Maintaining the Neutral Axis in the Treatment of Distal Femur Fractures Via Dual Plate or Nail Plate Combination Technique: When and How?

SUMMARY

Distal femur fractures in the elderly have been historically treated with locked plating or retrograde intramedullary nailing with good, reliable results. However, in certain more complex fracture patterns (native or periprosthetic), increased density of fixation via dual-plate or nail plate combination can help achieve immediate weight-bearing. It can also potentially increase rates of union by shifting and maintaining the neutral axis, distributing forces more evenly across the fracture site. Here, we discuss the indications, pros and cons of both dual-plate and nail plate combination techniques in a concise case-based format.

Dorsal Thompson: Approach to the Proximal Radial Shaft

Treatment principles in the management of radial shaft fractures, congruent with all fracture care, are to restore anatomy and function of the limb. Radial shaft fractures are unique in that preserving the anatomic bow of the radius, which allows for its rotation around the ulna during pronation and supination, is essential for proper function. The 2 main approaches for exposure of the proximal or middle third radial diaphyseal fractures are the volar "Henry" and the dorsal "Thompson." This article highlights the benefits of the dorsal Thompson approach, describes the key points of the operative technique, which allow for protection of the posterior interosseous nerve, and provides an overview of the measurable outcomes when using this approach. In the accompanying video, the steps of operative exposure to the proximal radial shaft with careful avoidance of the posterior interosseous nerve are demonstrated.

Is supplemental regional anesthesia associated with more complications and readmissions after ankle fracture surgery in the inpatient and outpatient setting?

BACKGROUND

There is concern that regional anesthesia is associated with increased risk of complications, including return to the hospital for uncontrolled pain once the regional anesthetic wears off.

METHODS

Retrospective database review of patients who underwent open reduction and internal fixation of a closed ankle fracture from 2014-16 who received general anesthesia alone (GA) or general anesthesia plus regional anesthesia (RA).

RESULTS

9459 patients met inclusion criteria. Patients in the RA group had significantly longer operative duration in both inpatient (GAI=71min vs RAI=79min, p=0.002) and outpatient setting (GAO=66min vs RAI=72min, p<0.001), lower overall LOS (GA=1.7 days vs RA=1.1 days, p<0.001), and higher readmission rate for pain (RAO=4 [0.3%] vs GAO=1 [0.0%], p=0.007).

CONCLUSIONS

Patients who received supplemental regional anesthesia had shorter hospital LOS, increased operative time, and increased readmission rates for rebound pain. However, the small number of patients needing readmission are not clinically significant demonstrating that regional anesthesia is safe, effective and readmission for rebound pain should not be a concern.

LEVEL OF EVIDENCE

III.

Newer generation of proximal tibia locking plates demonstrate large variability in their ability to capture the posteromedial fragment in bicondylar tibial plateau fractures

INTRODUCTION

The early generations of proximal tibial locking plates demonstrated inferior results when compared to dual plating in bicondylar tibial plateau fractures with posteromedial fragments (PMF). Modern plates have multiple rows of locking screws and variable angle technology -which tote the ability to capture the PMF. The purpose of this study was to determine if the modern plates could capture the PMF in a large series of bicondylar tibial plateau fractures.

MATERIALS & METHODS

Axial computer topography (CT) scans of 114 bicondylar tibial plateau fractures with PMF were analyzed. Five proximal tibia locking plates-in seven total configurations-were applied to radiopaque tibiae models. All possible screws were placed. Templates of screw trajectories were created based on the model CT scans. These were superimposed onto patient CT scan images to assess for screw penetration into the PMF. Number of screws fully within the PMF were recorded. Capture of the PMF was defined as having at least two screws within the fragment.

RESULTS

On average, all plates were able to capture 81.6% of PMF with an average of 3.77 [95% Confidence Interval (CI): 3.47-4.07] screws. However, their ability to capture all fragments varied greatly, from 55.7%-95.2% in fixed angle constructs. Overall, variable angle constructs had a significantly higher capture rate (98.5% vs. 74.9%; p<0.0001) and more screws in the PMF (5.88 [95% CI: 5.58-6.17] vs 2.93 [95% CI: 2.62-3.24]; p<0.0001) when compared to fixed angle constructs.

CONCLUSION

Newer generation locking plates vary greatly in their ability to capture the PMF. Variable angle technology dramatically increases the ability to capture the majority of PMFs. Prior biomechanical and clinical studies may yield substantially different results if repeated with these newer implants. Use of newer generation locked plates should not replace thorough preoperative planning.

