant, including two (4.4%) patients diagnosed without metal hypersensitivity testing. Twenty-six patients (57.8%) tested negative to their metal implant components. Of the 19 patients allergic to a constituent of their implant, 14 underwent hardware removal and improved. Four patients were asymptomatic and the last was symptomatic, but not revised. Of these, 23 patients retained their hardware (eight with skin reactions) and two symptomatic patients underwent hardware removal. ConclusionMetal hypersensitivity in the context of F&A surgery is not widely reported. It should be a differential diagnosis in patients who present with hypersensitivity-type symptoms once infection and mechanical failure are ruled out. This data informs a comprehensive algorithm for identifying and treating metal hypersensitivity in F&A patients. Level of evidenceLevel IV.

Medial oblique malleolar osteotomy for approach of medial osteochondral lesion of the talus.

The medial malleolar osteotomy is commonly performed to gain access to the medial talar dome for treatment of osteochondral lesions of the talus. The primary aim of this study was to assess osseous healing based on postoperative radiographs to determine consolidation, non-union and malreduction rates. Sixty-seven cases were reviewed where an oblique uniplanar medial malleolar osteotomy was performed to gain access to the medial talar dome for addressing an osteochondral lesion. Two, respectively three fully threaded 3.5mm corticalis screws were used to fixate the osteotomy. Postoperative radiographs were reviewed to assess consolidation, non-union, malreduction and dislocation of the osteotomy. Out of 67 patients, 66 patients had a consolidation of the osteotomy. 23.9% of the cases showed malreduction of the osteotomy. One patient suffered a non-union, which required a revision surgery. No significant difference was shown between two and three screws used for fixation in terms of malreduction and consolidation of the osteotomy. Eighty-four percent of the patients underwent hardware removal due to pain or medial impingement. The oblique medial malleolar osteotomy is a safe and relatively simple procedure with a high consolidation rate and low revision providing excellent exposure of the talus. The moderately high malreduction rate and required hardware removal surgery by most of the patients are relevant factors which should be considered before performing this surgery. Level III, retrospective cohort study.

Aucune différence dans les résultats cliniques et radiologiques après la fixation de fractures transversales de la rotule avec une fixation par une bandelette ou un cerclage métallique : une étude comparative rétrospective

IntroductionSeveral surgical techniques have been proposed for the treatment of patellar fractures. The aim of this study is to compare the clinical efficacy and complication rates of treatment using suture tape circumferential cerclage (STCC) and metallic wire circumferential cerclage (MWCC) for the surgical treatment of displaced transverse patellar fractures (TPFs). HypothesisThe hypothesis is that the use of the suture tape would be associated with a significantly lower rate of re-peration than metallic cerclage but no differences in other clinical outcomes. Patients and methodsA retrospective comparative analysis of the clinical outcomes of consecutive patients undergoing fixation of TPFs with either MWCC or STCC between January 2017 and December 2018 was undertaken. All patients underwent evaluation with standardised radiographs at one, three, and six months after surgery to determine rates of union, non-union, loss of fixation and malunion. All patients underwent a final clinical evaluation at 18 months post-operatively to evaluate clinical scores and complications. ResultsA total of 26 patients were included in the study. Thirteen patients underwent STCC and 13 underwent MWCC. There were no complications in the STCC group. In the MWCC group, one patient underwent hardware removal at two months post-operatively due to painful prominence. There was no significant difference in reoperation rates between the STCC and MWCC groups (p=1). There were no cases of non-union, malunion or loss of reduction throughout the series. At the final clinical follow-up of 18 months, there were no significant differences in KSS, KOOS or Böstman scores between the groups. ConclusionNo significant differences were identified when comparing the clinical outcomes of fixation of AO/OTA 34C1/2 fractures with suture tape or metallic cerclage fixation concerning re-operation rates, union rates, loss of fixation and functional outcome measures. These results cannot be extrapolated to more complex injury patterns or surgical techniques in which prominence of implanted material is more likely. Level of evidenceIII.

