Eben A. Carroll

Background: It is unclear whether postoperative pain differs by treatment type for patients with severe open tibial fractures. Methods: We performed a secondary analysis of data from the FIXIT study. Adults with severe open tibial fractures were randomized to undergo definitive modern external ring fixation (n = 122) or internal fixation (n = 132). Primary outcomes were pain intensity and interference at 6 and 12 months, measured by the Brief Pain Inventory. Secondary outcomes were Numeric Pain Rating Scale (NPRS) scores and the incidence of moderate to severe pain. Post hoc subanalysis compared pain in patients with and without pin-site infections and with and without external fixation removal. Results: At 6 months, median pain intensity did not differ significantly between the external fixation group (4.1 [interquartile range (IQR), 2.2 to 5.5]) and the internal fixation group (3.0 [IQR, 1.8 to 5.8]) (p = 0.11); however, patients who underwent external fixation had greater median pain interference (6.0 [IQR, 3.3 to 8.0]) than patients who underwent internal fixation (4.0 [IQR, 1.9 to 7.4]) (p = 0.01). At 12 months, pain intensity, pain interference, and NPRS scores did not differ by treatment type. The overall incidence of moderate to severe pain was 33% at 6 months and 35% at 12 months. At 6 months, pin-site infections were associated with greater pain intensity (p = 0.01) but not greater interference (p = 0.10). At 12 months, the presence of external fixation was associated with greater pain intensity (p = 0.01) and interference (p < 0.01). Conclusions: At 6 months after a severe open tibial fracture, patients treated with modern external ring fixation had greater pain interference than patients treated with internal fixation, partly because of pin-site infections. No differences in pain interference or intensity were seen at 12 months. At 12 months, patients with external fixation in place had greater pain intensity and interference than those whose external fixation had been removed, but this was not the case at 6 months. Approximately one-third of all patients had moderate to severe pain at both time points, highlighting that persistent pain is common, regardless of treatment type. These findings can guide surgeons in choosing ring external fixation or internal fixation for these fractures. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Background: This study compared the functional outcomes of patients with open tibial shaft fractures who were randomized to either modern external ring fixation (EF) or internal fixation (IF). We hypothesized that there would be differences in patient-reported function between the treatment groups. Methods: This preplanned analysis of secondary outcomes from the FIXIT study, a multicenter randomized clinical trial, included patients 18 to 64 years of age with a Gustilo-Anderson Type-IIIB or severe-Type IIIA diaphyseal or metaphyseal tibial fracture who were randomly assigned to either IF (n = 132) or EF (n = 122). Follow-up visits occurred at 6 weeks and 3, 6, and 12 months after randomization. Outcomes included Short Musculoskeletal Function Assessment (SMFA) scores, the Veterans RAND 12-Item Health Survey (VR-12) physical component score (PCS), use of ambulatory assistive devices, and ability to ambulate. Results: The mean VR-12 PCS was slightly higher (better) for IF (24.8) than for EF (22.6) at 3 months (mean difference, 2.2 [95% confidence interval (CI): 0.2, 4.3]; p = 0.03) and trended higher for IF (27.0) compared with EF (25.3) at 6 months (mean difference, 1.8 [95% CI: −0.9, 4.4]; p = 0.19). However, there was no difference between the groups at 12 months. There were no clinically important or significant differences in SMFA Dysfunction and Bother scores between the treatment groups at any time point. EF was associated with a higher risk of using any ambulatory assistive device at 6 months (relative risk, 1.5 [95% CI: 1.21, 1.82]; p < 0.0001). The absolute percentage of patients using any ambulatory device was 37.6% for IF and 45.4% for EF at 1 year. There was no difference in ambulatory status between the treatment groups at any time point. Conclusions: We found no difference in physical function between patients with severe tibial fractures treated with IF versus EF. There was a high rate of impairment overall. Assistive devices for walking were more often utilized in the EF group at 6 months, and both treatment groups demonstrated similar overall impairment. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Summary: Distal femur fractures in the elderly have been historically treated with locked plating or retrograde intramedullary nailing with good, reliable results. However, in certain more complex fracture patterns (native or periprosthetic), increased density of fixation via dual-plate or nail plate combination can help achieve immediate weight-bearing. It can also potentially increase rates of union by shifting and maintaining the neutral axis, distributing forces more evenly across the fracture site. Here, we discuss the indications, pros and cons of both dual-plate and nail plate combination techniques in a concise case-based format.

