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Indications for patellar fracture fixation

  • >4mm distraction
  • >2mm stepoff
  • intra-articular fragments
  • osteochondral fragment
  • lose of extensor mechanism

no data exist on post-op rehab protocols


What is the strongest construct for a patella fracture

figure of 8 wires with cannulated screws

interfrag screws for comminution


What is the most appropriate treatment for a comminuted inferior pole patellar fracture

  • debridement with tendon re-attachement to the extra-articular surface
  • don't take more than 40% of the patella
  • +/- circlage wire re-inforcement


What are indications for total patellectomy

  • failed ORIF
  • infection
  • tumor
  • PF OA
  • 47% of the strength of the quads is lost
  • should reinforce with VMO over the defect (shown to have better outcomes)


complications of patellar ORIF

  • hardware irritation
  • hardware migration is rare
  • stiffness
    • strength
    • pain
    • not associated with immobilization
  • Nonunion
  • deep infection
  • association with OA is unclear


What is the appropriate dosing for tetanus

  • Clean wound/G1
    • update vaccine (Toxoid) if no hx or if > 10yrs
  • Dirty wound/G2/G3
    • Unknown
      • Toxoid (vaccine)
      • TIG (immunoglobulin)
    • > 5 yrs
      • Toxoid (vaccine)


What are options for segmental bone defects

  • Acute shortening: 1-3 cm
    • problems with function after
  • Autologous bone graft < 5cm
    • more than that gets resobed
    • has no structural capacity
  • Induced membrane 5-24 cm
    • can use a RIA to fill the void
    • don't exceed 3:1  allograft:autograft
    • Requires more than one procedure
  • Bone transport 5-10cm
    • long time
    • can correct alignment and used with comprimised tissues
  • Vascularized fib graft 10-20 cm
    • donor site morbidity
  • Allograft bone is not useful due to unknown issues with incorperation
  • BMP unknown...interfere with membrane formation


What is the ladder of soft tissue reconstruction

  • secondary closure
  • primary closure
  • delayed closure
  • STSG
  • FTSG
  • Random flap
  • Axial Flap
  • Free muscle flap
  • Perforator flap


What are the pros and cons of various bone augmentation

  • Autologous (<5cm)
    • One-stage reconstruction; no disease transmission; no immunologic rejection; low cost; standard of care with osteoinductive, osteoconductive, and osteogenic properties 

    • Donor site morbidity, limited volume available, no structural capability 

  • Induced membrane (5-24cm)

    • adequate volume, internal or external fixation can be used, reconstruction time is independent of length of defect, low cost 

    • Donor site morbidity, two-stage technique, long reconstructive period (average, 9 mo), described using external fixation, ratio of allograft to autograft cannot exceed 3:1 with theoretic defect limits 

  • Distraction osteogenesis (5-10cm)

    • No donor site morbidity, no restrictions on defect length, reliable technique, can be used with a compromised soft-tissue envelope (STSG or free tissue flap), can decrease reconstructive time with multiple osteotomies and transport segments 

    • Long reconstructive period, reconstructive period is length- dependent, high rate of complications with prolonged external fixation, cost of ring or spatial external fixation frame 

  • Acute shortening (1-3cm)

    • Simplest and fastest method, allows early primary closure of soft-tissue wounds, well tolerated in upper extremity, well tolerated in single bone extremity segment, no donor site morbidity, low cost 

    • Limb dysfunction especially in lower extremities, defect length is limited, may require secondary lengthening procedures to correct limb-length discrepancy 

  • Vascularized fibular graft (10-20cm)

    • Substantially shorter reconstruction time for large defect compared with Masquelet and Ilizarov techniques, fibular hypertrophy to support weight-bearing, low cost 

    • Donor site morbidity, requires specialized microsurgical capability, high rate of regenerated bone fracture, typically limited to tibial defects 


What is considered a critical segmental bone loss

  • bone loss requiring augmentation
  • >50%
  • >2cm
  • depends on bone and patient


What are not acceptable bone augments for critical deficiets 

  • Allograft alone
    • Limited graft incorporation/ remodeling, potential disease transmission, no osteoinductive or osteogenic properties, cost/expense 

  • Demineralized bone matrix

    • No structural property, no evidence for segmental bone defect reconstruction, cost/expense 

  • BMP

    • Interferes with Masquelet technique, no structural capability, cost/expense 


What are common marine organisms

  • The most common infections are still staph aureus and strep pyogenes
    • but need extra coverage for the strange bugs
  • A hydrophilia - fresh
  • pseudomonas
  • mycobacterium marinum - swimming pool
    • chronic or occult
  • Vibrio - salt water