No difference in clinical and radiological outcomes following fixation of transverse patella fractures with either suture tape or metallic cerclage: A retrospective comparative study

IntroductionSeveral surgical techniques have been proposed for the treatment of patellar fractures. The aim of this study is to compare the clinical efficacy and complication rates of treatment using suture tape circumferential cerclage (STCC) and metallic wire circumferential cerclage (MWCC) for the surgical treatment of displaced transverse patellar fractures (TPFs). HypothesisThe hypothesis is that the use of the suture tape would be associated with a significantly lower rate of re-operation than metallic cerclage but no differences in other clinical outcomes. Patients and methodsA retrospective comparative analysis of the clinical outcomes of consecutive patients undergoing fixation of TPFs with either MWCC or STCC between January 2017 and December 2018 was undertaken. All patients underwent evaluation with standardised radiographs at one, three, and six months after surgery to determine rates of union, non-union, loss of fixation and malunion. All patients underwent a final clinical evaluation at 18 months postoperatively to evaluate clinical scores and complications. ResultsA total of 26 patients were included in the study. Thirteen patients underwent STCC and 13 underwent MWCC. There were no complications in the STCC group. In the MWCC group, one patient underwent hardware removal at 2 months postoperatively due to painful prominence. There was no significant difference in re-operation rates between the STCC and MWCC groups (p=1). There were no cases of non-union, malunion or loss of fixation throughout the series. At the final clinical follow-up of 18months, there were no significant differences in KSS, KOOS or Böstman scores between the groups. ConclusionNo significant differences were identified when comparing the clinical outcomes of fixation of AO/OTA 34C1/2 fractures with suture tape or metallic cerclage fixation concerning re-operation rates, union rates, loss of fixation and functional outcome measures. These results cannot be extrapolated to more complex injury patterns or surgical techniques in which prominence of implanted material is more likely. Level of evidenceIII.

Pediatric surgical rib fixation: A collected case series of a rare entity.

Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data. Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up. Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months. Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma. Collected case series, level V.

Arthroscopic coracoclavicular button fixation versus anatomic locking plate fixation for unstable distal clavicular fractures.

HypothesisNeer type II distal clavicle fractures are unstable and associated with high nonunion rates. The aim of this retrospective study was to compare the clinical and radiographic outcomes of anatomic locking plate fixation and arthroscopic coracoclavicular button fixation for unstable distal clavicle fractures.MethodsForty-seven patients with Neer type II distal clavicle fractures were treated surgically using either anatomic locking plate fixation (group 1, n = 20) or all arthroscopic coracoclavicular button fixation (group 2, n = 27) between 2012 and 2019 in 2 centers. Clinical and radiographic outcomes after an average follow-up period of 49 months for group 1 and 32 months for group 2 were assessed using the American Shoulder and Elbow Surgeons Shoulder score, Constant-Murley score, visual analog scale score and X-rays.ResultsAt the final follow-up, the mean American Shoulder and Elbow Surgeons Shoulder score, Constant-Murley score, and visual analog scale score for group 1 and group 2 were 92.5 ± 3.9 (range 88.3-98.3), 93.6 ± 4.0 (range 90-100), and 0.6 ± 0.6 (range 0-2) and 95 ± 3.3 (range 86.6-100), 96.2 ± 3.0 (range 88-100), and 0.4 ± 0.5 (range 0-1), respectively (P = .32, P = .15, and P = .59, respectively). At the final follow-up, acceptable reduction and bone healing were achieved in all patients. All patients in both groups were able to resume work as well as sports activities. Postoperative complications included 1 case of acromioclavicular joint arthritis and 1 case of screw penetration in group 1 and 2 cases of coracoid process fracture that did not require additional surgery in group 2. Five patients underwent hardware removal owing to skin irritation and dissatisfaction with the cosmetic appearance in group 1.ConclusionBoth distal anatomic locking plate fixation and arthroscopic coracoclavicular button fixation provide satisfactory functional and radiological outcomes. Both procedures can be used to treat distal clavicle fractures because they have a minimal risk of complications and present similar, high union rates.

Clinical feasibility of fracture healing assessment through continuous monitoring of implant load

Current fracture fixation follow-up is based on subjective radiological and clinical examination. Efforts to objectify the procedure have been undertaken since decades. Assessment of implant load as an indirect predictor of callus maturity has so far failed to enter clinical routine due to limited practicability, technical obstacles and its snap-shot nature.We recently introduced the concept of continuous implant load monitoring to aid in diagnosing fracture healing progression. This study aimed at investigating the feasibility of the system in a clinical context. Ten patients treated with Taylor-Spatial-Frame external fixators following pathological tibia fractures were equipped with a Fracture Monitor device attached to a fixator-strut and were monitored until hardware removal. Two patients were excluded due to technical issues.Implant load and fracture activity was continuously and autonomously measured for 139 ± 89 days (mean ± SD). Data was wirelessly collected with consumer smartphones. Relative implant load initially rose for 34.1 ± 22.2 days and finally declined to a level of 45.0 ± 33.8% of the maximum implant load. In five patients the load dropped below 50% of the maximum load. These patients underwent hardware removal according to the clinical assessment. In three patients, whose external fixators were exchanged to internal fixation at the end of the study, implant load did not drop below the 50% margin.The continuous measurement principle allows resolving implant load progression and appears indicative for the bone healing status. Data can be acquired in a homecare setting and is believed to provide valuable information to support timely healing assessment and enable patient specific after-care.

