Publications by authors named "John A Scolaro"

50 Publications

Muscular forces responsible for proximal humeral deformity following fracture.

J Orthop Trauma 2021 May 14. Epub 2021 May 14.

University of California Irvine School of Medicine University of California Irvine, Department of Orthopedic Surgery Cornell University Orthopaedic Biomechanics Laboratory, Congress Medical Foundation.

Objectives: To evaluate the contribution of each of the rotator cuff muscles and deltoid to fracture deformity in a two-part proximal humerus fracture model. Our hypothesis was that superior cuff muscles would have the greatest contribution to coronal plane deformity while muscles with anterior and posterior attachments would have the greatest contribution to axial and sagittal plane deformity.

Methods: A medial wedge osteotomy was created in eight cadaveric shoulder specimens. A custom shoulder testing system was used load to each rotator cuff muscle and deltoid under increasing loading conditions. Fracture displacement was measured using a Microscribe digitizing system. The primary outcome was the contribution of each muscle to varus collapse. Secondary outcomes included contributions of each muscle to apex anterior/posterior deformity and humeral head anteversion/retroversion.

Results: Unbalanced loading of the supraspinatus resulted in the greatest varus deformity (34.5±2.3°) followed by the infraspinatus (22.3±3.6°) and subscapularis (21.7±3.1°) (p<0.05). Unbalanced loading of the subscapularis induced the greatest apex posterior (27.5±4.8°, p<0.05) and retroversion (39.0±5.6°, p<0.05) deformity while the infraspinatus induced the greatest apex anterior (8.7±3.4°, p>0.05) and anteversion (17.7±5.7°, p>0.05) deformity.

Conclusions: In this proximal humerus fracture model, the supraspinatus was the primary driver of varus deformity while the subscapularis and infraspinatus contributed to apex posterior/retroversion and apex anterior/anteversion, respectively. The subscapularis and infraspinatus are also important secondary drivers of varus deformity. This study establishes a physiologically relevant fracture model that mimics in vivo conditions for future biomechanical testing.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000002142DOI Listing
May 2021

Knowledge and Opinion on Cannabinoids Among Orthopaedic Traumatologists.

J Am Acad Orthop Surg Glob Res Rev 2021 04 19;5(4). Epub 2021 Apr 19.

From the Department of Orthopaedic Surgery, University of California, Irvine, CA (Dr. Chin, Dr. Lim, and Dr. Scolaro), Orange, CA; the University of California, Irvine School of Medicine, Irvine, CA (Mr. Etiz); and the Department of Anesthesiology and Perioperative Care, Division of Pain Medicine, University of California (Dr. Nelson), Irvine, Orange, CA.

Introduction: Cannabinoids are an increasingly popular therapy among orthopaedic patients for musculoskeletal conditions. A paucity of evidence to support their use in orthopaedics exists, likely because of the incongruence of federal and state legalization and the stigma surrounding cannabis. The purpose of this study is to elucidate sentiments and knowledge base of the orthopaedic trauma community with regard to cannabinoid-containing compounds.

Methods: A 21-question online survey was distributed to the members of the Orthopaedic Trauma Association with a response window of 3 months.

Results: We evaluated 251 responses. Most (88%) of the respondents did not believe that they were knowledgeable about the mechanism of action of cannabis/cannabidiol (CBD) but did feel that cannabis or CBD products play a role in managing postoperative pain (73%). Most respondents did not believe that they would be stigmatized if they suggested CBD (83%) or cannabis (67%) to patients. Despite this, fewer respondents have suggested CBD (38%) or cannabis (29%) to their patients.

Conclusions: Sentiment toward cannabinoids among orthopaedic traumatologists is remarkably favorable; however, in-depth understanding is admittedly poor and routine use is uncommon. More clinical research for cannabinoids is needed to help orthopaedic traumatologists provide guidance for patients seeking advice for this recently popular therapeutic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOSGlobal-D-21-00047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057750PMC
April 2021

Treatment of tibial plateau fractures with a novel fenestrated screw system for delivery of bone graft substitute.

Eur J Orthop Surg Traumatol 2021 Jan 24. Epub 2021 Jan 24.

Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

Purpose: The purpose of this study was to describe the incidence of subsidence in patients with AO/OTA 41 (tibial plateau) fractures which were repaired with a novel fenestrated screw system to used to deliver CaPO4 bone substitute material to fill the subchondral void and support the articular reduction.

Methods: Patients with unicondylar and bicondylar tibial plateau fractures were treated according to the usual technique of two surgeons. After fixation, the Zimmer Biomet N-Force Fixation System®, a fenestrated screw that allows for the injection of bone substitute was placed and used for injection of the proprietary calcium phosphate bone graft substitute into the subchondral void. For all included patients, demographic information, operative data, radiographs, and clinic notes were reviewed. Patients were considered to have articular subsidence if one or more of two observations were made when comparing post-operative to their most recent clinic radiographs: > 2 mm change in the distance between the screw and the lowest point of the tibial plateau, > 2 mm change in the distance between the screw and the most superior aspect of the plate. Data were analyzed to determine if there were any identifiable risk factors for complication, reoperation, or subsidence using logistic regression. Statistical significance was set at p < 0.05.

