Grand Rounds : Journal of Orthopaedic Trauma

​​​​​​​​​​​​​JOT Grand Rounds

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Ankle Fractures With Syndesmotic Injury Treated With Distal Fibula Plates and Syndesmotic Fixation Device: A Case Report

Hector J. Cerón, BS, Luis Guevara, DO, MPH, and Eildar Abyar, MD

Ankle fractures with concurrent syndesmotic injuries requiring stabilization are prevalent and require immediate care to avoid long-term complications. There are many surgical fixation options for syndesmotic disruption resulting in an ongoing search for the “gold standard." The present case report aimed to introduce a novel device for syndesmotic fixation and compare this technique with cortical screw and suture button fixation.

Publication support provided by DePuy Synthes​

Upper Extremity​​

Treatment of a High-Velocity Ballistic Humerus Fracture With Circular External Fixation and Polyacial Locking Struts: A Case Report

David J. Cinats, MD, MSc

Ballistic fractures of the extremities pose many challenges for orthopaedic surgeons because they can be associated with soft-tissue and neurovascular injuries. Fractures of the humerus comprise approximately 25% of ballistic upper extremity injuries. The fracture pattern tends to be diaphyseal, multifragmentary, and have a large zone of injury. This is a case of a 22-year-old man with a diaphyseal, multufragmentary, ballistic humeral shaft fracture with associated ballistic both bones forearm fracture, arm and forearm compartment syndrome, and antecubital fossa soft-tissue loss. The humerus fracture was treated in a closed manner with application of a circular external fixator and novel polyaxial locking struts. 

Publication provided by DePuy Synthes​​

Treatment of Chronic Radial Head Fracture/Dislocation With Radial Head Replacement​​

Jennifer Blanda, MD, Mikhail Alexeev, MD, and Steven M. Kane, MD

Upper extremity elbow trauma is commonly encountered in clinical practice. Various treatment options exist for radial head fractures depending on how destabilizing the injury is to the elbow's mechanical function. The purpose of this case report is to demonstrate a surgical treatment option for comminuted radial head fractures requiring replacement using a new radial head replacement system.

Publication provided by DePuy Synthes​

Use of the Femoral Neck System for the Treatment of a Femoral Neck Fracture in Active Middle-Aged Adults

Justin Kuether, MD, David Molho, MD, and Michael P. Leslie, DO

Femoral neck fractures in young and middle-aged patients are a challenging clinical scenario. They have a high complication rate and behave distinctly different than those found in an elderly population. Historically, there were limited fixation options for this age group; however, the recent introduction of the femoral neck system offers a new tool to manage these fractures. This system may have advantages over previously available methods, and the capabilities of this device may offer increased stability and improved outcomes for challenging femoral neck fractures.

Publication provided by DePuy Synthes 

Terrible Triad Elbow Fracture-Dislocation With a Significant Coronoid Fracture

Francisco Rubio, MD

​The terrible triad elbow fracture-dislocation injury pattern is challenging to treat. The goal of treatment is to restore alignment and stability to the elbow joint. Typically, significant coronoid fractures associated with this injury pattern require management by internal fixation to confer elbow stability. We present a case of a terrible triad injury with a significant coronoid fracture that did not require coronoid fixation to provide stability to the elbow because of the placement of the internal joint stabilizer-elbow (IJS-E) device.

Publication support provided by Skeletal Dynamics

Simple Elbow Dislocation in Patients With High Body Mass Index​

Deana Mercer, MD and Allicia O. Imada, MD

In patients with a body mass index (BMI) above 30, simple elbow dislocations can have associated soft-tissue stripping and severe instability not typically seen in patients who have lower BMIs. We describe a patient with a BMI above 30 who had a simple elbow

dislocation and a complex elbow injury with severe soft-tissue stripping. Treatment included open reduction of the elbow joint, repair of the lateral ulnar collateral ligament, and placement of an internal joint stabilizer. At 4-year follow-up, the patient has a painless joint without arthritis and full-range of motion without any deficit.

