Autogenous iliac crest bone grating has been the gold standard. Recently, intramedullary bone graft harvest using a reamer-irrigator-aspirator (RIA) had been gaining more interest among orthopedic surgeons. Twenty-four RIA bone graft harvesting procedures in 23 consecutive patients with nonunions were included. The mean age was 37.8 years. Rates of perioperative complications, secondary surgical procedures, and union were assessed for all patients. At mean 10.1 months follow-up, three donor site complications occurred (12.5%), including two fractures (8.3%). Eighteen patients (78%) progressed to radiographic union, three (13%) were lost for follow-up, and two (9%) failed to achieve union. Mean reamer size was 13.7 mm (mode, 14.0 mm), producing an average volume of 39.4 mL (range, 15-90 mL) bone graft. While RIA bone grafting results in predictably high rates of union, patients should be counseled extensively about fracture risk. Tibial RIA may be less optimal as a primary source of bone grafting. (Journal of Surgical Orthopaedic Advances 26(4):233-238, 2017).

Bone grafting is one of the most common orthopedic procedures. We conducted a study to assess the possibility of passing a Reamer/Irrigator/Aspirator (RIA; DePuy Synthes) retrograde through the nonunion site in distal femur cases. This technique would avoid the complications and discomfort associated with a separate entry site for RIA. All patients with a distal femur nonunion treated with RIA bone grafting between 2009 and 2013 were included in the study. Nonunions were mobilized with excision of fibrous tissues. The distal part was angulated into varus, and then the guide wire was passed from the nonunion site laterally. Five patients had a RIA passed retrograde through the nonunion site. Mean age of these patients was 40.4 years (range, 22-66 years). Mean reamer size was 13.4 mm (mode, 14 mm), producing an average bone graft volume of 33 mL. There were no intraoperative or postoperative fractures. In 1 case, the reamer shaft broke. Passing a RIA retrograde through the nonunion site in distal femur cases is reproducible, and the technique avoids the discomfort and pain associated with a separate entry point as well as the complication of eccentric reaming of the proximal and distal part of the femoral canal.

Background: Treatment of sacral fractures and sacroiliac joint (SIJ) disruption with percutaneous ilio-sacral (IS) screw fixation had become a more popular treatment option. There has been no study that specifically assessed IS fixation in children. The purpose of this study is present our results with fixation of the sacral fractures and SIJ disruption using IS screw in children 18 years old and younger. Methods: This is a retrospective review chart for children with sacral fracture or SIJ disruption who were treated by IS fixation in the period from 2000 to 2012. The patients were assessed for the following (age, sex, type of injury, associated injuries, surgery, complications, postoperative return of function, healing of the injury, and return to function). Results: In the studied period (2000 to 2012), 11 patients who had either sacral fracture (4 patients) or SIJ (7 patients) disruption were treated by IS screws. The average age of these patients was 14 years (range, 6 to 17 y). Six patients had 1 screw and 5 patients had 2 screws. Eight patients had their entire fixation in S1, and 3 patients had 1 screw in S1 and 1 screw in S2. All screws were cannulated and were inserted over a guidewire with fluoroscopy and/or navigation guidance. Five patients had added anterior fixation of the pelvis. One patient was lost for follow-up. All patients (except 1) achieved healing of their injuries with no displacement or implant failure with return of function. One patient had failure of fixation and needed revision. One patient had neurological complication related to screw insertion. Conclusions: IS screws can be safely used to treat sacral fractures and SIJ injuries in children. This was feasible in children as young as 6 years old. The complications of the procedure were minimal with good stability obtained by IS screws. Level of Evidence: Level IV—case series.

Calcaneus fractures in children differ from those in adults. Most calcaneus fractures in children can be managed nonoperatively, with good long-term results expected. The width and height of the calcaneus can remodel with time in children. Recently, there has been a trend toward operative treatment of displaced intra-articular fractures of the calcaneus in children to correct the articular deformity. Studies of calcaneal fracture fixation in children used an extended lateral approach, with its possible complications. In the present report, we describe the operative treatment of 2 children (12 and 13 years old), who had a displaced intra-articular fracture of the calcaneus, using a minimally invasive sinus tarsi approach. Adequate reduction was obtained in both cases with no soft tissue complications or implant discomfort. Fixation was obtained using 3.5-mm cortical screws. Anatomic joint alignment was restored. The children were followed up until they had both resumed their full activities with no complications. We recommend this approach for operative treatment of displaced intra-articular fractures of the calcaneus, because it addresses the intra-articular displacement, which is the most important element of the deformity in children.

Nonunion of long bones fixed with nails may result in implant failure. Removal of a broken intramedullary nail may be a real challenge. Many methods have been described to allow for removal of the broken piece of the nail. In this paper, we are reviewing the different techniques to extract a broken nail, classifying them into different subsets, and describing a new technique that we used to remove a broken tibial nail with narrow canal. Eight different categories of implant removal methods were described, with different methods within each category. This classification is very comprehensive and was never described before. We described a new technique (hook captured in the medulla by flexible nail introduced from the locking hole) which is a valuable technique in cases of nail of a small diameter where other methods cannot be used because of the narrow canal of the nail. Our eight categories for broken nail removal methods simplify the concepts of nail removal and allow the surgeon to better plan for the removal procedure.

