SACRAL FRACTURE TREATMENT WITH A VARIATION OF THE LUMBOPELVIC FIXATION TECHNIQUE

ABSTRACT Spinopelvic instability is an uncommon injury that is caused by high-energy traumas. Surgical treatment is used, in the majority of cases, to restore stability and enable early mobilization. Various stabilization techniques have been used in the treatment of spinopelvic instability, and lumbopelvic fixation (LPF) is currently the technique of choice due to its biomechanical superiority. One of its limitations is the fact that the technique does not directly address the lower sacral segment, permitting a residual kyphotic deformity. This deformity has been attributed to unsatisfactory outcomes, including late development of pelvic floor muscle defects and complications during childbirth. We report a case of a patient with spinopelvic instability due to sacral fracture, which was treated using a variation of the LPF technique, in which rods and screws originally developed for cervicothoracic fixation were adapted to correct sacral deformity in the sagittal plane. The upper sacral segment was reduced indirectly using hip extension and femoral traction manoeuvres, associated with distraction manoeuvres via rods. Bone reduction forceps were used to reduce the kyphotic deviation in the lower sacral fragment, enabling its fixation to the lumbopelvic rod and screws system. There were no complications of infection, suture dehiscence, or breakage of the implants, and at the end of the first year of follow-up, the sacral kyphosis was normal and radiographic consolidation was confirmed. Our technique provides a viable and promising alternative to traditional LPF, making it especially useful in fractures with accentuated deviations of the lower sacral fragment. Level of Evidence: 4.Type of study: Case series

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Plafond Malreduction and Talar Dome Impaction Accelerates Arthrosis After Supination-Adduction Ankle Fracture

Foot & Ankle International ◽

10.1177/10711007211006032 ◽

2021 ◽

pp. 107110072110060

Author(s):

Michael F. Githens ◽

Malcolm R. DeBaun ◽

Kimberly A Jacobsen ◽

Hunter Ross ◽

Reza Firoozabadi ◽

...

Keyword(s):

Case Series ◽

High Energy ◽

Ankle Fractures ◽

Posttraumatic Arthritis ◽

Retrospective Case ◽

Level Of Evidence ◽

Radiographic Findings ◽

Posttraumatic Arthrosis ◽

Patient Reported

Background: Supination-adduction (SAD) type II ankle fractures can have medial tibial plafond and talar body impaction. Factors associated with the development of posttraumatic arthritis can be intrinsic to the injury pattern or mitigated by the surgeon. We hypothesize that plafond malreducton and talar body impaction is associated with early posttraumatic arthrosis. Methods: A retrospective cohort of skeletally mature patients with SAD ankle fractures at 2 level 1 academic trauma centers who underwent operative fixation were identified. Patients with a minimum of 1-year follow-up were included. The presence of articular impaction identified on CT scan was recorded and the quality of reduction on final intraoperative radiographs was assessed. The primary outcome was radiographic ankle arthrosis (Kellgren-Lawrence 3 or 4), and postoperative complications were documented. Results: A total of 175 SAD ankle fractures were identified during a 10-year period; 79 patients with 1-year follow-up met inclusion criteria. The majority of injuries resulted from a high-energy mechanism. Articular impaction was present in 73% of injuries, and 23% of all patients had radiographic arthrosis (Kellgren-Lawrence 3 or 4) at final follow-up. Articular malreduction, defined by either a gap or step >2 mm, was significantly associated with development of arthrosis. Early treatment failure, infection, and nonunion was rare in this series. Conclusion: Malreduction of articular impaction in SAD ankle fractures is associated with early posttraumatic arthrosis. Recognition and anatomic restoration with stable fixation of articular impaction appears to mitigate risk of posttraumatic arthrosis. Investigations correlating postoperative and long-term radiographic findings to patient-reported outcomes after operative treatment of SAD ankle fractures are warranted. Level of Evidence: Level IV, retrospective case series.