Results: 34 patients were included with an average follow-up of 32.03 ± 22.52 weeks. There were no overall differences between height relative to the medial plateau or the plate. Two patients (5.9%) had articular subsidence. Six patients (15.2%) underwent reoperation, two (6%) for manipulations under anaesthesia due to arthrofibrosis, and four (12%) due to infections. There were 6 (19%) total infections as 2 were superficial and required solely antibiotics. One patient had early failure.

Conclusion: Use of a novel fenestrated screw system for the delivery of CaPO4 BSM results in articular subsidence and complication rates similar to previously published values and appears to be a viable option for addressing subchondral defects in tibial plateau fractures.

Level Of Evidence: IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00590-021-02871-yDOI Listing
January 2021

Optimal Fixation of the Capitellar Fragment in Distal Humerus Fractures.

J Orthop Trauma 2021 07;35(7):e228-e233

Department of Orthopedic Surgery, University of California Irvine, Orange, CA; and.

Objectives: To determine if orthogonal or parallel plate position provides superior fixation of the separate capitellar fragment often present in intra-articular distal humerus fractures. We hypothesized that orthogonal plating would provide stiffer fixation given a greater number of opportunities for capitellar fixation and screw trajectories perpendicular to the fracture plane offered by a posterolateral plate compared with a parallel plate construct.

Methods: Ten matched pairs of cadaveric distal humeri were used to compare parallel and orthogonal plating in a fracture gap model with an isolated capitellar fragment. The capitellum was loaded in 20 degrees of flexion using a cyclic, ramp-loading protocol. Fracture displacement was measured using video tracking software. The primary outcome was axial stiffness for each construct. Secondary outcomes included maximum axial and angular fracture displacement.

Results: The parallel plate construct was more than twice as stiff as the orthogonal plate construct averaged across all loads (1464.8 ± 224.0 N/mm vs. 526.3 ± 90.8 N/mm, P < 0.001). Average axial fracture displacement was 0.15 ± 0.03 mm versus 0.53 ± 0.10 mm for parallel versus orthogonal plating, respectively (P = 0.003). Angular fracture displacement was minimal for both constructs (0.009 ± 0.001 degrees vs. 0.028 ± 0.006 degrees for parallel vs. orthogonal constructs).

Conclusions: Despite fewer points of fixation, a parallel plate construct provided stiffer fixation with less displacement of the simulated capitellar fracture fragment than an orthogonal plate construct in this biomechanical study. In the setting of an articular fracture, in which absolute stability and primary bone healing are desirable, parallel fixation should be considered even in fractures with a separate capitellar fragment if the size of fragment and fracture orientation allows.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000002012DOI Listing
July 2021

Techniques for management of hyperextension bicondylar tibial plateau fractures.

Injury 2021 04 27;52(4):1069-1073. Epub 2020 Oct 27.

Associate Professor - University of California, Irvine, Orange, CA USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.injury.2020.10.099DOI Listing
April 2021

Monofocal Compression-Distraction Osteosynthesis in a Distal Femoral Nonunion Using a Magnetic Medullary Nail: A Case Report.

JBJS Case Connect 2020 Jul-Sep;10(3):e2000124

1Department of Orthopaedic Surgery, University of California, Irvine, Irvine, California.

Case: A 65-year-old woman presented with a malaligned, shortened supracondylar distal femoral nonunion. An acute medial closing wedge osteotomy was performed through the nonunion and compressed with a retrograde magnetically controlled intramedullary nail. Osteogenesis with sequential compression and then distraction was performed at the osteotomy site using the nail to successfully restore limb length and alignment.

Conclusion: A magnetically controlled nail can be used to perform monofocal sequential compression-distraction osteosynthesis through a nonunion after an alignment correcting osteotomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.CC.20.00124DOI Listing
April 2021

Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery.

J Biomed Opt 2020 08;25(8)

Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States.

Significance: Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues.

Aim: The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery.

Approach: The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative.

Results: Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management.

Conclusion: While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1117/1.JBO.25.8.080601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457961PMC
August 2020

Major Orthopaedic Conference Abstract Publication: An Analysis of Abstracts Accepted for the AAOS Annual Meetings Between 2014 and 2017.

J Am Acad Orthop Surg 2021 Jun;29(12):e601-e608

From the School of Medicine (Le, Anderson, Chalmers), University of California Irvine, Irvine, CA, and the Department of Orthopaedic Surgery (Dr. Scolaro, Dr. Lee, and Dr. Bhatia), University of California Irvine, Orange, CA.

Introduction: The American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting provides an opportunity for clinicians to attain the most recent advancements in the orthopaedic field. However, the most recent study analyzing publication rates from the 2001 Annual Meeting determined that only 49% of the podium and poster abstracts were eventually published. The purpose of this study was to determine the publication rate, likelihood of publication based on the presentation format, and time to publication for abstracts presented at the 2014 to 2017 AAOS Annual Meetings.

Methods: We did a comprehensive search of PubMed and Google Scholar to determine whether abstracts presented in the podium, poster, and scientific exhibit formats from the 2014 to 2017 AAOS Annual Meetings were published in a peer-reviewed journal. Abstract title, authors, and keywords were used to query for publication status and date of publication.