Outcomes of Supplementary Spring Wire Fixation With Volar Plating for Volar Lunate Facet Fragments in Distal Radius Fractures.

Intra-articular distal radius fractures with small volar lunate facet fragments can be challenging to address with volar plate fixation alone. Volar locked plating with supplementary spring wire fixation has been previously described in a small series but has not been further described in the literature. We hypothesized that this technique can provide adequate fixation for volar lunate facet fragments smaller than 15 mm in length, which are at risk of displacement. We completed a retrospective chart review (2015-2019) of patients who underwent volar locked plating with the addition of supplementary spring wire fixation for intra-articular distal radius fractures with a volar lunate facet fragment (<15 mm). Postoperative radiographs were assessed to evaluate union, evidence of hardware failure, escape of the volar lunate facet fragment, and postoperative volar tilt. Clinical outcome was assessed with wrist flexion/extension, arc of pronosupination, and Quick Disabilities of the Arm, Shoulder, and Hand Score (QuickDASH) scores. Fifteen patients were identified, of which all went on to fracture union. There were no hardware failures or escape of the volar lunate facet fragment at final follow-up. One patient underwent hardware removal for symptoms of flexor tendon irritation. The mean wrist flexion was 59°, wrist extension was 70°, pronation was 81°, and supination was 76°. The mean QuickDASH score was 18.5. The mean postoperative volar tilt was 3.6°. Supplementary spring wire fixation with standard volar plating provides stable fixation for lunate facet fragments less than 15 mm. This technique is a safe and reliable alternative to commercially available fragment-specific implants.

Salvage of Failed Femoral Neck Fracture Fixation with Conversion Total Hip Arthroplasty Using the Direct Anterior Approach.

PurposeFailed femoral neck fracture (FNF) fixation with in situ pinning presents a surgical challenge. Osteoporotic bone, retained hardware, and a typically elderly population magnify the risks of surgery. Here, outcomes of conversion total hip arthroplasty (THA) using two separate incisions in these high-risk patients were examined.Materials and MethodsMedical records for 42 patients with a prior history of FNF fixation who underwent conversion THA with hardware removal between 2009 and 2019 were retrospectively reviewed. Surgery was performed by a single surgeon at a single institution. All patients underwent hardware removal followed by direct anterior approach (DAA) THA using two separate incisions. Clinical outcomes, radiographic findings, and perioperative morbidity and mortality are reported.ResultsClinically, there were no postoperative dislocations, periprosthetic fractures, or infections at follow-up. After a mean follow-up of 4 years, the mean hip disability and osteoarthritis outcome score, junior (HOOS, Jr) was 91. Radiographically, the mean postoperative cup abduction was 44 degrees and the mean cup anteversion was 21 degrees with an improvement in preoperative leg length discrepancy. Perioperative complications included one case of immediate foot drop and two readmissions for medical issues. One patient died one month after conversion THA.ConclusionSalvage of failed FNF treatment may be managed with conversion THA and DAA with a separate incision for hardware removal. Preservation of posterior soft tissues using a DAA and intraoperative fluoroscopy may mitigate well-known complications related to fracture and dislocation. While favorable clinical outcomes are possible, salvage surgery is still not without substantial surgical and medical risks.

CORR Synthesis: Can Guided Growth for Angular Deformity Correction Be Applied to Management of Pediatric Patellofemoral Instability?

CORR Synthesis: Can Guided Growth for Angular Deformity Correction Be Applied to Management of Pediatric Patellofemoral Instability?

Effect of Early Weightbearing Following Open Reduction and Internal Fixation of Unstable Ankle Fractures on Wound Complications or Failures of Fixation.