A Review of Impact of Textile Research on Protective Face Masks

COVID-19, classified as SARS-CoV-2, is causing an ongoing global pandemic. The pandemic has resulted in the loss of lives and has caused economic hardships. Most of the devices used to protect against the transmission of the novel COVID-19 disease are related to textile structures. Hence, the challenge for textile professionals is to design and develop suitable textile structures with multiple functionalities for capturing viruses, passivating them, and, at the same time, having no adverse effects on humans during the complete period of use. In addition to manufacturing efficient, biocompatible, and cost-effective protective face masks, it is also necessary to inform the public about the benefits and risks of protective face mask materials. The purpose of this article is to address the concerns of efficiency and efficacy of face masks by primarily reviewing the literature of research conducted at the Technical University of Liberec. The main focus is on the presentation of problems related to the specification of aims of face mask applications, mechanisms of capture, durability, and modes of sterilization. The recommendations, instead of conclusions, are addressed to the whole textile society because they should be leading players in the design, creation, and proper treatment of face masks due to their familiarity with the complex behavior of textile structures and targeted changes of structural hierarchy starting from polymeric chains (nano-level) and ending in planar textile structures (millimeter level) due to action by mechanical, physical and chemical fields. This becomes extremely critical to saving hundreds of thousands of lives from COVID-19.

Leveraging Existing Institutional Resources to Maintain Quality Assurance Practices in Anatomic Pathology in the Era of Social Distancing

Introduction/Objective

Due to the COVID-19 pandemic, hospitals had to adapt practices to incorporate social distancing while maintaining quality assurance (QA) in anatomic pathology (AP). Prior to this, our general surgical pathology (SP) and cytopathology (CP) services held daily consensus conferences (CC) at a multi-headed microscope. Implementing social distancing meant only a few faculty were present onsite and avoidance of interactions at the multi-headed scope. In an effort to preserve QA through CC, faculty exploited the use of web conferencing through our HIPAA-compliant Zoom. We describe the utility of this new practice.

Methods

From 3/25-4/30/20, all SP and CP cases selected for CC were presented by respective pathologists (n=8) in their own offices by using individual microscopes with cameras, image acquisition software, and screen-sharing through Zoom. One pathologist was responsible for sending out a new CC Zoom link daily and recording the consensus diagnosis. All onsite pathologists and those at home participated.

Results

We presented 95 SP and 31 CP cases through Zoom compared to 300 SP and 60 CP cases presented at a similar timeframe prior to social distancing. This 68% and 48% decline could be attributed to elective procedure cancellation. We assigned a consensus diagnosis to all cases, with 77% overall being malignant diagnoses, and breast being the most common SP specimen type (22%). Additionally, all participating pathologists felt comfortable with the new format irrespective of being onsite or at home. Apart from minor audio issues, we did not notice significant lag time or visual disturbances that interfered with diagnostic abilities. Importantly, the transition did not involve investing in new technology.

Conclusion

The new virtual CC allowed our department to maintain QA practices in AP without sacrificing quality and serves as a starting point to investigating the use of this technology to other applications in AP, such as overnight frozen sections.

Pulmonary Granuloma Associated with Pneumocystis Jirovecii in a Patient with Peripheral T-Cell Lymphoma: Presentation of a Rare Case with Review of the Literature

Casestudy: Although Pneumocystis jirovecii (PJ) is a known opportunistic pulmonary infection among immunocompromised patients, it is a rare (&lt;5%) cause of pneumonia in this cohort. Majority of cases are observed in patients with HIV or solid organ transplant recipients. Granuloma formation in patients infected with PJ is even rarer. We present a case of multiple pulmonary granulomas associated with PJ in a non-HIV patient. A 49-year-old female with a history of asthma presented with worsening dyspnea. Initial imaging revealed multifocal bilateral areas of consolidation and a diagnostic bronchoalveolar lavage (BAL) demonstrated PJ organisms. Additional investigation was pursued to determine the etiology of this infection in a seemingly immunocompetent patient. New findings noted during hospitalization included a new maculopapular skin rash, significant weight loss, and lymphopenia. A bone marrow biopsy revealed a clonal proliferation of plasma cells. Subsequent imaging revealed mediastinal adenopathy. There was no improvement in symptoms despite treatment for pneumonia and a month later, a lung wedge biopsy revealed organizing acute lung injury and multiple non-caseating granulomas without lymphoid rimming, asteroid, or Schaumann bodies. Silver stain highlighted numerous PJ organisms within and outside of the granulomas. An inguinal lymph node and skin biopsies eventually revealed involvement by peripheral T-cell lymphoma (PTCL). Repeat BAL revealed clearance of organisms after additional therapy; however, the PTCL was refractory to chemotherapy and palliative care was pursued. To date, we could only find &lt;30 cases of pulmonary PJ granulomas in patients with hematologic malignancies. Most are in patients with B cell lymphomas and just 1 report in a patient with adult T-cell leukemia/lymphoma. In summary, this case highlights that PJ associated pulmonary granulomas are uncommon, can be a harbinger of an underlying immunocompromised state, such as a lymphoma, and are even rarer to be associated with PTCL.