Results: We analyzed 5,902 abstracts from the 2014 to 2017 AAOS Annual Meetings. The overall publication rate for podium and poster presentations was 69.9%, with individual publication rates at 73.0% and 65.1%, respectively. A higher likelihood of publication in the podium format was noted with odds ratio 1.45 (P < 0.0001). Scientific exhibits displayed a publication rate of 46.9%. Most publications in all formats occurred within 2 years.

Conclusion: A large increase was noted in the quality of research being presented at the AAOS Annual Meeting. With 69.9% of podium and poster presentations from the 2014 to 2017 Annual Meetings being published in a peer-reviewed journal, clinicians can use the data presented as an up-to-date, adjunct source of guidance for their clinical practices.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-20-00501DOI Listing
June 2021

Complication Rates after Lateral Plate Fixation of Periprosthetic Distal Femur Fractures: A Multicenter Study.

Injury 2020 Aug 22;51(8):1858-1862. Epub 2020 May 22.

Department of Orthopaedic Surgery, Stanford University, Stanford, CA.

Objective: Periprosthetic fractures of the distal femur can be challenging injuries to treat; nonunion rates of up to 22% have been reported. The purpose of this study was to determine the rate of complications and nonunion in a multicenter series, and to identify patient or surgical factors that were associated with nonunion.

Design: Retrospective comparative study SETTING: Three Level 1 trauma centers PATIENTS: Fifty-five patients with a periprosthetic distal femur fracture proximal to a total knee arthroplasty. Minimum follow up for inclusion was six months or until union or failure.

Intervention: Surgical fixation using a precontoured lateral locking plate MAIN OUTCOME MEASUREMENT: Fracture union was the primary outcome. Patient demographic and injury variables (age, comorbidities, fracture classification and characteristics) and surgical technique factors (mode of plate fixation, plate material, working length, screw density, and proximal screw type) were identified and compared between patients who developed a nonunion and those who did not. Regression analysis was performed to identify independent risk factors for nonunion.

Results: The overall rate of nonunion was 18% and the total complication rate was 24%. After additional surgery, 49 of 55 patients went on to heal (89%). There were no statistical differences in patient demographic or injury variables between the union and nonunion groups, and none of the variables studied were independent risk factors for nonunion in the regression analysis.

Conclusions: In this series of 55 patients with periprosthetic distal femur fractures treated with precontoured lateral locking plates, 18% developed nonunion and the overall complication rate was 24%. No patient or surgical variables were identified as risk factors. Future research should seek to identify patients at high risk for complication and nonunion who could benefit from alternative fixation strategies or distal femoral replacement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.injury.2020.05.009DOI Listing
August 2020

Posterior Inferior Comminution Significantly Influences Torque to Failure in Vertically Oriented Femoral Neck Fractures: A Biomechanical Study.

J Orthop Trauma 2020 12;34(12):644-649

University of California Irvine Department of Orthopedic Surgery, Orange, CA.

Objectives: To evaluate axial fracture obliquity and posterior inferior comminution in vertically oriented femoral neck fractures (FNFs) in the physiologically young patient. A biomechanical investigation was designed to evaluate the impact of these fracture elements on torque to failure using cannulated screw (CS) and sliding hip screw fixation.

Methods: Four Pauwels III FNF models were established in synthetic femurs: (1) vertically oriented in the coronal plane (COR), (2) coronal plane with axial obliquity (AX), (3) coronal plane with posterior inferior comminution (CCOM), and (4) coronal plane with axial obliquity and posterior inferior comminution (ACOM). In each group (n = 10), specimens were fixed using either 3 CSs or a sliding hip screw with supplemental antirotation screw (SHS). Quasistatic cyclic ramp-loading to failure was performed using a custom testing jig combining axial preloading and torsional ramp-loading. The primary outcome was torque to failure, defined as angular displacement ≥5 degrees.

Results: In the CS group, torque to failure was 40.2 ± 2.6 Nm, 35.0 ± 1.4 Nm, 29.8 ± 1.5 Nm, and 31.8 ± 2.2 Nm for the COR, AX, CCOM, and ACOM fracture groups, respectively (P < 0.05). In the SHS group, torque to failure was 28.6 ± 1.3 Nm, 24.2 ± 1.4 Nm, 21.4 ± 1.2 Nm, and 21.0 ± 0.9 Nm for the COR, AX, CCOM, and ACOM fracture groups, respectively (P < 0.05). In both constructs, groups with posterior inferior comminution demonstrated significantly lower torque to failure compared to the COR group (P < 0.05). The CS construct demonstrated higher torque to failure in all groups when compared to the SHS construct (P < 0.01).

Conclusions: Posterior inferior comminution significantly affects torque to failure in vertically oriented FNFs. Three peripherally placed CSs may resist combined axial and torsional loading better than a sliding hip screw construct.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000001846DOI Listing
December 2020

Venous Thromboembolism Prophylaxis After Pelvic and Acetabular Fractures: A Survey of Orthopaedic Surgeons' Current Practices.

J Am Acad Orthop Surg 2020 Sep;28(18):750-755

From the Division of Orthopaedic Trauma, UC Irvine Department of Orthopaedic Surgery, Irvine, CA (Dr. Lim and Dr. Scolaro), and the Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA (Dr. Ahn).