What are approapriate antibiotics for open wounds

  • Gustilo 1
    • cefazolin
    • clinda if allergy
  • Gustilo 2/3
    • cefazolin
    • gentamycin
    • Farm wounds - penicillin or flagyl
  • Freshwater (A hydrophilia)
    • cipro or ceftazidime
  • Salt water (vibrio)
    • Doxycycline
    • ceftaxidime or cipro


What are the 4 C's of muscle viability




capacity to bleed


What is the best stictch for primary closure of an open fracture

  • Donati allgower
  • No difference in infection rates with primary or delayed closure
  • primary closure is recommended for Gustilo I-IIIa


Indications for delayed closure with VAC or bead pouch

  • limited soft tissue viability
  • lack of soft tissue coverage
  • severe contamination
  • Note - bead pouch or abx PMMA can significantly decreased risk of infection with delayed closure


What are options for local antibiotic delivery

bead pouch


calcium sulfate

demineralized bone matrix 

fibrin clot


What is the most important determinant for prevention of infection of >gustilo 3b

soft tissue coverage < 7 days


What is the algorythim for treament of open tibia fractures

  • Abx, tetanus
  • Abx as soon as possible
  • IM Nailing
    • has been shown to be safe initially for treatment gustilo I-IIIb
    • no consensus reamed vs unreamed
  • Ex-fix
    • If ex-fix required change to IM nail as soon as possible
  • Plates not recommended
  • Indications for Ex-fix
    • gross conatmination


Compare IM nail to plate fixation for distal tibia fractures

  • Plates have lower malunion rate
    • better for a very distal fracture
      • use anterolateral and MIPO
    • cause hardware irritation
  • Nails better for elderly patients with thin skin and poor soft tissues
    • fracture blisters, diabetes, open
    • cause knee pain
  • How to increase nail stability
    • locked screws
    • more screws
    • multi-planar screws


How does treatment of the fibula affect the outcome of distal tibia fractures

  • With IM nails
    • improved stiffness
    • improved alignment
    • increased risk of nonunion
      • avoid if causes tibial fracture gapping
  • Absolute indications
    • evidence of syndesmotic injury
    • medial tibial plating
      • to avoid valgus


Techniques to reduce a proximal tibia fracture

  • Blocking screws
  • Schantz pins/Femoral distractor
  • unicortical plate
  • more proximal/lateral start point
  • suprapatellar nailing
  • reduced herzog bend
  • reduction clamp


How can you avoid malreduction when nailing a distal tibial fracture

  • improved outcomes with reaming
    • ​may even be better than plates
  • no difference with weight bearing early
  • avoid eccentric reaming
  • stabilize posterior malleolus first
  • blocking screws
  • bone reduction forceps
  • distal locking screw first with appropriate technique
  • femoral distractor
  • unicortical plates
  • multiple screws
  • multiple planes
  • use of a VAC can decrese edema


What are your anatomical landmarks for positioning your humoral hemiarthroplasty

  • Normal alignment
    • 140 deg Neck shaft angle
    • 30 deg retroversion
  • humeral head is 5.6cm above pec major
    • >10mm proud = increased tuberosity failure
    • 15mm shortening tolerated
  • Use bicipetal groove or long head biceps to access version compared to fin
    • 20-30 deg retroversion 

  • Tuberosity placement 1-1.5cm distal to superior margin
    • wire or sutures can augment fixation


What factors predict survival of humeral head following fracture displacement

  • primarily anterior circumflex, although head debate becasue arcuate artery has significant anastomosis with the posterior circumflex
  • >2mm metaphyseal segment
  • valgus impaction
  • intact medial hinge


Indications for hemiarthroplasty in proximal humerus fracture

  • varus malalignment >20° in whom anatomic reduction cannot be achieved intraoperatively
  • moderate or severe osteopenia
  • aged >55 years with Neer three or four-part fracture dislocations
  • malunion
  • nonunion
  • hardware failure
  • osteonecrosis of the humeral head fol- lowing osteosynthesis 


What is the unhappy shoulder triad

prosthesis too proud

too retroverted

GT positioned too low


complications of humeral head arthroplasty

tuberosity nonunion

deep infection


proxmial migration humeral head


What are the common injuries associated with a tibial plateau fracture

  • meniscal tears
    • lateral meniscal tear
      • more common than medial
      • associated with Schatzker II fracture pattern 
    • medial meniscal tear
      • most commonly associated with Schatzker IV fractures 
  • ACL injuries
    • more common in type V and VI fractures (25%)
  • compartment syndrome


What are the complications associated with TEA

prosthetic loosening

polyethylene wear of the bushing

periprosthetic fracture