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Bullock TS, Ornell SS, Naranjo JMG, Morton-Gonzaba N, Ryan P, Petershack M, Salazar LM, Moreira A, Zelle BA. Risk of Surgical Site Infections in OTA/AO Type C Tibial Plateau and Tibial Plafond Fractures: A Systematic Review and Meta-Analysis. J Orthop Trauma 2022; 36:111-117. [PMID: 34483327 DOI: 10.1097/bot.0000000000002259] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyze the current incidence of postoperative infection for OTA/AO type C fractures of the tibial plateau and tibial plafond. DATA SOURCES Three medical databases: PubMed/MEDLINE, ScienceDirect, and the Cochrane Library, were used in our systematic literature search. Search results were restricted to articles transcribed in English/Spanish and publication date after January 1, 2000, to present day. STUDY SELECTION Inclusion criteria were studies reporting postoperative infection data for OTA/AO type 41C, 43C, or equivalent fractures of skeletally mature individuals. A minimum of 6 total fractures of interest and a frequency of 75% overall were required. Studies reporting on pathologic fractures, stress fractures, or low-energy fracture types were excluded. DATA EXTRACTION Two authors independently screened abstracts, evaluated full-text manuscripts, and extracted relevant data from included studies. Any instances of discrepancy were resolved within the study committee by consensus. DATA SYNTHESIS Outcomes were expressed using direct proportions (PR) with a 95% confidence interval. The effects of comorbidities on infection rates were reported using odds ratios with a 95% confidence interval. All analyses used a DerSimonian-Laird estimate with a random-effects model based on heterogeneity. The presence of publication bias was evaluated using funnel plots and Egger's tests. CONCLUSIONS Patients with these specific fractures develop infections at a notable frequency. The rates of deep infections were approximately 6% in tibial plateau fractures and 9% in tibial plafond fractures. These results may be useful as a reference for patient counseling and other future studies aimed at minimizing postoperative infection for these injuries. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | | | | | - Patrick Ryan
- Long School of Medicine, UT Health San Antonio, San Antonio, TX; and
| | | | - Luis M Salazar
- Long School of Medicine, UT Health San Antonio, San Antonio, TX; and
| | - Alvaro Moreira
- Department of Pediatrics, UT Health San Antonio, San Antonio, TX
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Heath DM, Nguyen AV, Bullock TS, Ornell SS, Bartush KC, Hogue GD. Intact PCL is a potential predictor of ACL graft size in the skeletally immature knee and other anatomic considerations for ACL reconstruction. J Exp Orthop 2022; 9:6. [PMID: 34989917 PMCID: PMC8739412 DOI: 10.1186/s40634-021-00437-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To develop a method for using an intact posterior cruciate ligament (PCL) as a predictor of anterior cruciate ligament (ACL) graft size and examine possible differences in tunnel length based on all-epiphyseal drilling method. METHODS One hundred one patients 5-18 years of age with magnetic resonance imaging (MRI) of the knee at an outpatient pediatric orthopaedic clinic from 2008 to 2020 were included. ACL and PCL coronal, sagittal, and length measurements were made in all patients. Tunnel length measurements were made in patients with open physes. Statistical analyses were performed to evaluate potential associations in patient bony or ligamentous measurements. RESULTS PCL sagittal width and PCL coronal width were statistically significant predictors of ACL sagittal width and ACL coronal width, respectively (p = 0.002, R = 0.304; p = 0.008, R = 0.264). The following equations were developed to calculate ACL coronal and sagittal width measurements from the corresponding measurement on an intact PCL; ACL Coronal Width (mm) = 6.23 + (0.16 x PCL Coronal Width); ACL Sagittal Width (mm) = 5.85 + (0.53 x PCL Sagittal Width). Mean tibial maximum oblique length (27.8 mm) was longer than mean tibial physeal sparing length (24.9 mm). Mean femoral maximum oblique length (36.9 mm) was comparable to mean femoral physeal sparing length (36.1 mm). Both were longer than mean femoral straight lateral length (32.7 mm). CONCLUSION An intact PCL is a predictor of native ACL size. Tunnel length differs based on chosen drilling method in all-epiphyseal technique. LEVEL OF EVIDENCE Diagnostic Level III.