Introduction: The goal of this study was to identify the current practices and rationale of orthopaedic surgeons regarding venous thromboembolism (VTE) prophylaxis for pelvic and acetabular (P&A) fractures.

Methods: A 25-item web-based questionnaire was made available to all Orthopaedic Trauma Association (OTA) members on the OTA website. Analysis of data was performed after the three-month study period.

Results: One hundred three active OTA members completed the survey. Most respondents practiced at an academic level I trauma centers. The most important factor in selecting a VTE regimen was its effectiveness, whereas cost was the least important. Low-molecular-weight heparin (LMWH) remains the preferred agent for VTE prophylaxis after P&A trauma. Factors such as surgical intervention and weight-bearing had a variable effect on surgeons' opinions regarding the type and duration of VTE prophylaxis.

Conclusion: Most surgeons treating P&A fractures use LMWH for VTE prophylaxis, but the decision on which agent to use and duration of treatment is multifactorial. Published VTE prophylaxis literature and guidelines provide some guidance, but there is no consensus. Overall, LMWH appears to be the VTE prophylaxis agent of choice for most orthopaedic trauma surgeons, irrespective of nonsurgical or surgical management of these fractures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-19-00409DOI Listing
September 2020

Supplemental Fixation of Supracondylar Distal Femur Fractures: A Biomechanical Comparison of Dual-Plate and Plate-Nail Constructs.

J Orthop Trauma 2020 Aug;34(8):434-440

University of California, Irvine, Department of Orthopaedic Surgery, Orange, CA; and.

Objectives: This biomechanical study compares the effectiveness of dual-plate (DP) and plate-nail (PN) constructs for fixation of supracondylar distal femur fractures in synthetic and cadaveric specimens.

Methods: Twenty-four synthetic osteoporotic femurs were used to compare 4 constructs in an extra-articular, supracondylar fracture gap model (OTA/AO type 33-A3). Constructs included: (1) distal lateral femoral locking plate (DLFLP), (2) retrograde intramedullary nail (rIMN), (3) DLFLP + medial locking compression plate (DP construct), and (4) DLFLP + rIMN (PN construct). DP and PN constructs were then directly compared using 7 matched pairs of cadaveric femurs. Specimens underwent cyclic loading in torsion and compression. Biomechanical effectiveness was measured by quantifying the load-dependent stiffness of each construct.

Results: In synthetic osteoporotic femurs, the DP construct had the greatest torsional stiffness (1.76 ± 0.33 Nm/deg) followed by the rIMN (1.67 ± 0.14 Nm/deg), PN construct (1.44 ± 0.17 Nm/deg), and DLFLP (0.68 ± 0.10 Nm/deg) (P < 0.01). The DP construct also had the greatest axial stiffness (507.9 ± 83.1 N/mm) followed by the PN construct (371.4 ± 41.9 N/mm), DLFLP (255.0 ± 45.3 N/mm), and rIMN (109.2 ± 47.6 N/mm) (P < 0.05). In cadaveric specimens, the DP construct was nearly twice as stiff as the PN construct in torsion (8.41 ± 0.58 Nm/deg vs. 4.24 ± 0.41 Nm/deg, P < 0.001), and over one-and-a-half times stiffer in compression (2148.1 ± 820.4 vs. 1387.7 ± 467.9 N/mm, P = 0.02).

Conclusions: DP constructs provided stiffer fixation than PN constructs in this biomechanical study of extra-articular distal femur fractures. In the clinical setting, fracture morphology, desired healing mode, surgical approach, and implant cost should be considered when implementing these fixation strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000001749DOI Listing
August 2020

Treatment of Patellar Fractures and Injuries to the Extensor Mechanism of the Knee: A Critical Analysis Review.

JBJS Rev 2018 Oct;6(10):e1

Department of Orthopaedic Surgery, University of California, Irvine, Orange, California.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.RVW.17.00172DOI Listing
October 2018

Anterior Pelvic Ring: Introduction to Evaluation and Management.

J Orthop Trauma 2018 Sep;32 Suppl 6:S1-S3

Department of Orthopaedic Surgery, University of California, Irvine, Orange, CA.

The evaluation and management of pelvic ring injuries continues to evolve. Historic treatment was primarily nonsurgical, which yielded to open surgical treatment as the benefits of restoring pelvic anatomy and stability became clear. The development of percutaneous techniques for pelvic ring fixation enabled surgeons to reduce and stabilize certain injuries without the need for large open surgical dissections. Although percutaneous iliosacral screw fixation of sacral fractures and sacroiliac disruptions is the standard for most posterior pelvic ring injuries, the evaluation and treatment of anterior pelvic ring disruptions remains a controversial topic among surgeons who treat these injuries. Universally accepted indications for anterior pelvic ring stabilization do not exist, and there is little comparative data to support one surgical technique over another. In fact, some believe that for many injuries, the anterior ring rarely requires fixation after stable fixation of the posterior pelvic ring. The purpose of this work is to present a brief history on management of the anterior pelvic ring as a component of pelvic ring disruptions and briefly review the anatomy of the anterior pelvic ring. Finally, we will introduce the current techniques available for anterior pelvic reduction/stabilization and present information on evaluation of anterior ring stability as a means of guiding treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000001249DOI Listing
September 2018

Use of 3D Printed Models in Resident Education for the Classification of Acetabulum Fractures.