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Radiographic Assessment of Relative First Metatarsal Length Following Modified Lapidus Procedure

Foot & Ankle International ◽

10.1177/1071100720924016 ◽

2020 ◽

Vol 41 (8) ◽

pp. 972-977 ◽

Cited By ~ 1

Author(s):

Wessel Greeff ◽

Andrew Strydom ◽

Nikiforos Pandelis Saragas ◽

Paulo Norberto Faria Ferrao

Keyword(s):

Hallux Valgus ◽

Sagittal Plane ◽

Case Series ◽

Relative Length ◽

Long Term Results ◽

Retrospective Case ◽

Level Of Evidence ◽

First Metatarsal ◽

Patient Reported ◽

The Mean

Background: The modified Lapidus is a surgical procedure for managing moderate to severe hallux valgus, especially in the presence of first tarsometatarsal joint arthritis or hypermobility. It has good long-term results but reportedly can lead to transfer metatarsalgia due to inherent shortening of the first metatarsal. Methods: A retrospective analysis of all adult patients who underwent a modified Lapidus procedure during a 3-year period was performed. Clinical notes were evaluated to look for nonunion or any other complications related to the surgery. Pre- and postoperative standard weightbearing radiographs were used to establish the relative metatarsal length (RML), intermetatarsal angle (IMA), hallux valgus angle (HVA), and distal metatarsal articular angle (DMMA). A total of 69 modified Lapidus procedures were identified, with 32 included in the study. Results: The mean pre- and postoperative RMLs were −0.8 and −4.9 mm, respectively. The average RML shortening due to the procedure was −4.1 ( P < .0001). The mean pre- and postoperative IMAs were 15 and 5 degrees, respectively ( P < .0001). The mean pre- and postoperative HVAs were 33 and 9 degrees, respectively ( P < .0001). One patient reported transfer metatarsalgia, which was attributed to elevation of the first metatarsal. Conclusion: We found a statistically significant degree of shortening of the relative length of the first metatarsal without any clinically significant metatarsalgia. The low rate of transfer metatarsalgia following the modified Lapidus procedure could be attributed to the sagittal plane correction and stability obtained by performing a first tarsometatarsal fusion. Level of Evidence: Level IV, retrospective case series.

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Modified oblique high tibial osteotomy with minimal fixation for correction of adolescent tibia vara: a prospective case series study

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.15.200097 ◽

2020 ◽

pp. 1-6

Author(s):

Ahmad Saeed Aly ◽

Ahmed Refaat Abdelhamid Alsabir ◽

Hesham Ahmad Fahmy ◽

Tamer A. Fayyad

Keyword(s):

High Tibial Osteotomy ◽

Sagittal Plane ◽

Case Series ◽

Varus Deformity ◽

The Body ◽

Tibial Osteotomy ◽

Tibia Vara ◽

Level Of Evidence ◽

Case Series Study ◽

Prospective Case Series

Purpose To assess the reliability and efficacy of the modified oblique high tibial osteotomy for correction of complex deformity in adolescent tibia vara. Methods A total of 19 patients (25 legs) with adolescent tibia vara were enrolled in this study. There were 16 male (84.2%) and three female (15.8%) patients who had modified Rab oblique osteotomy with minimal fixation performed. The age of the patients at time of surgery ranged from 12 years to 30 years (mean 17.23 (sd 5.27)). The body mass index ranged from 22 kg/m2 to 42 kg/m2 (mean 32.05 (sd 6.13)). All patients were followed up for over two years (mean 3.4; 2 to 5). Results The femoro-tibial angle was improved from -34° to -12° (mean -20.04° (sd 5.24°) preoperatively and from -12° to 7°, postoperatively (mean 2.04° (sd 4.07)). Medial deviation of the mechanical axis corrected from 38 mm to 125 mm (mean 76.13 (sd 23.29)) preoperatively to 0 mm to 36 mm (mean 5.74 (sd 7.3)) postoperatively. The time needed to achieve union ranged from eight weeks to 16 weeks (mean 10.2 (sd 2.42)). According to the Lysholm functional knee score scale, there were 15 excellent (78.9%), two good (10.5%), one fair (5.2%) and one poor (5.2%) after correction of the deformity. Conclusion Modified Rab osteotomy with minimal fixation by two or three screws shows promising results with good correction of varus deformity (coronal plane), internal torsion (axial plane) and procurvatum (sagittal plane), in management of adolescent tibia vara with minimal morbidity and complications. Level of evidence IV