​Publication support by Skeletal Dynamics ​

Managing a Terrible Triad With Concomitant Posteromedial Rotatory Instability: A Surgical Case Study​

Jorge L. Orbay, MD, Menar Wahood, DO, and Gabriel Pertierra, MS

Complex elbow injuries involving the anteromedial facet of the coronoid (AMF) may result in persistent posteromedial rotatory instability. Management of these injuries often results in poor outcome. An 86-year-old patient was treated with a posterior elbow dislocation and unstable anterior and medial coronoid facet fractures (O'Driscoll type 2–3) that proved unstable after closed reduction. In this case, an internal joint stabilizer applied from the lateral side was successful in restoring joint congruency, maintaining AMF reduction, and permitting early rehabilitation. The AMF was partially reduced by closed manipulation and healed in a position that provided stability.​

Publication support provided by Skeletal Dynamics​ ​​

Treatment of Chronic Unreduced Posterior Elbow Dislocation With an Internal Joint Stabilizer
Evan S. Fene, MD, Ishvinder S. Grewal, MBBS, John L. Eakin, MD, and Adam J. Starr, MD

Chronic unreduced elbow dislocations remain difficult to treat with a high rate of complications. This injury is rare in the United States; more often, it is seen in underdeveloped countries where many patients seek traditional treatment from

local bone setters before ever seeing an orthopaedic surgeon. The purpose of this report is to present successful surgical management of a patient with a chronic elbow dislocation treated with an internal joint stabilizer of the elbow.

Publication support provided by Skeletal Dynamics. 

Humeral Plate Augmentation of an Elbow Internal Joint Stabilizer

Kendrick Khoo, MD, Kamran Movassaghi, MD, MS, and Nathan Hoekzema, MD

We describe a unique case of a distal humerus fracture involving the capitellum with associated elbow dislocation. Preoperative computed tomography demonstrated avulsion fractures of the medial collateral ligament, triceps insertion, and lateral epicondyle indicative of significant elbow instability. The patient underwent capitellar fixation and internal joint stabilizer.  Because of the osseous compromise of the lateral distal humerus, the internal joint stabilizer was augmented with a precontoured lateral distal humeral plate to maintain the axis pin position.

Publication support provided by Skeletal Dynamics 

New-Generation Femoral Neck Fixation for the Treatment of a Nondisplaced Femoral Neck Fracture in an Elderly Patient

Eben A. Carroll, MD

Femoral neck fractures are challenging fractures to treat.  In the elderly with nondisplaced or stable valgus-impacted fracture patterns, success hinges on a construct's ability to maintain reduction. New-generation femoral neck fixation constructs may decrease failure rates by providing increased mechanical stability.  This case explores the use of a new-generation femoral neck fixation construct to stabilize a femoral neck fracture in an elderly patient.

Publication support provided by DePuy Synthes

Open Reduction and Internal Fixation of a Distal Radius Fracture With a Volar Locking Plate: A Case Report

John Wyrick, MD​

Fracture of the distal radius is the most common fracture of the upper extremity and one of the most common fractures treated by orthopedists. With th​e population continuing to age, the annual incidence of more than 600,000 is expected to increase as well. ​Over the past 10 years, a more aggressive treatment approach has been adopted by the orthopaedic community with a 2-fold increase in the number of patients treated with surgery from 1998 to 2008. This includes an even larger increase in the number of fractures treated with open reduction and internal fixation (ORIF) with volar locking plates. Publication support provided by Stryker Trauma & Extremities​

Precontoured Plate Fixation With Interfragmentary Lag Screw Use in a Middle Third Clavicle Fracture Fixation

Alireza Naderipour, MD and Michael D. McKee, MD, FRCS(C)

Middle third clavicle fractures are common injuries that need surgical fixation in a certain subset of patients. The use of precontoured clavicle plates facilitates intraoperative fixation
and can reduce soft tissue irritation and hardware removal rates.We report a 46-year-old patient with a mid-shaft right clavicle fracture who was treated with this technique, which resulted in an excellent clinical outcome.  Publication support provided by Stryker Trauma & Extremities

Talus Fracture Fixation With Headless Screws From a Posterior to Anterior Direction—A Case Report

Lower Extremity

Intramedullary Nailing With Angle Stable Locking Technique of an Intra-articular Distal Tibial Fracture and an Extra-articular Distal Tibial Shaft Fracture

Cade A. Morris, BS and Phillip M. Mitchell, MD

Evolution of distal interlocking technology with “angle stable" screws has improved fixation in the treatment of far distal tibia fractures in more osteoporotic patients. This report details the use

of a suprapatellar tibial IMN with angle stable locking screws in the treatment of an open distal tibial fracture with intra-articular extension in a 67-year-old man who fell off a ladder. ​