J Surg Educ 2018 Nov;75(6):1679-1684

UC Irvine Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Irvine, California. Electronic address:

Objective: To determine if three-dimensional (3D) printed models can be used to improve acetabular fracture pattern recognition and be a valuable adjunct in orthopedic resident education.

Design: Fifteen randomized testing stations with each containing plain radiographs (XRs), two-dimensional computed tomography (CT) scans, or 3D model of an acetabular fracture.

Setting: Two orthopedic residency programs based at Level 1 trauma centers.

Participants: Forty-one orthopedic residents, PGY 1-5.

Results: Senior residents were superior to junior residents at correctly identifying the provided acetabular fracture pattern. Overall, use of CT scans or the 3D model improved fracture classification as compared to standard XRs, but there was no significant difference between use of the CT scans and 3D models. Subjective survey results indicated agreement among residents that 3D models were accurate representations of acetabular fractures and that models would be a desired educational modality.

Conclusions: 3D models improved the accuracy of acetabular fracture identification compared to XR. In addition, trainees were able to use 3D models to obtain similar accuracy compared to CT scans despite not having previous exposure to the models. Interobserver agreement improved when comparing CT to 3D, but did not provide greater than a fair agreement indicating that fracture patterns were difficult to accurately classify even with the use of 3D models. Residents' subjective responses indicated a positive experience with the use of 3D models. We conclude that the incorporation of 3D models could be an important adjunct to orthopedic residency education for the evaluation complex fracture patterns, but is not significantly superior to identification with CT scans.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jsurg.2018.04.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6346736PMC
November 2018

Acute femoral shortening for reconstruction of a complex lower extremity crush injury.

Strategies Trauma Limb Reconstr 2018 Nov 23;13(3):185-189. Epub 2018 May 23.

Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Drive South, Orange, CA, 92868, USA.

Traumatic through-knee or transfemoral amputations with concomitant ipsilateral femoral fractures are extremely rare injuries. The initial goal of management is patient resuscitation and stabilization. Subsequent interventions focus on limb salvage and the creation of a residual limb that can be fitted successfully for a functional lower extremity prosthesis. We present the case of a patient who sustained a traumatic through-knee amputation ipsilateral to an open comminuted femoral fracture. Soft tissue injury prohibited initial primary closure over the distal femoral condyles. A functional residual limb was achieved with acute femoral shortening, maintenance of the femoral condyles and fracture stabilization with a short retrograde intramedullary nail. This approach allowed maintenance of muscular attachments to the femur, soft tissue closure and resulted in a residual limb of acceptable length with a broad weight-bearing surface that was fitted with a prosthesis successfully.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11751-018-0311-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6249149PMC
November 2018

Fixed angle plate fixation of comminuted patellar fractures.

Injury 2018 Jun 27;49(6):1203-1207. Epub 2018 Mar 27.

University of California, Irvine, Orange, CA, USA. Electronic address:

Introduction: Comminuted patella fractures are uncommon and difficult fractures to manage. Multiple treatment modalities have been suggested, with little clinical data to support practice. Recent biomechanical and technical investigations have described successful plate fixation of comminuted patella fractures. The purpose of this study was to evaluate radiographic, clinical and functional outcome of comminuted patella fractures treated with a fixed angle locking plates. We believe stable fixation, which results in successful fracture union and functional recovery, can be achieved with this technique.

Materials And Methods: A retrospective review was performed at a single regional academic Level 1 trauma hospital. All comminuted patella fractures treated with a fixed angle locking plate (AO/OTA 34C2 and C3) over a six-year period were evaluated. Thirty-six patients were identified. Average length of follow up was 154 weeks (range 12-297 weeks). Twenty patients were available for functional outcome scoring. Primary outcome measures were: Knee Outcome Score (KOS), Lower Extremity Functional Scale (LES) and goniometer measured knee range of motion. Secondary outcomes evaluated the need for additional screw or cerclage fixation, reoperation for any reason, bothersome hardware, infection and nonunion.

Results: Average KOS = 57.2 (20-74), average LES = 58.9 (15-80). Median extension = 0° (full extension), median flexion = 130°. Supplemental screws were used in 17/36 cases; cerclage used in 2/36 cases. Hardware irritation was noted in 4/20 patients, no patient requested elective hardware removal, one patient had failure of fixation and no nonunions were identified.

Conclusion: Fixed angle plate stabilization of comminuted patella fractures is a viable technique for fracture fixation. Good to excellent return of knee function and low complication rates, including need for hardware removal, can be expected.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.injury.2018.03.030DOI Listing
June 2018

Risk of Knee Sepsis After Treatment of Open Tibia Fractures: A Multicenter Comparison of Suprapatellar and Infrapatellar Approaches.

J Orthop Trauma 2018 02;32(2):88-92

Department of Orthopaedic Surgery, University of California-Irvine, Orange, CA.