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Bone Marrow Concentrate Injection Treatment Improves Short-term Outcomes in Symptomatic Hip Osteoarthritis Patients: A Pilot Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120966162 ◽

2020 ◽

Vol 8 (12) ◽

pp. 232596712096616

Author(s):

Kaitlyn E. Whitney ◽

Karen K. Briggs ◽

Carolyn Chamness ◽

Ioanna K. Bolia ◽

Johnny Huard ◽

...

Keyword(s):

Bone Marrow ◽

Rating Scale ◽

Short Form ◽

Case Series ◽

Hip Osteoarthritis ◽

The United States ◽

Harris Hip Score ◽

Level Of Evidence ◽

Promising Alternative ◽

Bone Marrow Concentrate

Background: Osteoarthritis (OA) is one of the leading causes of disability in the United States, the hip being the second most affected weightbearing joint. Autologous bone marrow concentrate (BMC) is a promising alternative therapy to conventional treatments, with the potential to mitigate inflammation and improve joint function. Purpose: To investigate the effectiveness of a single intra-articular BMC injection for patients with symptomatic hip OA. Study Design: Case series; Level of evidence, 4. Methods: A total of 24 patients diagnosed with symptomatic hip OA who elected to undergo a single BMC injection were prospectively enrolled in the study. Patients were excluded if they reported a preinjection Numeric Rating Scale (NRS) score for pain with activity of <6 points out of 10. The Western Ontario and McMaster Universities Arthritis Index (WOMAC), modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), 12-Item Short Form Health Survey (SF-12), and NRS pain scores were collected before and after the procedure (6 weeks, 3 months, and 6 months). Joint space and Tönnis OA grade scores were recorded on preinjection anteroposterior pelvis radiographs. Results: A total of 18 hips from 16 patients (7 male and 9 female) (mean age, 57.6 ± 11; mean body mass index, 25.9 ± 3.6 kg/m2) were used in the final analysis. Significant improvements were observed in NRS pain with activity (from 8 to 4.5; P < .001) and without activity (from 5 to 1; P < .001), WOMAC (from 31 to 16; P = .006), mHHS (from 63 to 80; P = .004), and HOS-ADL (from 71 to 85; P = .014) over 6 months. At 6 months, all patients maintained their improvements and did not return to preprocedure status. BMI significantly correlated with baseline WOMAC scores ( P = .012) and inversely correlated with 6-month SF-12 Physical Component Summary ( P = .038). Tönnis grades 2 and 3 were inversely correlated with 6-week SF-12 Mental Component Summary ( P = .008) and 3-month pain with activity ( P = .032). No serious adverse events were reported from the BMC harvest or injection procedure. Conclusion: A single BMC injection can significantly improve subjective pain and function scores up to 6 months in patients with symptomatic hip OA. Further studies are warranted to evaluate BMC treatment against other therapeutics in a larger sample size and compare the biological signature profiles that may be responsible for the therapeutic effect.

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Cell-Enhanced Acellular Nerve Allografts for Peripheral Nerve Reconstruction: A Systematic Review and a Meta-Analysis of the Literature

Neurosurgery ◽

10.1093/neuros/nyy374 ◽

2018 ◽

Vol 85 (5) ◽

pp. 575-604 ◽

Cited By ~ 4

Author(s):

Francesca Alice Pedrini ◽

Filippo Boriani ◽

Federico Bolognesi ◽

Nicola Fazio ◽

Claudio Marchetti ◽

...

