Management of Chronic Fracture-Related Infection.

Chronic fracture-related infection is a complex, costly clinical problem with a wide spectrum of clinical presentations. The goals of treatment are infection control with a healed fracture covered by well-vascularized soft tissue and improvement of patient pain and function. Management is both medical, with culture-targeted antimicrobial agents, and surgical, requiring meticulous irrigation and débridement.

Management of Acute and Subacute Fracture-Related Infection.

Fracture-related infection (FRI) is a serious complication that occurs primarily in surgically treated fractures. FRIs occur when bacteria enter the site of bony injury and alter the healing inflammatory response within the bone. This can prevent bone regeneration and can lead to long-lasting complications such as chronic infection, pain, nonunion, and amputation.

Prevention of Fracture-Related Infection.

Fracture-related infections are a significant burden to the patient, associated with high health care costs and use of resources. Therefore, prevention is more critical than treatment of infection. There are injury- and patient-related risk factors that are mostly not modifiable, with the exception of a few patient-specific ones such as control of blood glucose levels in patients with diabetes.

Diagnosis and Evaluation of Fracture-Related Infection.

Following fracture fixation, fracture-related infection (FRI) is a common complication and requires systematic evaluation to allow for an optimal treatment strategy. A high index of suspicion is necessary for early and timely diagnosis, to diagnose occult infection, and to prevent untreated infections from worsening. Diagnosis of FRI includes evaluation based on history and clinical examination, surgical exploration, serum inflammatory markers, imaging modalities, microbiology, histopathology, and, when needed, molecular biology.

Disintegration of Multiple Parts of a Bone Transport Nail During Planned Removal: A Case Report.

Case: A 34-year-old man with a distal tibia bone defect was treated with an intramedullary bone transport nail (Precice Bone Transport System, NuVasive). During planned removal after successful treatment, 7 separate subcomponents of the nail became disconnected and had to be separately removed using specialized instrumentation. This occurred despite adherence to the manufacturer's recommended technique for nail removal and in the absence of clinical or radiographic evidence of implant failure.

Management of greater tuberosity fracture dislocations of the shoulder.

Background: Despite extensive literature dedicated to determining the optimal treatment of isolated greater tuberosity (GT) fractures, there have been few studies to guide the management of GT fracture dislocations. The purpose of this review was to highlight the relevant literature pertaining to all aspects of GT fracture dislocation evaluation and treatment.

Methods: A narrative review of the literature was performed.

Humerus fractures: selecting fixation for a successful outcome.

Current evidence suggests at least one-third of humeral shaft fractures initially managed nonoperatively will fail closed treatment, and this review highlights surgical considerations in those circumstances. Although operative indications are well-defined, certain fracture patterns and patient cohorts are at greater risk of failure. When operative intervention is necessary, internal fixation through an anterolateral approach is a safe and sensible alternative.

Suture button placed beneath plate fixation for complex distal clavicle fractures and acromioclavicular joint injuries: a technical note.

Patients with complex distal clavicle and acromioclavicular (AC) joint injuries are at risk of loss of reduction, especially when plates are removed postoperatively. The purpose is to review the authors' preferred technique for treatment of distal clavicle and AC joint injuries utilizing combined suture button and plate fixation, aiming to optimize biomechanical strength of fixation and limit loss of reduction after implant removal. Pre-contoured locking plates or hook plates were utilized atop suture buttons to maintain reduction and optimize biomechanical strength.

Anatomic Osteochondral Allograft Reconstruction for Concomitant Large Hill-Sachs and Reverse Hill-Sachs Lesions.

Glenohumeral instability causing bipolar bone loss is increasingly being recognized and treated to minimize recurrence. Large Hill-Sachs and reverse Hill-Sachs lesions of the humerus must be addressed at the time of surgery to prevent recurrent dislocations and restore the native anatomic track. For patients with epilepsy, locked dislocations may create defects that must be addressed with bony procedures, including osteochondral allograft reconstruction as soft-tissue remplissage may not adequately addresses the magnitude of the bone loss.

Displaced Intra-articular Calcaneus Fractures: Extensile Lateral and Less Invasive Approaches.

Treatment of displaced intra-articular calcaneal fractures is controversial and must be individualized by patient and fracture type. With an extensile lateral approach, all components of the deformity in displaced intra-articular calcaneal fractures can be addressed. The extensile lateral approach is indicated in more complex fracture patterns and when delay of surgery is necessary because of severe soft-tissue injury beyond 2 to 3 weeks.

Fractures of the Talus and Pantalar Dislocations.