Objectives: The suprapatellar approach for medullary nailing of the tibia is increasing. This requires intra-articular passage of instruments, which theoretically places the knee at risk of postoperative sepsis in the setting of open fracture. We hypothesized that the risk of knee sepsis is similar after suprapatellar or infrapatellar nailing of open tibia fractures.

Design: Retrospective, multicenter.

Setting: Three urban level 1 trauma centers.

Patients: All patients treated with medullary nailing for open diaphyseal tibia fractures (OTA 42) from 2009 to 2015. Patients younger than 18 years of age and with less than 12 weeks of follow-up were excluded. We identified 289 fractures in 282 patients.

Intervention: Suprapatellar (SP) or infrapatellar (IP) medullary nailing of open tibia fractures.

Main Outcome Measurement: Occurrence of ipsilateral knee sepsis, defined as presence of a positive culture from knee aspiration or arthrotomy. Deep infection requiring operative debridement, superficial infection requiring antibiotic therapy alone, and all-cause reoperation were also recorded.

Results: IP nailing was used for 142 fractures. There were 20 infections (14.1%), of which 14 (9.8%) were deep. Fourteen tibias (9.8%) required reoperation for noninfectious reasons for 28 total reoperations (19.7%). SP nailing was used in 147 fractures. There were 24 infections (16.2%), of which 16 (10.8%) were deep. Fourteen additional tibias (9.5%) required reoperation for noninfectious reasons for a total of 30 reoperations (20.4%). There were no differences in the rates of infection, deep infection, or reoperation between groups. There were 2 cases of knee sepsis after SP nailing (1.4%) but zero cases after IP nailing (P = 0.5).

Conclusions: There was no significant difference in the rate of knee sepsis with SP or IP approaches. The risk of knee sepsis after SP nailing of open fractures is low, but present.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000001024DOI Listing
February 2018

Management of Interprosthetic Femur Fractures.

J Am Acad Orthop Surg 2017 Apr;25(4):e63-e69

From the Department of Orthopaedic Surgery, UC Irvine Health, Orange, CA (Dr. Scolaro), and the Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY (Dr. Schwarzkopf).

Femoral fractures between a total hip arthroplasty prosthesis and total knee arthroplasty prosthesis, also called interprosthetic fractures, are challenging clinical problems. The number of patients who have undergone ipsilateral primary or revision joint arthroplasty procedures in both the hip and the knee continues to rise, and the number of interprosthetic fractures is increasing, as well. The growing body of biomechanical and clinical literature on interprosthetic fractures reflects the increased frequency of and interest in these injuries. Similar to the management of periprosthetic fractures, the management of interprosthetic fractures depends on the location of the fracture, the stability of the implant, and the ability to achieve stable fracture fixation. These factors are the basis of recently described classification systems and treatment strategies. In patients with stable implants, fracture fixation alone is performed. When the implant is loose, both revision arthroplasty and fracture fixation may be required to provide stability of the limb.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-15-00664DOI Listing
April 2017

Management and radiographic outcomes of femoral head fractures.

J Orthop Traumatol 2017 Sep 10;18(3):235-241. Epub 2017 Feb 10.

The University of Texas, Health Sciences Center at Houston, Houston, TX, USA.

Background: Femoral head fractures are uncommon injuries. Small series constitute the majority of the available literature. Surgical approach and fracture management is variable. The purpose of this study was to evaluate the incidence, method of treatment, and outcomes of consecutive femoral head fractures at a regional academic Level I trauma center.

Materials And Methods: A retrospective review of a prospective database was performed over a 13-year period. All AO/OTA 31C femoral head fractures were identified. A surgical approach and fixation method was recorded. Clinical and radiographic evaluation was performed for patients with 6 months or greater follow-up. Radiographs were evaluated for fixation failure, heterotopic ossification (HO), avascular necrosis (AVN) and post-traumatic arthritis.

Results: We identified 164 fractures in 163 patients; 147 fractures were available for review. Treatment was operative reduction and internal fixation (ORIF) in 78 (53.1%), fragment excision in 37 (25.1%) and non-operative in 28 (19%). An anterior approach and mini-fragment screws were used in the majority of patients treated with fixation. Sixty-nine fractures had follow-up greater than 6 months. Sixty-two fractures (89.9%) proceeded to uneventful union. All Pipkin III fractures failed operative fixation. Six patients developed AVN, seven patients had a known conversion to hip arthroplasty; HO developed in 28 (40.6%) patients and rarely required excision.

Conclusions: Fractures of the femoral head are rare. An anterior approach can be used for fragment excision or fixation using mini-fragment screws. Pipkin III fractures represent catastrophic injuries. Non-bridging, asymptomatic HO is common. AVN and posttraumatic degenerative disease of the hip occur but are uncommon.

Level Of Evidence: IV-prognostic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10195-017-0445-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5585088PMC
September 2017

Video Review as a Tool to Improve Orthopedic Residents׳ Performance of Closed Manipulative Reductions.

J Surg Educ 2017 Jul - Aug;74(4):663-667. Epub 2017 Jan 30.

Department of Orthopaedic Surgery, University of California, Irvine, Orange, California. Electronic address:

Objective: Orthopedic residents commonly perform closed manipulative reductions as a part of their training. Traditionally, this skill is taught early in training but difficult to simulate. Proficiency is achieved through repetition and experience; faculty observation and instruction is unfortunately often limited. Direct resident teaching has been shown to increase competency, comfort, and long-term skill retention. We hypothesize that video review of closed fracture reductions will provide an inexpensive and valuable tool for resident education and improve skill performance.