There is a growing trend toward early weightbearing as tolerated (WBAT) after open reduction and internal fixation (ORIF) of ankle fractures. To date, studies have excluded fractures with associated syndesmotic injuries from their cohorts. In this retrospective cohort study, a chart review was performed at a single level 1 trauma center, identifying all unstable ankle fractures that underwent operative fixation between July 2016 and July 2017. After exclusion criteria, 63 patients were identified and 31 were included in the final analysis, with 14 undergoing syndesmotic fixation. WBAT was initiated after suture removal, between 2 and 4 weeks postoperatively. Outcomes included fracture union, radiographic maintenance of alignment, hardware failures, wound complications, and the need for repeat surgery. Weightbearing was initiated at an average of 17.8 days. All 31 patients progressed toward fracture union, with no hardware failures. Three patients developed superficial wound breakdown, which was treated with protected weightbearing in all cases and oral antibiotics in 1 case. All 3 went on to heal from their incisions. One patient had delayed wound breakdown and required a split-thickness skin graft that subsequently healed without complication. One patient underwent hardware removal 6 months postoperatively. There were no revision ORIF procedures. There is literature supporting early WBAT after ORIF of unstable ankle fractures in patients without major comorbidities. This article supports this trend, demonstrating that a group of ankle fractures requiring syndesmotic fixation were included in the early weightbearing cohort without a higher rate of catastrophic failure or increased wound problems. Level IV, retrospective cohort study.

Return to Sport and Patient Satisfaction Following Concomitant High Tibial Osteotomy and Osteochondral Allograft Transplantation

Objectives: Varus deformity of the knee predisposes patients to chondral and meniscal pathology of the medial compartment. Young patients with symptomatic chondral defects of the medial femoral with varus alignment often undergo concomitant opening wedge high tibial osteotomy (HTO) and cartilage restoration including allograft transplantation (OCA). Limited information is available regarding return to sporting activities after combined HTO and osteochondral allograft transplantation (OCA). Methods: All patients who underwent concomitant HTO and OCA by a single surgeon for medial knee pain due to a focal chondral defect of the medial femoral condyle were retrospectively identified through a prospectively collected data base. The primary indication for HTO was varus malalignment ≥ 5 degrees. At final follow-up, patients completed a subjective sports questionnaire, the Marx activity scale, a pain visual analog scale (VAS), a Single Assessment Numerical Evaluation (SANE), and a satisfaction questionnaire. Patients were excluded for having undergone any concomitant procedure other than cartilage restoration or &lt; 2 years of follow-up. Results: Of 39 concomitant HTO and OCA patients, 28 (71.8%) were available for follow-up at an average 6.07 +/- 4.09 years (range: 2-13 years). The average age at the time of surgery was 35.8 +/- 8.2 years, and 22 patients (78.6%) of patients were male. Four patients (14.3%) also underwent a concomitant medial meniscal allograft transplantation. Nearly all patients had undergone a prior ipsilateral knee surgery (26 patients, 92.8%). Reoperation was performed in 14 patients (50.0%) by the time of final follow-up for persistent symptoms: 6 patients received a meniscal debridement/meniscectomy, 2 patients received a total knee replacement, 1 patient received a unicompartmental knee arthroplasty, 4 patients underwent hardware removal, and 1 patient underwent autologous chondrocyte implantation of a new defect. Of the 22 patients who participated in sports within 3 years prior to their HTO + OAG, 18 patients (67.9%) returned to sport at an average of 11.4 +/- 6.4 months following operative management; however, only 35.7% of patients were able to return to their pre-injury level. Additionally, 60.7% of patients reported being satisfied or extremely satisfied with their return to sport activity. The most common reasons for discontinuing sports were: to prevent further damage (62.5%), persistent pain (54.2%), persistent swelling (33.3%), and fear of further injury (20.8%). Specific sports had high direct rates of return to sport: golf (100%), cross-fit/high-intensity (83.3%), cycling (88.9%), heavy-weightlifting (100%), swimming (60%), running (44.4%) (Figure 1). Conclusion: In a young and active population, concomitant HTO and OA provides a high rate of return to sport 11.4 months postoperatively, although only 35.7% could return to preinjury level or better. Additionally, at an average of 6.07 years following the index procedure, 60.7% of patients were satisfied regarding their sports and activities. When indicated, concomitant HTO and OCA may provide good results in young and active patients who wish to resume sports and physical activities.

Intramedullary Fixation of Distal Radius Fractures Using CAGE-DR Implant.