Talar fractures and pantalar dislocations are usually the results of high-energy trauma. Dislocations and open injuries are managed urgently. Temporary stabilization with splinting, Kirschner wires, or external fixation may be performed until the soft tissues are ready for definitive fixation.

Difficult Diaphyseal Femur Fractures: Pearls and Pitfalls.

Diaphyseal femur fractures are common injuries globally and range in complexity. The most common mechanism worldwide is motor vehicle accidents. Initial evaluation should include Advanced Trauma Life Support protocol and evaluation of the soft tissues, neurovascular examination, and associated injuries.

Subtrochanteric Femur Fractures: Pearls and Pitfalls.

Management of subtrochanteric femur fractures is challenging because of the multiple planes of fracture deformity. Specific techniques starting with patient positioning and appropriate operating room table selection can improve the efficiency of the surgery. Sequential reduction techniques starting with closed methods, percutaneous techniques, and finally open clamping can be performed to obtain anatomic reduction of the fracture.

Intertrochanteric Hip Fractures: Pearls and Pitfalls in Managing Difficult Fractures.

Intertrochanteric hip fractures are among the most common osteoporotic fractures seen by orthopaedic surgeons. These fractures have a significant effect on a patient's mobility, independence, and mortality. In addition, they represent a substantial component of health care spending.

Femoral Neck Fractures in Young and Middle-Aged Adults: Pearls and Pitfalls.

The management of femoral neck fracture in young and middle-aged adults remains challenging. Although the influence of timing on the outcome is controversial, surgical management within 12 hours is recommended. Reduction quality is the most important modifiable factor that is correlated with outcomes.

Incidence and risk factors of clinically important venous thromboembolism in tibial plateau fractures.

While there are multiple reports on venous thromboembolism (VTE) associated with several orthopedic procedures, the knowledge regarding incidence and risk factors of VTE in tibial plateau fractures is limited. This study aimed to investigate the incidence and risk factors of clinically important venous thromboembolism (CIVTE) in patients with tibial plateau fractures. All adult patients who underwent surgical treatment of tibia plateau fractures between 2003 and 2018 in our level 1 trauma center were included in the study.

Anatomic Radial Head Arthroplasty: The Importance of Implant Angle.

Purpose: Multifragmentary radial head and neck fractures not amenable to open reduction and internal fixation are usually treated with radial head arthroplasty (RHA). Although the optimal implant design is still subject to debate, anatomic designs are common. We hypothesized that positioning of the implant leading to increased radial stem angle (RSA) (angle of the RHA stem with respect to the proximal radius shaft, RSA) in anatomic RHA designs will contribute to failures.

Interobserver and Intraobserver Reliability of Classification Systems for Radiographic Complications After Radial Head Arthroplasty.

Purpose: Although several classifications are used to assess radiographs following radial head arthroplasty (RHA), including the Popovic classification for radiolucency, the Chanlalit classification for stress shielding (SS), the Brooker classification for heterotopic ossification (HO), and the Broberg-Morrey classification for radiocapitellar arthritis, little is known about the reliability of these classification systems. The purpose of this study was to determine the interobserver and intraobserver reliability of these classifications.

Methods: Six orthopedic surgeons at various levels of training reviewed elbow radiographs of 20 patients who underwent RHA and classified them according to the Popovic, Chanlalit, Brooker, and Broberg-Morrey classifications for radiolucency, SS, HO, and RHA, respectively.

Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment.

Perioperative pain management remains an important focus of both patient and provider attention in orthopaedic trauma surgery. There is a constant effort to improve pain management while decreasing opioid consumption, and peripheral nerve blocks are a safe and effective way to achieve these two goals. This is particularly relevant because more procedures are being done in outpatient surgery centers, and the need to safely provide analgesia without the systemic risk of opioid medications is paramount.

Intraoperative Fluoroscopy for Correcting Rotational Malalignment After Fixation of Tibial Shaft Fracture: A Case Report.

Case: A 29-year-old man previously treated with closed reduction and intramedullary nail (IMN) fixation for a right tibial shaft fracture presented with complaint of the foot pointing outward compared with uninjured side. He was diagnosed with tibial malrotation, and a novel intraoperative imaging technique was used for correction.

Conclusion: Literature suggests that the prevalence of tibial malrotation after IMN fixation is greater than previously thought.

Protocol-based interdisciplinary co-management for hip fracture care: 3 years of experience at an academic medical center.

Background: Interdisciplinary standardized protocols for the care of patients with hip fractures have been shown to improve outcomes. A hip fracture protocol was implemented at our institution to standardize care, focusing on emergency care, pre-operative medical management, operative timing, and geriatrics co-management. The aim of this study was to evaluate the efficacy of this protocol.