Design: Closed reductions performed by orthopaedic residents were recorded using a secured mobile tablet device in the emergency department (ED). Video review sessions were performed with both peer and faculty feedback/analysis of reduction technique. Anonymous resident and faculty surveys were completed following each session to evaluate the usage and perceived benefit of the program.

Setting: University-based Level I Trauma Center.

Participants: Orthopedic surgery residents and faculty.

Results: All junior orthopedic residents (postgraduate year [PGY] 1-3) reported that direct video observation by faculty was beneficial. Furthermore, 97% of junior resident and 100% of faculty responses reported that they would use this educational technology in the future. Residents and faculty both strongly agreed that video review was more useful than other methods, improved resident preparation for ED fracture care, and felt this technique would improve patient care and outcomes. Compared with senior residents (PGY 4-5), PGY-1s believed that this technique helped them prepare for ED fracture care (p = 0.02).

Conclusions: Video review provides a useful, innovative, and inexpensive method to improve resident competency in closed fracture reduction-a critical skill in orthopedic patient care. These procedures are uncommonly available for direct faculty observation. We have demonstrated that both residents and faculty were satisfied with the ability to review procedures, identify weaknesses, and obtain or provide direct feedback on this skill. Additionally, fracture reduction video review may help residents meet and achieve clinical milestones, an area of future investigation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jsurg.2017.01.003DOI Listing
May 2018

Intramedullary Tibial Nail Fixation of Simple Intraarticular Distal Tibia Fractures.

J Orthop Trauma 2016 Nov;30 Suppl 4:S12-S16

*Department of Orthopaedic Surgery, University of California, Irvine, Orange, CA; †School of Medicine, University of California, Irvine, Orange, CA; and ‡Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.

The optimal treatment strategy for distal tibia fractures, especially those with intraarticular extension, remains controversial. Although open reduction and internal fixation with a plate and screw device is commonly performed for these injuries, the risk of soft tissue complications using this approach is significant. Staged treatment protocols and alternative means of fixation have been proposed to address these undesired events. Although potentially more technically demanding than fixation of diaphyseal or extraarticular tibial fractures, intramedullary nail (IMN) fixation of simple intraarticular distal tibia fractures is a viable treatment alternative with unique advantages. This article presents a review of the literature and rationale for intramedullary tibial nail fixation of simple intraarticular distal tibia fractures and a surgical approach commonly utilized for successful implementation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000000697DOI Listing
November 2016

Introduction.

J Orthop Trauma 2016 Nov;30 Suppl 4:S1

*Department of Orthopaedic Surgery, University of California, Irvine, Orange, CA; †Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; ‡University of South Florida, Tampa, FL; and §Florida Orthopaedic Institute, Tampa, FL.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000000696DOI Listing
November 2016

The Morel-Lavallée Lesion: Diagnosis and Management.

J Am Acad Orthop Surg 2016 Oct;24(10):667-72

From the Department of Orthopaedic Surgery, University of California, Irvine, Orange, CA (Dr. Scolaro), Kern County Medical Center, Bakersfield, CA (Dr. Chao), and the Orthopaedic Trauma Service, St. Alphonsus Medical Center, Boise, ID (Dr. Zamorano).

The Morel-Lavallée lesion is a closed soft-tissue degloving injury commonly associated with high-energy trauma. The thigh, hip, and pelvic region are the most commonly affected locations. Timely identification and management of a Morel-Lavallée lesion is crucial because distracting injuries in the polytraumatized patient can result in a missed or delayed diagnosis. Bacterial colonization of these closed soft-tissue injuries has resulted in their association with high rates of perioperative infection. Recently, MRI has been used to characterize and classify these lesions. Definitive management is dictated by the size, location, and age of the injury and ranges from percutaneous drainage to open débridement and irrigation. Chronic lesions may lead to the development of pseudocysts and contour deformities of the extremity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-15-00181DOI Listing
October 2016

Femoral Head Fractures.

JBJS Rev 2015 Nov;3(11)

1Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, 1520 San Pablo, Suite 2000, Los Angeles, CA 90033 2Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA 92868 3University of Texas-Health Sciences Center at Houston, 6431 Fannin Street, Houston, TX 77030.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.RVW.N.00098DOI Listing
November 2015

Treatment of Pediatric and Adolescent Pelvic Ring Injuries With Percutaneous Screw Placement.

J Pediatr Orthop 2018 Mar;38(3):133-137

The University of Texas Health Sciences Center at Houston Houston, TX.

Background: Pediatric and adolescent pelvic ring injuries are frequently treated without surgery. In patients with unstable injuries to the pelvic ring, surgical stabilization aids in resuscitation, provides pain relief, and allows for mobilization. Percutaneous pelvic screw fixation is commonly performed in adult patients for unstable pelvic ring injuries, but a paucity of literature exists regarding their use in pediatric patients. The purpose of this study is to review the use, outcome, and management of percutaneous posterior pelvic screws in pediatric patients with unstable pelvic ring injuries.