Publication provided by DePuy Synthes​​​

Treatment of a Multifragmentary Patella Fracture Using a Novel Anatomic Locking Plate​

Adeet Amin, MD, Patrick J. Kellam, MD, and Stephen J. Warner, MD, PhD

Multifragmentary patellar fractures present a challenge for orthopaedic surgeons regarding treatment options.  Presented in this care report is a 50-year-old active gentleman who presented with a closed multifragmentary patella fracture treated with open reduction internal fixation using a 2.7-mm variable angle locking patella plate. This plate allowed for multiplanar and interfragmentary screw fixation in each fragment with early range of motion postoperatively. The patient returned to full activities and range of motion at 6 months postoperatively. 

Publication provided by DePuy Synthes​​

Correction of Pediatric Distal Tibial Malunion With an Automated Hexapod External Fixator​

Christian Blough, MD, Abrianna Robles, BS, Kenneth D. Illingworth, MD, and Geoffrey S. Marecek, MD

Angular deformity and limb length discrepancy (LLD) are common sequelae of growth arrest after pediatric physeal fractures. This combination of skeletal deformity can be treated in a variety of ways. One such technique is the use of hexapod external fixation to simultaneously address the angular deformity and LLD in a gradual fashion. New technology, in the form of automated hexapod struts, facilitates such a correction and may provide several advantages for the surgeon and patient.

We present the case of an 11-year-old girl with marked distal tibial varus and LLD after an ankle fracture who was treated with angular and length correction using a hexapod external fixator with automated struts.​

Publication provided by DePuy Synthes​​

Limb Salvage Reconstruction of the Lower Leg with Automatic Hexapod Struts​

Austin T. Fragomen, MD

Circular frame external fixation is a mainstay in the treating surgeon's armamentarium for managing complex limb salvage cases. Automatic hexapod struts have revolutionized the patient experience by removing the burden of adjustments from the patient, but these novel struts have been available in limited quantities and have been employed judiciously. This case report reviews the use of automatic struts for a moderate tibial lengthening-bone transport case, highlighting the ease of use and excellent radiographic results.

Publication provided by DePuy Synthes​​

Effective Medullary Debridement of Long Bone Osteomyelitis​

Brett D. Crist, MD

The case presented was a chronically infected open tibia fracture with a history of methicillin-resistant Staphylococcus aureus bacteremia and recurrent draining tibial wounds. Along with sinus tract excision, implant removal, extramedullary debridement, resorbable local antibiotic delivery, and culture-specific antibiotics, the second-generation Reamer Irrigator Aspirator (DePuy Synthes, West Chester, PA) was used for medullary canal debridement because of concern for medullary sepsis in the setting of chronic osteomyelitis and indwelling tibial intramedullary nail. Cultures were obtained using the graft filter to help direct culture-specific antibiotic therapy. The patient went on to resolve his infection and was asymptomatic 14 months after surgery.

Publication provided by DePuy Synthes​

Nailing of a Proximal Third Tibial Shaft Fractures Using Cortical Substitution Screws​

Melissa M. Gross, MD and Brian M. Weatherfod, MD

The proximal third tibial shaft continues to be a region fraught with fixation challenges. The deforming forces acting on the proximal tibia and the broad metaphyseal diameter in relation to the nail heavily influence the surgeon's ability to obtain reduction, maintain alignment, and achieve union while allowing for early range of motion and weight-bearing. Advances in nail design and refinement of surgical technique have led to increase utilization of nailing for proximal tibial metaphyseal fractures. This case outlines the use of threaded wires and interlocking screws both as intraoperative reduction aids and cortical substitution devices to restore the mechanical axis of the limb and prevent late loss of reduction.

Publication provided by DePuy Synthes​

Fixation of Distal Femoral Periprosthetic Fracture With a Retrograde Nail and Locking Attachment Washer Combination: A Case Report​

M. Kareen Shaath, MD and George J. Haidukewych, MD

Periprosthetic distal femoral fractures are challenging injuries to treat due to patients' poor bone quality and limited bone stock. The 2 main treatment strategies are laterally based locked plates and intramedullary nails. The authors present a case of a periprosthetic distal femoral fracture successfully treated with the new retrograde femoral nailing system. The novel attributes of this implant, the surgical technique, and our postoperative protocol are described.