Update: This article was updated on October 29, 2018, because of a previous error. On page 1645, in the group authorship footnote listing the members of the Major Extremity Trauma Research Consortium (METRC), the name “Anna N. Miller” was not included in the list of members. The list now reads “Major Extremity Trauma Research Consortium (METRC): Christine Churchill, Joseph R. Hsu, Rachel B. Seymour, Stephen H. Sims, A. Alex Jahangir, Robert H. Boyce, Manish K. Sethi, Andres Rodriguez-Buitrago, Vamshi Gajari, Jason W. Nascone, Marcus F. Sciadini, Theodore Manson, Timothy G. Costales, Merryjessica Fuerst, W. Andrew Eglseder, Christopher LeBrun, Andrew N. Pollak, J. Brett Goodman, Jason J. Halvorson, Martha B. Holden, Anna N. Miller, Jerald R. Westberg, Dennis Mann, and Susan Collins”. An erratum has been published: J Bone Joint Surg Am. 2018 Dec 5;100(23):e151. Background: We recorded measurements of muscle perfusion using near-infrared spectroscopy (NIRS) and intramuscular pressure (IMP) in a study designed to develop a decision rule for predicting acute compartment syndrome (ACS). The purpose of this study was to report our experience measuring NIRS data in the context of this broader investigation and to explore factors related to variations in data capture. Methods: One hundred and eighty-five patients with lower-leg injuries had data consisting of continuous NIRS measurement of the O₂ saturation in the anterior compartment of the injured limb and the contralateral (control) limb, and continuous IMP recording in the anterior and deep posterior compartments of the injured leg as part of their participation in an institutional review board-approved multicenter trial. All monitoring was done for a prescribed period of time. For both types of data, the percentage of valid data capture was defined as the ratio of the minutes of observed data points within a physiological range to the total minutes of expected data points. Clinically useful NIRS data required simultaneous data from the injured and control limbs to calculate the ratio. Statistical tests were used to compare the 2 methods as well as factors associated with the percent of valid NIRS data capture. Results: For the original cohort, clinically useful NIRS data were available a median of 9.1% of the expected time, while IMP data were captured a median of 87.6% of the expected time (p < 0.001). Excluding 46 patients who had erroneous NIRS data recorded, the median percentage was 31.6% for NIRS compared with 87.4% for IMP data (p < 0.00001). Fractures with an associated hematoma were less likely to have valid data points (odds ratio [OR], 0.53; p = 0.04). Gustilo types-I and II open fractures were more likely than Tscherne grades C0 and C1 closed fractures to have valid data points (OR, 1.97; p = 0.03). Conclusions: In this study, NIRS data were not collected reliably. In contrast, IMP measurements were collected during >85% of the expected monitoring period. These data raise questions about the utility of current NIRS data capture technology for monitoring oxygenation in patients at risk of ACS.

Summary: The optimal technique for a transtibial amputation in a young, active, and healthy patient is controversial. Proponents of the Ertl procedure (in which the cut ends of the tibia and fibula are joined with a bone bridge synostosis) argue that the residual limb is more stable which confers better prosthetic fit and improved function especially among high-performing individuals. At the same time, the Ertl procedure is associated with longer operative and healing time and may be associated with a higher complication rate compared with the standard Burgess procedure. The TAOS is a prospective, multicenter randomized trial comparing 18-month outcomes after transtibial amputation using the Ertl versus Burgess approach among adults aged 18 to 60. The primary outcomes include surgical treatment for a complication and patient-reported function. Secondary outcomes include physical impairment, pain, and treatment cost.