Methods: A retrospective review of a prospectively collected orthopaedic trauma database was performed over a 7-year period at a regional level-1 trauma center. All patients between the ages of 7 and 17 who sustained an injury to the pelvic ring and were treated with percutaneous fixation of the posterior pelvic ring were identified. We evaluated the frequency of this technique in the described patient population, incidence of nerve injury, infection, loss of fixation, and need for hardware removal.

Results: A total of 238 pediatric patients who sustained a pelvic ring injury were initially identified; following application of study criteria, 67 (28.1%) patients were included in the study. Additional anterior ring fixation was performed in 33 (49.2%) patients. There were no iatrogenic nerve injuries, no infections, and surgical blood loss was <50 mL in all cases. Clinical and radiographic follow-up averaged 33 weeks. No loss of reduction was observed. Eight patients (13%) reported persistent low back pain at last follow-up. Elective hardware removal was performed in 3 patients.

Conclusions: The majority of pediatric pelvic ring injuries can be treated without surgery. In the setting of instability, percutaneous pelvic screw fixation can be performed safely. A computed tomography scan is used to evaluate the available osseous pathways for screws and intraoperative fluoroscopy is used to safely perform this technique. Screw removal should be discussed in select patients.

Level Of Evidence: Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BPO.0000000000000790DOI Listing
March 2018

Stabilisation of infected peri-articular nonunions with an antibiotic impregnated cement coated locking plate: Technique and indications.

Injury 2016 Jun 12;47(6):1353-6. Epub 2016 Mar 12.

University of Pennsylvania, Philadelphia, PA USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.injury.2016.03.010DOI Listing
June 2016

Posteromedial Approach for Open Reduction and Internal Fixation of Talar Process Fractures.

Foot Ankle Int 2016 Apr 3;37(4):446-52. Epub 2016 Mar 3.

Department of Orthopaedic Surgery, University of California-Irvine, Orange, CA, USA.

Unlabelled: Fractures of the posteromedial process of the talus are frequently the result of high-energy trauma to the lower extremity. The treatment of these uncommon injuries may be unfamiliar and challenging to many surgeons. Significant pain and disability can result if these injuries are not recognized or treated appropriately. Open reduction and internal fixation via a posteromedial approach with screws is a mainstay of operative treatment for simple fractures. In cases of fracture impaction and/or comminution, a medial uniplanar external fixator may be used to improve intraoperative fracture visualization and mini-fragment plates and screws can be used to secure areas of comminution.

Level Of Evidence: Level V, expert opinion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1071100716635813DOI Listing
April 2016

Surgical Management of Complex Lower-Extremity Trauma With a Long Hindfoot Fusion Nail: A Case Report.

Foot Ankle Spec 2016 Aug 8;9(4):354-60. Epub 2015 Oct 8.

Department of Orthopaedic Surgery (NSJ, GDL, SSB, JAS), University of California, Irvine, Orange, CaliforniaAesthetic and Plastic Surgery Institute (GAW), University of California, Irvine, Orange, California

Unlabelled: High-energy injuries can result in complete or partial loss of the talus. Ipsilateral fractures to the lower limb increase the complexity of surgical management, and treatment is guided by previous case reports of similar injuries. A case of complex lower-extremity trauma with extruded and missing talar body and ipsilateral type IIIB open tibia fracture is presented. Surgical limb reconstruction and salvage was performed successfully with a single orthopaedic implant in a manner not described previously in the literature. The purpose of this case report is to present the novel use of a single orthopaedic implant for treatment of a complex, open traumatic injury. Previous case reports in the literature have described the management of complete or partial talar loss. We describe the novel use of a long hindfoot fusion nail and staged bone grafting to achieve tibiocalcaneal arthrodesis for the treatment of complex lower-extremity trauma.

Levels Of Evidence: Therapeutic, Level IV: Case study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1938640015609982DOI Listing
August 2016

Open surgical management of high energy ipsilateral fractures of the fibula and calcaneus.

Foot Ankle Surg 2015 Sep 29;21(3):182-6. Epub 2014 Nov 29.

University of Washington - Harborview Medical Center, Department of Orthopaedic Surgery and Sports Medicine, 325 Ninth Avenue, Seattle, WA 98104-2499, United States. Electronic address:

Background: Simultaneous ipsilateral fractures of the calcaneus and fibula are the result of high-energy injuries. Open surgical treatment of both fractures can be performed with incisions based on the described blood supply of the lower extremity.

Methods: A retrospective review for all patients with ipsilateral fractures of the calcaneus and fibula was performed over an eight-year period. Thirty-eight patients were identified. Eleven patients (28.9%) were treated with open reduction and internal fixation through two separate incisions. Average follow-up was 48.8 weeks.

Results: Two patients (18.1%) required a secondary procedure. Three patients (27.2%) developed incisional cellulitis that resolved with oral antibiotics and one patient required local wound care. All fractures united.

Conclusions: Ipsilateral fractures of the calcaneus and fibula require open reduction and internal fixation when closed or percutaneous treatment is not appropriate. We describe an operative approach based on the angiosomes of the lower extremity that allows for treatment of these complex injuries and report the associated complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fas.2014.11.006DOI Listing
September 2015