The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population

OBJECTIVE

The purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications.

DESIGN

Retrospective case control study.

SETTING

Academic level-1 trauma center.

PATIENTS/PARTICIPANTS

Patients with long bone, lower extremity fractures requiring operative fixation.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

Postoperative hospital admissions, emergency room (ER) visits, and reoperations.

RESULTS

399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9-39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003).

CONCLUSIONS

Our study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.

Below-Knee Amputation Resulting from an Arterial Thrombosis from Tourniquet Use in a Patient with Undiagnosed Factor V Leiden: A Case Report

CASE

A 38-year-old woman presented with previously undiagnosed factor V Leiden (FVL), who suffered a complete superficial femoral arterial thrombosis after tourniquet use during the surgical repair of one of her bilateral tibial plafond fractures. This patient's injury eventually resulted in a below-knee amputation.

CONCLUSION

We recommend expanding hypercoagulable screening on patients with risk factors based on a detailed history and physical examination. We also recommend limiting or negating tourniquet use in patients with FVL or other hypercoagulable disorders.

Anterolateral distal tibia locking plate osteosynthesis and their ability to capture OTAC3 pilon fragments

BACKGROUND

Intra-articular Pilon fractures remain therapeutically challenging due to osteochondral fracturing and comminution, marginal impaction, and insult to the soft tissue envelope. The purpose of this study was to compare the efficacy of anterolateral distal tibial locking plates in capturing main fracture fragments in tibial plafond fractures.

METHODS

From May 2011 to Dec 2015, 169 OTA C-type pilon fractures met inclusion and exclusion criteria with computed tomographic (CT) scans performed prior to definitive fixation. For each patient, the fracture lines were mapped, digitized, and graphically superimposed to create a compilation of fracture lines. Based on these average measurements, three distal tibia sawbones had three different anterolateral plates applied. Axial CT scan images were used to determine the efficacy of screw purchase in main fracture fragments in pilon fractures.

RESULTS

The Smith & Nephew PERI-LOC plate secured the largest number of fracture lines (90.1%) but missed the Volkmann fragment with greatest frequency at 3.6%. The Synthes 2.7/3.5 mm VA-LCP captured 87.3% of the fracture lines while missing the Volkmann fragment 3.2% of the time. The Synthes 3.5 mm LCP captured 86.5% of the fracture lines but was the best at securing the Volkmann fragment (1.2% missed). All three implants were deficient in capturing the medial malleolar fragment. The PERI-LOC and 2.7/3.5 mm VA-LCP did not differ with respect to percentage of fragments captured (p = 0.721) but both outperformed the 3.5 mm LCP (p = 0.021 and p = 0.05, respectively).

CONCLUSIONS

This study was consistent with prior literature in defining three main fracture fragments: anterior, medial, and posterior. All three plates were deficient in capturing the medial malleolar fragment. The Smith and Nephew PERI-LOC plate secured the most number of fracture lines, while the Synthes 3.5 mm LCP was least likely to miss the Volkmann fragment and most likely to miss the medial malleolar fragment. No plate was found to be superior to the other in capturing all fracture lines of the OTAC3 pilon fragments.

LEVEL OF EVIDENCE

Three.

Coronal Plane Deformity Correction in Distal Radius Fracture Fixation With the Volar Locking Plate

The goal of treatment for distal radius fractures is anatomic articular reduction and restoration of coronal and sagittal plane alignment, rotation, and angulation of the metadiaphyseal component of these fractures. This article presents a reproducible technique for restoring coronal plane alignment of the metadiaphyseal component of the fracture using an indirect reduction maneuver leveraging the volar locking plate as an indirect reduction aid. After applying an appropriately sized volar locking plate, the first screw is placed in the center of the shaft of the plate. Next, the distal row of subarticular locking screws is placed to neutralize a reduced articular surface. The shaft screw is subsequently loosened, and two Freer elevators are used to rotate the plate, indirectly translating the distal articular block and achieving improved coronal plane alignment. Last, the remaining diaphyseal screws are applied to appropriately neutralize the fracture. (Journal of Surgical Orthopaedic Advances 27(2):160-163, 2018).