Publication provided by DePuy Synthes​

Use of a Variable-Angle Locking Plate for the Treatment of a Comminuted Patella Fracture

Augustine M. Saiz, Jr, MD and Mark A. Lee, MD

Historically, patellectomy was considered the treatment of choice for highly comminuted or complex patella fractures, but resection shortens the extensor mechanism and that affects symptoms and function. Contemporary fixation strategies exist with the goals of (1) restoration of the functional integrity and strength of the extensor mechanism and (2) restoration of articular congruity. A meticulous surgical technique using basic fracture care principles coupled with the new variable-angle screw and plate technology may offer unique fixation advantages that translate to improved clinical outcomes in the most challenging fractures.

Publication provided by DePuy Synthes​

Complex Distal Femur Fracture: A New and Novel Technique to Maximize Fixation and Promote Early Wight-Bearing - A Case Report​​

Frank A. Liporace, MD, Luke G. Menken, DO, and Richard S. Yoon, MD

The authors present a new technique incorporating the concept of combining fixation options to enhance distal femur fragment stability with retrograde intramedullary nailing to allow for early weightbearing and decreased risk of fixation failure by combining retrograde nailing with a locking attachment washer.

Publication provided by DePuy Synthes​

Advancing the Treatment of Segmental Defects: Eliminating "Graft Escape" During the Second Stage of Masquelet Technique​

Luke G. Menken, DO, Jaclyn M. Jankowski, DO, Frank A. Liporace, MD, and Richard S. Yoon, MD​

Segmental bone defects can arise from a variety of etiologies including trauma or malignancy, both with or without infection. One accepted treatment modality, the Masquelet technique, is a 2-staged procedure that involves bone grafting during the second stage. No matter the size of the defect, ensuring that the graft remains in the bony void in the desired configuration can be a difficult task; often, “graft escape" can occur, where even weight-bearing may cause the graft to move from its ideal position. The authors describe the use of a TRUMATCH(R) Graft Cage - Long Bone to eliminate “graft escape" and maintain ideal bone graft position within the void.

Publication provided by DePuy Synthes

Ankle Fractures With Syndesmosis Sprain Repaired With a Novel Screw-Suture Construct: A Report of 2 Cases​

Babar Shafiq, MD and Davis Rogers, MD

Syndesmotic fixation remains a foundational operative technique in reconstructing ankle stability. Standard transsyndesmotic surgical options for the treatment of syndesmotic instability include screw fixation and/or fixation with a suture button. However, syndesmotic implants  frequently require removal; suture button tension consistency remains inconsistent; and certain complex ankle fractures increase the difficulty of inserting syndesmotic fixation without interfering with implants required to stabilize the bony fragments. Two cases are presented in which a new method of syndesmotic fixation is used and demonstrates restoration of the distal tibiofibular articulation via a modular system with which tension can be adjusted. 

Publication support provided by DePuy Synthes

Treatment of a Segmental Defect in the Humerus With Induced Membrane Technique

Clay A. Spitler, MD

Treatment of large long bone segmental defects is typically performed by bone transport or induced membrane technique. Although both methods are more frequently described in the lower extremity, descriptions and outcomes of upper extremity defects are less well described. The purpose of this case report is to describe the management of a segmental bone defect in the humerus using induced membrane technique with bone graft harvest from the ipsilateral femoral medullary canal.

Publication support provided by DePuy Synthes  ​

Polymethylmethacrylate Augmentation in Revision of a Proximal Femur Fracture

Douglas W. Lundy, MD, MBA and Jennifer L. Bruggers, MD

Augmentation of fixation using polymethylmethacrylate is a reliable method to increase stability in complex proximal femoral fractures.  Salvage after cutout can be challenging because the bone stock of the proximal femur in elderly patients is often compromised by the cavitation defect created in the femoral head.  The bone loss after cutout can often be sufficient to make subsequent fixation technically difficult or impossible.  This report describes the use of polymethylmethacrylate (PMMA) to augment femoral head fixation in a patient with cutout after failed fixation of a subtrochanteric femoral fracture.

Publication support provided by DePuy Synthes

Lateral Malleolus Fixation With a Fibular Rod

Darryl A. Auston, MD, PhD

In the surgical treatment of fibula fractures, some patient populations may benefit from less invasive approaches and indirect reduction associated with fibular rods. The aim of this report is to demonstrate successful treatment of an unstable ankle injury in a geriatric patient with insulin-dependent diabetes using a fibular rod. Publication support provided by Acumed.