Keyword(s):

Peripheral Nerve ◽

Nerve Regeneration ◽

Case Reports ◽

Case Series ◽

Future Research ◽

Nerve Reconstruction ◽

Level Of Evidence ◽

Promising Alternative ◽

Positive Effects

Abstract BACKGROUND Peripheral nerve reconstruction is a difficult problem to solve. Acellular nerve allografts (ANAs) have been widely tested and are a promising alternative to the autologous gold standard. However, current reconstructive methods still yield unpredictable and unsuccessful results. Consequently, numerous studies have been carried out studying alternatives to plain ANAs, but it is not clear if nerve regeneration potential exists between current biological, chemical, and physical enrichment modes. OBJECTIVE To systematically review the effects of cell-enhanced ANAs on regeneration of peripheral nerve injuries. METHODS PubMed, ScienceDirect, Medline, and Scopus databases were searched for related articles published from 2007 to 2017. Inclusion criteria of selected articles consisted of (1) articles written in English; (2) the topic being cell-enhanced ANAs in peripheral nerve regeneration; (3) an in vivo study design; and (4) postgrafting neuroregenerative assessment of results. Exclusion criteria included all articles that (1) discussed central nervous system ANAs; (2) consisted of xenografts as the main topic; and (3) consisted of case series, case reports or reviews. RESULTS Forty papers were selected, and categorization included the animal model; the enhancing cell types; the decellularization method; and the neuroregenerative test performed. The effects of using diverse cellular enhancements combined with ANAs are discussed and also compared with the other treatments such as autologous nerve graft, and plain ANAs. CONCLUSION ANAs cellular enhancement demonstrated positive effects on recovery of nerve function. Future research should include clinical translation, in order to increase the level of evidence available on peripheral nerve reconstruction.

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High Burden of Associated Injuries Occurring With Major Fractures of the Talus

Foot & Ankle International ◽

10.1177/1071100719892300 ◽

2019 ◽

Vol 41 (3) ◽

pp. 324-330

Author(s):

Ishaq O. Ibrahim ◽

Michael Y. Ye ◽

Jennifer Jacobs ◽

Jeremy T. Smith ◽

John Y. Kwon ◽

...

Keyword(s):

Lumbar Spine ◽

Case Series ◽

High Energy ◽

Spine Injury ◽

Associated Injuries ◽

Level Of Evidence ◽

Severe Injuries ◽

Concomitant Injuries ◽

Orthopedic Injury ◽

Organ Systems

Background: Talus fractures are severe injuries typically occurring after high-energy trauma. As a result, associated injuries to different anatomic sites and organ systems occur with high frequency. The objective of this study was to determine what injuries occur with high incidence in patients presenting with major fractures of the talus and to identify clinical injury patterns that may warrant special attention in these patients. Methods: We performed a retrospective review of patients presenting to 3 level 1 trauma centers with fractures of the talar neck, body, or head over a 14-year period. Patient charts were reviewed for associated orthopedic and nonorthopedic injuries identified during the initial patient encounter and hospitalization. Results: In total, 262 fractures in 258 unique patients met criteria for inclusion. Overall, 33.3% of talus fractures occurred in isolation. One or more associated injuries were identified in the remainder of cases (66.7%). The incidence of associated injuries was similar across fracture patterns. Mean total number of injuries per patient was 2.2 (range, 0-15). The ipsilateral foot was the most frequent site of associated orthopedic injury. Noncontiguous injuries occurred in 36% of cases. Lumbar spine injury occurred in 10.5% of cases. Lower extremity vascular injury was uncommon but bore significant association with open talus fractures. Conclusion: Talus fractures are commonly associated with injuries to different anatomic sites and organ systems. A similar rate of lumbar spine trauma may occur with major talus fractures as has been historically associated with calcaneal fractures. Thorough evaluation and a high index of suspicion are necessary when evaluating patients with major fractures of the talus to avoid missing concomitant injuries. Level of Evidence: Level IV, retrospective case series.