Purpose CAGE-DR implant is a novel Food and Drug Administration approved intramedullary fracture fixation device used for distal radius fractures. We examine a series of 22 patients and report the outcomes with this device. Materials and Methods A total of 24 patients with distal radius fractures (8 articular AO type C1/C2; 16 extra-articular AO type A2/A3) underwent open reduction and internal fixation (ORIF) using CAGE-DR implant by a single surgeon. Data including fracture type, angle of displacement, radiographic consolidation, grip strength, wrist range of motion (ROM), patient-rated wrist evaluation (PRWE), and Visual Analog Scale (VAS) pain scores were recorded at time of surgery and at standard follow-up. Results All 24 patients underwent uneventful ORIF. At first follow-up visit (9 days), all patients had full digital ROM (measured as 0 cm tip-to-palm distance). Two patients were lost to follow-up. Eighteen of the remaining 22 patients had sufficient radiographic follow-up and all 18 demonstrated healing. At latest follow-up (mean 9.7 months, range, 3-20), VAS pain scores averaged 0.6 (range, 0-8) and PRWE averaged 12.1 (range, 0-53.5). Grip strength of the operated hand averaged 58 lbs (range, 20-130). ROM included: wrist flexion 73° (50-95), wrist extension 78° (60-110), pronation 77° (60-90), supination 79° (60-90), ulnar deviation 31° (5-45), and radial deviation 17° (10-30). Three patients underwent screw removal to prevent tendon irritation. One patient underwent hardware removal due to prominence on imaging but was asymptomatic. There were otherwise no major complications, including complex regional pain syndrome, in the series to date. Conclusion The CAGE-DR fracture fixation system is a promising alternative to established methods of distal radius internal fixation. This series has a low reported pain score starting immediately postoperatively and a low complication rate. This novel device is a promising option for internal fixation of displaced distal radius fractures with a low complication profile. Level of Evidence This is a level IV, therapeutic study.

Outcomes Following Posterior and Posterolateral Plating of Distal Fibula Fractures.

Ankle fractures are common orthopaedic injuries often requiring open reduction and internal fixation. A variety of positions for plate placement exist for surgical fixation of distal fibula fractures, including direct lateral, posterior, or posterolateral. Direct lateral is more common, despite evidence that posterior and posterolateral placement is mechanically superior. However, concern for peroneal tendon injury from posterior plating remains. Our study investigates clinical and functional outcomes of patients who underwent operative fixation of distal fibula fractures with posterior or posterolateral plating over a 3-year period. Analyses were performed on 59 patients with at least 2 years of follow-up. Questionnaires were used to obtain demographic data, in addition to information regarding the presence of ankle pain, subsequent hardware removal, and Foot and Ankle Outcome Scores (FAOS). In patients with at least 2 years of follow-up (average 39.6 ± 10.6 months), 37.2% reported ongoing ankle pain; 11 patients underwent hardware removal (18.6%), with 8 patients undergoing removal because of hardware-related pain (13.6%). FAOS scores (n = 51) were as follows: pain (79.9 ± 22.3), activities of daily living (84.2 ± 22.6), symptoms (75.7 ± 23.5), sports (69.4 ± 31.6), and quality of life (58.3 ± 30.5). Posterior and posterolateral plating achieved good clinical and high functional outcomes across our study population. The percentage of hardware removal in our study was either equivalent to, or less than, historical controls for any type of fibular fixation, and removal may be helpful for those patients whose postoperative ankle pain is subjectively related to the hardware. Levels of Evidence: Therapeutic, Level IV: Retrospective.

Tibial Bone Grafting for Wrist Reconstruction.

Background Iliac crest bone graft harvesting is routinely performed for upper extremity orthopedic procedures despite high complication rates associated with sensory nerve injury, hematoma, chronic pain, and fracture. Description of Technique Cancellous bone graft is harvested from the proximal tibia using a medial approach, minimizing donor site morbidity. Patients and Methods A retrospective review was undertaken of 14 patients who underwent cancellous proximal tibia bone graft harvesting to augment healing of wrist reconstruction, with 2 months minimum follow-up. We report donor limb tourniquet time, time to union, visual analog scale (VAS) pain score, and complications. Patients were also contacted by phone to administer a retrospective questionnaire and record experiences with the harvesting technique. Results Average donor site VAS for the immediate postoperative period was 7.4. Average tourniquet time was 28 minutes. Average time to union of the recipient site was 45 days. One patient experienced delayed union after corrective osteotomy, attributed to osteoporosis. Two patients underwent hardware removal from the operative wrist, unrelated to bone graft harvesting. One patient with a history of chronic neuropathy and foot drop developed dysesthesia and allodynia about the ipsilateral ankle, but was asymptomatic at the proximal tibia donor site; ankle symptoms resolved 3 weeks postoperatively. No patient reported any residual donor site difficulties 24.2 months postoperatively. Conclusion In consideration of the minimal complication rate, favorable clinical parameters, and excellent patient tolerance, we advocate proximal tibia bone graft harvesting as opposed to iliac crest harvesting for wrist reconstruction when a moderate amount of autogenous cancellous graft is needed. Level of Evidence IV.