Deep vein thrombosis and pulmonary embolism are major complications that can occur after ankle injuries. We present the case of a patient with an ankle fracture who developed deep vein thrombosis and massive pulmonary embolism after surgical treatment of the ankle fracture. A review of the published data on this topic is presented. The treating physician should assess patients with ankle fracture for their risk of developing a venous thromboembolic event on an individual basis and provide thromboprophylaxis for those with an increased risk of developing such complications.

Abstract Distal femoral metaphyseal fractures are common injuries in children. Multiple treatment options have been described for this type of injury. For older children with distal metaphyseal fracture, there is still no optimal method of fixation. We propose that the commonly used proximal humeral plate can provide good method of fixation for this fracture in adolescents. Two children (12 and 14 years old) with distal metaphyseal femoral fracture were treated with proximal humeral plate. We describe the surgical technique and postoperative management. The two children healed with good alignment and full range of motion of the knee. No external immobilization (other than knee immobilizer for the first 2 weeks) was used. We concluded that proximal humeral plate can provide adequate fixation for teenagers with distal femoral metaphyseal fracture. It is readily available; provide multiple options for screw fixation in the distal part of the fracture and fits easily on the distal part of the femur proximal to the physis.

Necrotizing fasciitis is a rare soft tissue infection associated with a high mortality rate. Several risk factors for the development of necrotizing fasciitis have been studied, which has given surgeons insight into the types of patients who are more likely to present with this rapidly progressive infection. The concomitant diagnosis of hepatitis C viral infection has not been reported in the literature previously. In this retrospective study covering a 12-year period in 1 Level I trauma center, 10 (34%) of 29 patients presenting with necrotizing fasciitis had an underlying diagnosis of hepatitis C viral infection. The mortality rate in patients with hepatitis C viral infection was 30% compared with 21% for those without hepatitis C viral infection (P=.59). The proportion of patients presenting with the concomitant diagnosis of hepatitis C viral infection and necrotizing fasciitis was statistically greater than that expected from the prevalence of hepatitis C viral infection in the general population (1.8%; P<.001).Our study showed that hepatitis C viral infection is a risk factor for developing necrotizing fasciitis. Although our sample size was too small to show a statistical significance, we believe that a clinically significant increase in mortality of necrotizing fasciitis occurred in patients with concomitant hepatitis C viral infection. Therefore, the presence of hepatitis C viral infection in patients presenting with symptoms of necrotizing fasciitis should raise the clinical suspicion for this diagnosis, with the potential for a worse prognosis.

Exposure of patients and practitioners to ionizing radiation for diagnostic and therapeutic purposes has become the norm rather than the exception. This article discusses the findings from a literature review of intraoperative risks from ionizing radiation to patients and surgeons and the validity of substituting the conventional intraoperative fluoroscopy with computer-assisted orthopedic surgery (CAOS) in orthopedic trauma surgery. Diversity of study designs and measurements exists in reporting intraoperative ionizing radiation, making direct study comparisons difficult. CAOS can effectively reduce the amount of radiation exposure. There are definite advantages and disadvantages for using CAOS in the field of orthopedic trauma. Implementation of CAOS may hold the answer to better patient and surgeon intraoperative radiation safety with decreased operative time and increased procedure precision. The increased safety for patients and surgeons is a critical consideration in recommending CAOS in trauma surgery.

Computer assisted orthopedic surgery (CAOS) is a recent concept inorthopedics. Its use in orthopedic trauma is becoming more popular.Pelvic and acetabular trauma is one of the applications where CAOScan play an important role to facilitate the surgery. In this review article,we provide an overview of the structure of CAOS with specialemphasis on its role in pelvic and acetabular trauma. Th e use of CAOShas many advantages in the fi eld of orthopedic trauma, however, manyobstacles are still present that prevent its wide use.

Treatment of the posterior malleolus has been debated among orthopedic surgeons. Most orthopedic surgeons will fix the posterior malleolus if it is larger than 25% to 30% of the distal articular surface. The most common method of fixation of the posterior malleolus is by indirect reduction and anteroposterior screws. In the present study, we describe the technique and results of treatment of the posterior malleolus by direct reduction through the posterolateral approach to the ankle. The decision to fix the posterior malleolus was determined by its size and displacement. A total of 12 consecutive patients underwent the posterolateral approach to reduce the posterior malleolus, and these were fixed by posterior plate. Two patients were lost to follow-up in the early postoperative period (both after 2 months). No deep infection or wound dehiscence occurred. Ten patients had adequate (<2-mm displacement of the articular surface) radiologic reduction at the final follow-up visit. There were 2 cases of 2 mm or more of articular surface displacement at the final follow-up visit (1 patient had 2-mm displacement noted in the immediate postoperative period and 1 patient had adequate reduction in the beginning but was displaced with additional follow-up). The posterolateral approach to the ankle is a useful tool to treat certain cases of posterior malleolus fracture. It allows good visualization and stable fixation of the posterior malleolus.