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Knee Extension Does Not Reliably Reduce Acute Type II Tibial Spine Fractures: MRI Evaluation of Displacement During Extension Versus Resting Flexion

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119860066 ◽

2019 ◽

Vol 7 (7) ◽

pp. 232596711986006

Author(s):

Peter C. Cannamela ◽

Noah J. Quinlan ◽

Travis G. Maak ◽

Temitope F. Adeyemi ◽

Stephen K. Aoki

Keyword(s):

Closed Reduction ◽

Sagittal Plane ◽

Statistical Significance ◽

Case Series ◽

Knee Extension ◽

Acute Type ◽

Type Ii ◽

Level Of Evidence ◽

Tibial Spine ◽

Bony Fragment

Background: Type II tibial spine avulsion (TSA) fractures have traditionally been managed by first attempting to achieve closed reduction with extension and immobilization, with surgical indications reserved for those who fail to reduce within 3 mm. However, the frequency with which appropriate reduction can be achieved is largely unknown. Purpose: To evaluate changes in displacement of type II TSA fractures by comparing magnetic resonance imaging (MRI) scans obtained with the knee in flexion and in extension. Study Design: Case series; Level of evidence, 4. Methods: Ten patients with type II TSA fractures were identified. Fracture displacement was measured using 3 images for each patient: (1) initial lateral view radiography, (2) sagittal-plane MRI of the knee in resting flexion, and (3) sagittal-plane MRI of the knee in passive extension. Maximum displacement of the bony fragment was measured in the 2 MRI studies for all patients, and the corresponding change in displacement was calculated. Displacement in flexion was compared with displacement in extension using a paired-sample t test. Statistical significance was set at P < .05. Results: The displacement distance of the bony fragment was reduced by a mean of 0.97 mm on MRI when the knee was in extension compared with flexion in patients with type II TSA fractures ( P = .02). Mean displacement with extension was 6.14 mm, with no fractures reduced below 4 mm. The largest reduction observed was 2.80 mm. The displacement distance increased in 2 knees with extension. The intermeniscal ligament (IML) was entrapped in 4 of 10 patients; however, the amount of reduction achieved did not differ based on the presence of IML entrapment ( P = .85). Conclusion: While the amount of tibial spine displacement warranting surgical treatment can be debated, the study findings suggest that knee extension is not reliable in obtaining adequate closed reduction for type II TSA fractures. Management decisions may need to be based on the initial displacement distance of the fracture, with a lower threshold for operative treatment than previously recognized.

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Mini TightRope Suspension Allows for Accelerated Rehabilitation following Ligament Reconstruction Interposition Arthroplasty of the Basal Joint of the Thumb

Journal of Hand and Microsurgery ◽

10.1055/s-0041-1730887 ◽

2021 ◽

Author(s):

Rasmus Wejnold Jørgensen ◽

Kiran Annette Anderson ◽

Claus Hjorth Jensen

Keyword(s):

Ligament Reconstruction ◽

Case Series ◽

Early Mobilization ◽

Level Of Evidence ◽

Suture Button ◽

Usual Procedure ◽

Trapeziometacarpal Osteoarthritis ◽

Increased Risk ◽

Patient Reported ◽

A Prospective Study

Abstract Introduction Surgical treatment of thumb trapeziometacarpal osteoarthritis usually involves 4 to 8 weeks of postoperative casting and splinting followed by varying mobilization protocols. Suspension arthroplasty has been described as an alternative to allow earlier range of motion exercises. The purpose of this study was to compare patient-reported outcomes (PRO) when adding a two-string suture-button suspension arthroplasty (Mini TightRope, MTR) to our usual procedure of ligament reconstruction and tendon interposition (LRTI), allowing early mobilization. Can we allow early mobilization using this technique without jeopardizing the PRO results at the 1 year follow-up and without an increased risk of complication? Materials and Methods A prospective study using the MTR system (Arthrex) as a suture-button suspensionplasty was conducted. Twelve patients (MTR group) and 36 historical patients (LRTI alone) were included. Results At 12 months, the median value for quick disabilities of the arm, shoulder, and hand was 11.3 (range, 0–43.2) in the MTR group and 13.6 (range, 0–88.6) in the LRTI group, resulting in similar improvements, p = 0.46. One in twelve patients in the MTR group was dissatisfied and 9 in 36 in the LRTI group were dissatisfied, p = 0.41. No complications were observed during the first year. Conclusion Supplemental suture-button suspensionplasty can be utilized for high demand patients and patients who want to reduce immobilization time without major complications and with similar PRO as LRTI at 6 and 12 months. Level of evidence Four case series

