Background and Objective Porcine translational models have become the gold-standard translational tool to study the effects of major injury and hemorrhagic shock because of their similarity to the human immunologic response to trauma. Segmental bone defects (SBDs) typically occur in warfighters with associated severe limb trauma. The purpose of this study was to develop a translational porcine diaphyseal SBD model in Yucatan minipigs (YMPs), which could be used in bone healing investigations that simulate injury-relevant conditions. We were specifically working toward developing a critical sized defect (CSD). Methods We used an adaptive experimental design in which both 25.0 mm and 40.0 mm SBDs were created in the tibial mid-diaphysis in skeletally mature YMPs. Initially, eight YMPs were subjected to a 25.0 mm SBD and treated with intramedullary nailing (intramedullary nail [IMN] 25mm). Due to unanticipated wound problems, we subsequently treated four specimens with identical 25.0 mm defect with dual plating (open reduction with internal fixation [ORIF] 25mm). Finally, a third group of four YMPs with 40.0 mm defects were treated with dual plating (ORIF 40mm). Monthly radiographs were made until sacrifice. Modified Radiographic Union Score for Tibia fractures (mRUST) measurements were made by three trauma-trained orthopedic surgeons. CT scans of the tibias were used to verify the union results. Results At 4 months post-surgery, mean mRUST scores were 11.7 (SD ± 1.8) in the ORIF 25mm YMPs vs. 8.5 (SD ± 1.4) in the IMN 25mm YMPs (P < .0001). All four ORIF 25mm YMPs were clinically healed. In contrast, none of the IMN 25mm YMPs were clinically healed and seven of eight IMN 25mm YMPs developed delayed wound breakdown. All four of the ORIF 40mm YMPs had flail nonunions with complete hardware failure by 3 months after surgery and were sacrificed early. CT scanning confirmed that none of the IMN 25mm YMPs, none of the ORIF 40mm YMPs, and two of four ORIF 25mm YMPs were healed. A third ORIF 25mm specimen was nearly healed on CT scanning. Inter-rater and intra-rater reliability interclass coefficients using the mRUST scale were 0.81 and 0.80, respectively. Conclusions YMPs that had a 40 mm segment of bone removed from their tibia and were treated with dual plating did not heal and could be used to investigate interventions that accelerate bone healing. In contrast, a 25 mm SBD treated with dual plating demonstrated delayed but successful healing, indicating it can potentially be used to investigate bone healing adjuncts or conversely how concomitant injuries may impair bone healing. Pigs treated with IMN failed to heal and developed consistent delayed wound breakdown presumably secondary to chronic limb instability. The porcine YMP SBD model has the potential to be an effective translational tool to investigate bone healing under physiologically relevant injury conditions.
Objective: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction.
Background: To identify the time course for efficacy of corticosteroid injections in the treatment of trigger finger. Methods: A prospective single-center observational study was conducted, consisting of 38 patients with 41 trigger digits that were injected. Enrolled patients completed an initial Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire to determine the severity of their symptoms. Following the injection, patients were contacted at scheduled time points for up to 12 weeks to determine if, and when, objective resolution of symptoms occurred. Patients who received additional treatment, such as a second injection or surgery, and those who did not have objective relief of symptoms by 12 weeks were classified as failed. Upon symptom resolution or injection failure, patients were given a DASH exit questionnaire. Results: 30 of 41 injected trigger digits resolved and 11 failed treatment with a single corticosteroid injection. The latest that any study participant experienced resolution of symptoms was 69 days. At 38 days, the rate of resolution of the study population slowed significantly. Conclusions: Although symptomatic resolution of trigger finger from a single corticosteroid injection can occur early on, a follow-up of 4 weeks (28 days) does not allow enough time for symptom resolution. The earliest a surgeon and patient should consider a secondary treatment is at 38 days. After 69 days without resolution, both surgeon and patient can be confident that further treatment is needed.
Background Extra-articular fractures of the distal radius are often treated with a trial of nonoperative management if radiographic parameters are within an acceptable range, especially in the elderly population. Unfortunately, some malunions become symptomatic or become grossly misaligned during nonoperative management which require corrective surgery to restore the normal osseous anatomy and restore function. Description of Technique We describe correction of a distal radius malunion utilizing a distraction-type volar osteotomy, a volar plate specific distraction device, and a novel resorbable calcium phosphate bone cement (Trabexus) designed to withstand compressive loads. Patients and Methods Twelve patients with 13 distal radius fractures were included in this study. The average patient age was 60.9 years and average time from injury to corrective osteotomy was 96.3 days. Radiographic measures (radial inclination, volar tilt, and ulnar variance) and clinical assessment (wrist/forearm range of motion and grip strength) were done pre- and postoperatively and compared. Results The average time from corrective surgical osteotomy to final clinical follow-up was 375.8 days. After surgical intervention, there was a statistically significant improvement in mean volar tilt (−19.8 vs. +0.5 degrees) and mean ulnar variance (+2.8 vs. −0.4 mm). Improvements were also seen in grip strength (1.7 vs. 43.6 lb), wrist flexion (30.5 vs. 48.3 degrees), wrist extension (33.3 vs. 53.8 degrees), forearm pronation (75.0 vs. 88.8 degrees), and forearm supination (53.8 vs. 81.3 degrees). On average, 56.0% of Trabexus bone substitute remained on final clinical radiographs. Conclusion This simplified technique of distraction corrective osteotomy after distal radius malunion results in improved clinical and radiographic outcomes for patients.
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