Use of Volar Plate for Indirect Coronal Plane Reduction in an Intraarticular Distal Radius Fracture

Management of intraarticular distal radius fractures requires precise reconstruction of the articular surface to optimize outcomes. Treatment goals also include restoration of alignment, rotation, and angulation in both the coronal and sagittal planes of the metaphyseal component of these fractures. Surgical management with open reduction and internal fixation with a volar plate is often the preferred method of open treatment. However, a variety of different techniques have been described, and the preferred technique may be determined on an individual basis by the fracture characteristics, patient-dependent factors, or surgeon experience.

Thromboembolic Disease in Patients with Metastatic Femoral Lesions: A Comparison Between Prophylactic Fixation and Fracture Fixation

BACKGROUND

We are not aware of any previous studies that have compared the rate of venous thromboembolic events in patients who underwent prophylactic intramedullary nailing because of an impending fracture with the rate in patients who underwent intramedullary nailing after a pathological fracture. The objective of the present study was to determine if the rate of venous thromboembolic events varies between patients who are managed with prophylactic fixation and those who are managed with fixation after a pathological fracture.

METHODS

We performed a retrospective comparative study in which the Nationwide Inpatient Sample database was used to identify all patients who had undergone femoral stabilization, either for a pathological femoral fracture or for prophylactic fixation of femoral metastatic lesion, over a period of 10 consecutive years (between 2002 and 2011) in the United States. Demographic data, comorbidities, venous thromboembolic event rates, and other common postoperative complications were compared between the 2 groups.

RESULTS

Patients who were managed with prophylactic fixation had significantly higher rates of pulmonary embolism (p < 0.001; adjusted odds ratio, 2.1) and deep-vein thrombosis (p = 0.03; adjusted odds ratio, 1.5). Patients who were managed with fixation after a pathological fracture had a significantly greater need for blood transfusion, higher rates of postoperative urinary tract infection, and a decreased likelihood of being discharged to home (p < 0.001 for all).

CONCLUSIONS

Patients with metastatic disease who undergo prophylactic intramedullary nailing have higher observed rates of venous thromboembolic events than those who undergo nailing for the treatment of a pathological fracture and should be actively and vigilantly managed in the postoperative period.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Utility of portable monitoring in the diagnosis of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common but underdiagnosed sleep disorder, which is associated with systemic consequences such as hypertension, stroke, metabolic syndrome, and ischemic heart disease. Nocturnal laboratory-based polysomnography (PSG) is the gold standard test for diagnosis of OSA. PSG consists of a simultaneous recording of multiple physiologic parameters related to sleep and wakefulness including electroencephalography (EEG), electrooculography (EOG), surface electromyography (EMG), airflow measurement using thermistor and nasal pressure transducer, pulse oximetry and respiratory effort (thoracic and abdominal). Multiple alternative and simpler methods that record respiratory parameters alone for diagnosing OSA have been developed in the past two decades. These devices are called portable monitors (PMs) and enable performing sleep studies at a lower cost with shorter waiting times. It has been observed and reported that comprehensive sleep evaluation coupled with the use of PMs can fulfill the unmet need for diagnostic testing in various out-of-hospital settings in patients with suspected OSA. This article reviews the available medical literature on PMs in order to justify the utility of PMs in the diagnosis of OSA, especially in resource-poor, high-disease burden settings. The published practice parameters for the use of these devices have also been reviewed with respect to their relevance in the Indian setting.

Life-stage Analysis of Solvent Induced Fissures under Static Stress in PET Fibers

The paper discusses the impact of drawing poly(ethylene terephthalate) (PET) fibers in the presence of solvents, which consist of the first five homologues of aliphatic primary alcohols, namely methanol to amyl alcohol. The solvent induced deformation under tensile load leads to surface fissures characterized by four stages: fissure formation (birth), incipient draw (neck formation), partial draw, and full draw. This process results in internal void formation in the presence of a propagating neck. A design of experiment (DOE) was performed to screen out the process parameters critical for understanding surface fissure formation. Four process parameters were investigated: initial material properties (orientation); environment of draw (i.e. type of alcohols used as solvent); rate of extension; and amount of extension. The response of solvent induced deformation were characterized by the natural draw force reduction; number of fissures formed at time of birth, fissure width at time of formation, and neck angle. Of all the four process parameters involved, the analysis indicates that the material properties and amount of extension were the best predictors of solvent induced fissure formation. Organic solvents reduce the tension required for draw and create internal voids, a porous network, with possibly the penetrant being “sucked” into the interior of PET fibers drawn in the presence of alcohols.