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Mobilization protocol and early postoperative weight-bearing in transyndesmal ankle fractures

Journal of the Foot & Ankle ◽

10.30795/jfootankle.2021.v15.1539 ◽

2021 ◽

Vol 15 (2) ◽

pp. 100-104

Author(s):

Diego Yearson ◽

Ignacio Melendez ◽

Federico Anain ◽

Santiago Siniscalchi ◽

Juan Drago

Keyword(s):

Weight Bearing ◽

Case Series ◽

Early Mobilization ◽

Lateral Approach ◽

Full Weight Bearing ◽

Level Of Evidence ◽

Rehabilitation Protocol ◽

Joint Mobilization ◽

Everyday Activities ◽

Early Return

Objective: To disseminate a rehabilitation protocol with early mobilization and ambulation, with no external supports, reducing the time until full weight-bearing and providing greater postoperative comfort. Methods: We prospectively assessed a series of 68 patients, with level of evidence IV, mean age of 33.3 years. We performed open reduction with ankle lateral approach (Kocher) and internal fixation with an interfragmentary compression screw and a one-third locked tubular plate for neutralization. All patients were subjected to a rehabilitation protocol with early mobilization and weight-bearing. Results: No fracture displacements were observed on the postoperative radiographic controls, neither loosening nor ruptures of implants. There was no need to change rehabilitation guidelines either due to pain or to other subjective limitation. Conclusion: We can state that early joint mobilization and controlled progressive support, with appropriate osteosynthesis, resulting in an early return to everyday activities, both work and sports ones. Level of Evidence IV; Therapeutic Studies; Case Series.

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Peripheral talus fractures

Journal of the Foot & Ankle ◽

10.30795/jfootankle.2021.v15.1223 ◽

2021 ◽

Vol 15 (1) ◽

pp. 26-30

Author(s):

Marcos Sakaki ◽

Jordanna Bergamasco ◽

Lais Pinheiro ◽

Caio Rosa e Silva ◽

Kenji Missima

Keyword(s):

Case Series ◽

High Energy ◽

Open Fractures ◽

Short Term ◽

Triple Arthrodesis ◽

Level Of Evidence ◽

The Mean ◽

Secondary Hospital ◽

American Orthopaedic ◽

The Moment

Objective: To present the epidemiology and assess short-term clinical and radiological outcomes of peripheral talus fractures treated between 2013 and 2019 at a secondary hospital. Methods: This is a retrospective study based on a series of 21 cases of peripheral talus fractures. Out of these 21 cases, 11 underwent functional assessment using the ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society (AOFAS) and radiological assessment after a mean period of 24.5 months. Results: Regarding the epidemiology of the 21 reported cases, the mean age was 28.7 years and 76.2% of the patients were male. The left foot was affected in 71.4% of the cases, and the most frequent type of trauma was motorcycle accident (47.6%); 23.8% of the cases had open fractures. Complete peritalar dislocation occurred in 38.0% of the cases and the most common fracture was that of the lateral process of the talus, in 42.8% of the cases. Eleven patients returned for reassessment and presented a mean AOFAS score of 80.9 points. All fractures were consolidated at the moment of assessment, and one of them progressed to subtalar and talonavicular osteoarthritis, requiring triple arthrodesis. Conclusion: The peripheral fractures studied here were caused by high-energy traumas with open fractures in one-quarter of the cases and were frequently associated with other fractures. The short-term functional outcome is good but has potential for severe complications such as stiffness and persistent pain. Level of Evidence IV, Therapeutic Studies; Case Series.

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