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Affiliation(s)
- David M Heath
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, 78249, USA
| | - Alexander V Nguyen
- Department of Orthopaedics, Lenox Hill Hospital, New York, NY, 10075, USA
| | - Travis S Bullock
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, 78249, USA
| | - Samuel S Ornell
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, 78249, USA
| | - Katherine C Bartush
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, 78249, USA
| | - Grant D Hogue
- Department of Orthopaedics, Boston Children's Hospital/Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
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Dang KH, Ornell SS, Huynh RA, DeLeon JC, Pesek R, Karia RA. Early clinical and radiographic outcomes of a mini-fragment, low profile plating system in tibial plafond fractures. Injury 2019; 50:1773-1780. [PMID: 31362824 DOI: 10.1016/j.injury.2019.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/23/2019] [Accepted: 07/21/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The Smith and Nephew mini-EVOS plating system is a mini-fragment, low profile, variable-angled plating system designed to obtain anatomic reduction while also minimizing soft tissue handling. However, literature has been limited in reporting the clinical and surgical outcomes of these specific plates. The goal of our study is to evaluate the safety and efficacy of the Smith and Nephew mini-EVOS plate in pilon fracture management, where significant high energy forces can result in severe fracture patterns and soft tissue injury. METHODS Patients 18-65 years of age who underwent plate fixation of their tibial plafond fractures (OTA/AO) using the Smith and Nephew mini-EVOS plating system at our urban university-based level-1 trauma center were included in this retrospective investigation. A total of 37 patients (37 fractures) from January 2015 to March 2018 were included in this study. Primary outcome measure was mechanical hardware failure. Secondary outcome measures included nonunion, malunion, medical and surgical complications. RESULTS The fractures were classified according to the OTA/AO classification as 43C1 (n = 15), 42C2 (n = 6), and 43C3 (n = 16). A mechanical failure was observed in three patients (8.1%). Six additional patients needed a re-operation of the surgical site including two nonunion repairs, one malunion repair, one symptomatic hardware removal, and two soft tissue debridements. The mean follow-up was 298.9 days (range: 96-936). CONCLUSIONS Early results of operative fixation of tibial plafond fractures using the Smith-Nephew mini-EVOS demonstrated low hardware failure and complication rates. This plating system is a safe and effective implant. LEVEL OF EVIDENCE Therapeutic Level IV.
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Affiliation(s)
- Khang H Dang
- UT Health San Antonio, Department of Orthopaedics, San Antonio, TX 78229, United States
| | - Samuel S Ornell
- UT Health San Antonio, Department of Orthopaedics, San Antonio, TX 78229, United States.
| | - Rose Ann Huynh
- UT Health San Antonio, Department of Orthopaedics, San Antonio, TX 78229, United States
| | - Jorge C DeLeon
- UT Health San Antonio, Department of Orthopaedics, San Antonio, TX 78229, United States
| | - Rachel Pesek
- UT Health San Antonio, Department of Orthopaedics, San Antonio, TX 78229, United States
| | - Ravi A Karia
- UT Health San Antonio, Department of Orthopaedics, San Antonio, TX 78229, United States
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Dang KH, Ornell SS, Reyes G, Hussey M, Dutta AK. A new risk to the axillary nerve during percutaneous proximal humeral plate fixation using the Synthes PHILOS aiming system. J Shoulder Elbow Surg 2019; 28:1795-1800. [PMID: 31031168 DOI: 10.1016/j.jse.2019.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/10/2019] [Accepted: 01/11/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Percutaneous aiming arms have been developed to minimize injury during placement of submuscular proximal humerus plates. The purpose of this study was to determine the risk of axillary nerve injury during percutaneous proximal humeral plate fixation using the Synthes PHILOS aiming system. METHODS By use of 10 fresh-frozen cadavers (20 shoulders), a 3.5-mm locking compression proximal humeral plate was fixated percutaneously to the humerus through a lateral deltoid-splitting approach using the PHILOS aiming guide. Dissection of the axillary nerve was then carried out, and measurements of its relation to the screw holes in row A through row G of the plate were taken. The lateral acromion-to-axillary nerve distance was also measured. RESULTS The axillary nerve traversed row D in every shoulder, whereas it crossed over row C in 11 shoulders and both holes in row E in 16 shoulders. The closest distance to the axillary nerve achieved was 4.5 mm, corresponding to the distal (left) screw in row B. A significant negative correlation was found for the distance from the nerve to the closest proximal and distal screws (row B and row G, respectively) in both right shoulders (ρ = -0.797; 95% confidence interval, -0.916 to -0.548) and left shoulders (ρ = -0.615; 95% confidence interval, -0.831 to -0.237). CONCLUSION The axillary nerve traverses rows C, D, and E of the proximal humeral plate using the PHILOS aiming system. Importantly, our study is the first to demonstrate that the axillary nerve crosses over row C. Left-sided plate screws also came in closer proximity to the axillary nerve than right-sided plate screws.
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Affiliation(s)
- Khang H Dang
- Department of Orthopaedics, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Samuel S Ornell
- Department of Orthopaedics, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Guy Reyes
- Department of Orthopaedics, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Michael Hussey
- Department of Orthopaedics, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Anil K Dutta
- Department of Orthopaedics, University of Texas Health San Antonio, San Antonio, TX, USA.