The effects of sustained delivery of alendronate on the kidney in ovariectomized female rats

Bisphosphonates are indicated for the treatment and prevention of osteoporosis in adults; the treatment and prevention of glucocorticoid-induced osteoporosis; the treatment of Paget’s disease; and the treatment of multiple myeloma in patients with documented bone metastases. Two long-term trials in cancer patients demonstrated an increase in serum creatinine (SCr) when 8 mg of bisphosphonate was administered, prompting a recommendation to reduce the dose to 4 mg. The risk for renal toxicity remains a possibility following chronic administration of bisphosphonate treatment for osteoporosis. The goal of the study was to evaluate the kidney of osteoporotic female rats following chronic administration of alendronate using a drug delivery device for 4 weeks and compare the finding with control non-ovariectomized animals, ovariectomized control animals (OVX), and ovariectomized animals with an empty drug delivery system. The results of the study showed significant increases in body weights in the ovariectomized animals compared with non-ovariectomized animals. The organ wet-weights were not statistically different between the control and treatment groups or the ovariectomized and non-ovariectomized animals. Histological and histomorphometric analysis of the kidney revealed significant changes in the glomerular area on alendronate treated animals at 4 weeks when compared with ovx, ovx-sham and control non-ovariectomized animals. The results indicate chronic use of alendronate for osteoporosis may impair renal function or increase renal related problems in patients with existing kidney disease.

Impaired blood pressure recovery to hemorrhage in obese Zucker rats with orthopedic trauma

We have shown that obese Zucker rats with orthopedic trauma (OZT) exhibit a loss of arteriolar tone in skeletal muscle. We hypothesize that the loss of arteriolar tone in OZT blunts vasoconstrictor responses to hemorrhage, resulting in an impaired blood pressure recovery. Orthopedic trauma was induced with soft tissue injury and local injection of bone components in both hindlimbs in lean (LZT) and OZT (11-13 wk). One day after the orthopedic trauma, blood pressure responses following hemorrhage were measured in conscious control lean, control obese, LZT, and OZT. In another set of experiments, the spinotrapezius muscle of control and trauma animals was prepared for microcirculatory observation. Arteriolar responses to phenylephrine (PE) or hemorrhage were determined. Hemorrhage resulted in similar blood pressure responses in control animals and LZT, but the blood pressure recovery following hemorrhage was blunted in the OZT. In the spinotrapezius, OZT exhibited decreased arteriolar tone and blunted vasoconstrictor responses to PE and hemorrhage. Treatment with glibenclamide improved the blood pressure recovery in the conscious OZT and improved the arteriolar tone, and PE induced vasoconstriction in the spinotrapezius of the OZT. Thus, ATP-dependent K(+) channel-mediated loss of arteriolar tone in OZT blunts the arteriolar constriction to hemorrhage, resulting in impaired blood pressure recovery.

Orthopedic trauma-induced pulmonary injury in the obese Zucker rat

OBJECTIVE

Obese subjects with orthopedic trauma exhibit increased inflammation and an increased risk of pulmonary edema. Prostaglandin E(2) (PGE(2) ) production is elevated during inflammation and associated with increased vascular permeability. We hypothesize that pulmonary edema in obesity following orthopedic trauma is due to elevated PGE(2) and resultant increases in pulmonary permeability.

METHODS

Orthopedic trauma was induced in both hindlimbs in lean (LZ) and obese Zucker rats (OZ). On the following day, plasma interleukin-6 (IL-6) and PGE(2) levels, pulmonary edema, and pulmonary gas exchange capability were compared between groups: LZ, OZ, LZ with trauma (LZT), and OZ with trauma (OZT). Vascular permeability in isolated lungs was measured in LZ and OZ before and after application of PGE(2) .

RESULTS

As compared with the other groups, the OZT exhibited elevated plasma IL-6 and PGE(2) levels, increased lung wet/dry weight ratio and bronchoalveolar protein concentration, and an impaired pulmonary gas exchange. Indomethacin treatment normalized plasma PGE(2) levels and pulmonary edema. Basal pulmonary permeability in isolated lungs was higher in OZ than LZ, with a further increase in permeability following treatment with PGE(2) .

CONCLUSIONS

These results suggest that pulmonary edema in OZ following orthopedic trauma is due to an elevated PGE(2) and resultant increases in pulmonary permeability.