There is a high prevalence of wrong level surgery among spine surgeons; 1 of every 2 spine surgeons may perform a wrong level surgery during his or her career. Although all spine surgeons surveyed report using at least 1 preventive action, the following measures are highly recommended but inconsistently adopted: direct preoperative communication with the patient by the surgeon, marking of the intended site, and the use of intraoperative verification radiograph.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
ImportanceUnstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared with nonoperative treatment. However, to date, an adequately powered, randomized clinical trial to support operative treatment has been lacking.ObjectiveTo compare outcomes of surgical treatment of acute unstable chest wall injuries with nonsurgical management.Design, Setting, and ParticipantsThis was a multicenter, prospective, randomized clinical trial conducted from October 10, 2011, to October 2, 2019, across 15 sites in Canada and the US. Inclusion criteria were patients between the ages of 16 to 85 years with displaced rib fractures with a flail chest or non–flail chest injuries with severe chest wall deformity. Exclusion criteria included patients with significant other injuries that would otherwise require prolonged mechanical ventilation, those medically unfit for surgery, or those who were randomly assigned to study groups after 72 hours of injury. Data were analyzed from March 20, 2019, to March 5, 2021.InterventionsPatients were randomized 1:1 to receive operative treatment with plate and screws or nonoperative treatment.Main Outcomes and MeasuresThe primary outcome was ventilator-free days (VFDs) in the first 28 days after injury. Secondary outcomes included mortality, length of hospital stay, intensive care unit stay, and rates of complications (pneumonia, ventilator-associated pneumonia, sepsis, tracheostomy).ResultsA total of 207 patients were included in the analysis (operative group: 108 patients [52.2%]; mean [SD] age, 52.9 [13.5] years; 81 male [75%]; nonoperative group: 99 patients [47.8%]; mean [SD] age, 53.2 [14.3] years; 75 male [76%]). Mean (SD) VFDs were 22.7 (7.5) days for the operative group and 20.6 (9.7) days for the nonoperative group (mean difference, 2.1 days; 95% CI, −0.3 to 4.5 days; P = .09). Mortality was significantly higher in the nonoperative group (6 [6%]) than in the operative group (0%; P = .01). Rates of complications and length of stay were similar between groups. Subgroup analysis of patients who were mechanically ventilated at the time of randomization demonstrated a mean difference of 2.8 (95% CI, 0.1-5.5) VFDs in favor of operative treatment.Conclusions and RelevanceThe findings of this randomized clinical trial suggest that operative treatment of patients with unstable chest wall injuries has modest benefit compared with nonoperative treatment. However, the potential advantage was primarily noted in the subgroup of patients who were ventilated at the time of randomization. No benefit to operative treatment was found in patients who were not ventilated.Trial RegistrationClinicalTrials.gov Identifier: NCT01367951
Various surgical techniques exist to approach an ischial tuberosity avulsion fracture, including open reduction and internal fixation with screws and suture anchors, augmentation with allograft tendon, and excision of the fragment. However, the majority of these techniques approached acute fractures, and nonunions were not addressed nor studied. This case series describes two adolescent patients treated for ischial tuberosity nonunions with a posterior column screw through a subgluteal approach. Both patients demonstrated radiographic healing of their nonunion sites at 6 months' follow-up. Each patient reported no pain during activity, had symmetric hamstring strength, and were able to return to pre-injury level of activity by final follow-up. In conclusion, the authors utilized a muscle-sparing approach to the ischial tuberosity nonunion site through a cosmetically appealing incision and introduced a novel approach to nonunion fixation without the use of bone graft, resulting in excellent clinical outcomes.
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Objective: To document angles, from 2 difference starting points, or danger zones that should be avoided to minimize risk of injury or irritation to the saphenous neurovascular bundle (SNVB) during suture button (SB) fixation for distal tibiofibular syndesmosis injuries. Design: Retrospective imaging study. Setting: Academic Level 1 trauma center. Patients: Forty-eight randomly selected patients with healthy ankles and computed tomography scans for nonankle diagnoses. Main Outcome Measures: Computed tomography scans and 3D reconstructed images were used to define the angle between the SNVB and 2 different fibular starting points, using the direct lateral (DL) and the posterolateral (PL) starting points. Descriptive analyses were performed to identify angles that should be avoided during suture button fixation. Distances from the SNVB using preset angles of 0, 10, 20, and 30 degrees were analyzed. In addition, the width of the SNVB, the midsubstance angle of the SNVB, and the distance from the 30-degree point to the tibialis anterior were recorded. Results: The mean angle between the SNVB and the standard DL starting point was 13.7 ± 5.0 degrees (P < 0.05), whereas the mean angle using the alternate PL starting point was 17.2 ± 5.3 degrees (P < 0.05). The SNVB width was 5.2 mm [range, 2.6–9.1 mm] (P < 0.05). The distances from the SNVB were greatest for the DL 30-degree group and the PL 0-degree group. Conclusions: The results document angles that should be avoided when using suture button fixation for syndesmosis injuries. Device characteristics and surgery-related variables may require intraoperative modifications, and knowledge of this anatomical relationship may reduce SNVB injury during those situations. Considering our results, we recommend that surgeons place suture buttons from the DL starting point with a 30-degree trajectory to avoid injuries to the SNVB.
Fractures of the femoral neck present a threat to the mobility and independence of geriatric patients. Multiple treatment options exist for femoral neck fractures, each with its inherent advantages and disadvantages. Internal fixation produces good results if the complications of nonunion, avascular necrosis and shortening can be avoided. Unfortunately, these complications remain prevalent in many circumstances leading many to proceed with femoral head replacement. Complicating decisionmaking are the multiple variations of replacements that are available. These include cemented or uncemented femoral stems, unipolar or bipolar head components and the option of placing an acetabular component. Many factors are relevant to decision-making with this injury. These include patient age, activity, co-morbidities and functional demands. These must be considered alongside fracture variables that include displacement, comminution and bone quality. This review will sequentially consider the available treatment options and attempt to distill the existing literature into practical treatment guidelines.
Acromioclavicular (AC) joint separations are common in both sports and trauma injuries. Many surgical options exist for fixation of these injuries. Although the suture button has become popular, it has a moderately high complication rate. The most common complication is the loss of reduction, but another common complication is knot-related pain. This article outlines a method of suture button fixation that addresses both of these complications with a novel knotless construct using TightRopes.
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