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Zelle BA, Dang KH, Ornell SS. High-energy tibial pilon fractures: an instructional review. Int Orthop 2019; 43:1939-1950. [PMID: 31093715 DOI: 10.1007/s00264-019-04344-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/01/2019] [Indexed: 12/16/2022]
Abstract
High-energy tibial pilon fractures continue to represent a significant challenge to the treating orthopaedic surgeon. Pre-operative evaluation includes a careful clinical assessment of the associated soft tissue injury, which frequently dictates surgical management. Staged surgical reconstruction remains the standard treatment protocol at most trauma centres. This includes application of a temporary spanning external fixator for approximately one to four weeks, followed by open reduction and internal fixation once the surrounding soft tissues are amendable. Despite careful soft tissue management protocols, the risk of wound complications continues to be relatively high compared to other orthopaedic trauma procedures. The functional long-term outcomes of these injuries remain limited, and recent data has emphasised that the majority of patients do not regain their pre-operative work status. In addition, the health-related quality of life scores fare poorly when compared to other orthopaedic and non-orthopaedic patient populations, and many patients develop post-traumatic arthritis within the tibiotalar joint. It has been shown that the quality of fracture reduction may significantly correlate with the long-term functional outcomes. While the orthopaedic community has come a long way with regard to safe management of high-energy tibial pilon fractures, the clinical outcomes continue to remain limited. In particular, the persistently high rates of wound complications and the limited functional long-term outcomes leave significant room for improvement. Future investigators may focus on further innovations to minimise the risk of wound complications. The surgical team may emphasise the quality of fracture reduction as an important treatment goal.
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Affiliation(s)
- Boris A Zelle
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA.
| | - Khang H Dang
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
| | - Samuel S Ornell
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
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Zelle BA, Webb AJ, Matson C, Morwood M, Dang KH, Ornell SS, Gostigian G, Ramirez CM, Mir H. Safety and efficacy of a two-screw cephalomedullary nail for intertrochanteric femur fracture fixation: a retrospective case series in 264 patients. Patient Saf Surg 2018; 12:31. [PMID: 30410578 PMCID: PMC6218954 DOI: 10.1186/s13037-018-0177-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/17/2018] [Indexed: 12/27/2022] Open
Abstract
Introduction Recent advances have led to the design of a new cephalomedullary nail, which aims to decrease the risk of failures in patients with intertrochanteric hip fractures by allowing for insertion of two interdigitating screws into the head segment. The goal of this study is to evaluate the safety and efficacy of this two-screw cephalomedullary nailing system. Patients/participants Patients 18 years of age and older who underwent intramedullary nailing of their intertrochanteric femoral fracture using the InterTAN nailing system (Smith and Nephew, Memphis, TN) from 2012 to 2016 were included in this retrospective study which was performed at two urban certified level-1 trauma centers and one urban certified level-3 trauma center. The study data was collected through a retrospective chart review and review of the existing radiographic studies. Primary outcome measure was mechanical hardware failure and screw cutout. Secondary outcome measures included nonunion, malunion, medical and surgical complications. Results A total of 264 patients were included in this analysis. Two patients (0.75%) were found to have a screw cut out requiring revision surgery. Two other revision surgeries were performed for malrotation (n = 1) and malunion (n = 1). Other implant-related complications occurred in 19 cases (7.9%), which included broken distal screws (n = 9), distal screw loosening (n = 8), and loose lag screws (n = 2). There was a total of 10 (3.8%) surgical wound complications, including four deep and six superficial infections. Discussion This modified cephalomedullary nail is a reliable, safe, and effective implant for management of intertrochanteric hip fractures. Surgical treatment of patients with intertrochanteric hip fractures can be performed in a safe fashion using this implant.
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Affiliation(s)
- Boris A Zelle
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX 78229 USA
| | - Antonio J Webb
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX 78229 USA
| | - Christopher Matson
- 2Department of Orthopaedics, University of South Florida, Tampa, FL 33606 USA
| | - Michael Morwood
- 3Department of Orthopaedics, Florida Orthopedic Institute, Tampa, FL 33606 USA
| | - Khang H Dang
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX 78229 USA
| | - Samuel S Ornell
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX 78229 USA
| | - Gabrielle Gostigian
- 2Department of Orthopaedics, University of South Florida, Tampa, FL 33606 USA
| | - Cody M Ramirez
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX 78229 USA
| | - Hassan Mir
- 3Department of Orthopaedics, Florida Orthopedic Institute, Tampa, FL 33606 USA
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