Painful Residual Limb Neuromas in Lower Extremity Amputees

Pet MA, Ko JH, Friedly JL, Smith DG. Traction Neurectomy for Treatment of Painful Residual Limb Neuroma in Lower Extremity Amputees. J Orthop Trauma 2015;29:e321-e325.

I applaud the authors for highlighting the troubles with the commonly performed traction neurectomy in patients with lower extremity amputations. As we all know, the problems of those sustaining a lower extremity amputation, especially following trauma, are not always solved once they receive their amputation. Even if there are no post-operative complications such as infection or wound dehiscence, problems such as the development of a painful neuroma can present months, if not, later down the road to recovery. Following their initial amputation, limb swelling improves over the first several weeks followed by limb atrophy which continues for several months post-operatively. As the limb shrinks, once asymptomatic neuromas can become symptomatic.

The authors evaluate outcomes following the most common surgical management of symptomatic neuromas-traction neurectomy. Unfortunately, their results, are not that encouraging. Forty-two percent (16/38) of patients had recurrent or persistent neuroma-type pain following traction neurectomy more than 3 years post procedure. In fact, 21% (8/38) underwent subsequent surgical management of their symptomatic neuromas.  The authors noted that 87% of their patients had a bony procedure performed in addition to their traction neurectomy, which they state may have contributed to the higher rate of persistent symptoms post-operatively. Despite this, their data provides good evidence that other options should be considered when surgical management of a painful neuroma is considered.

Our initial surgical management for painful neuromas in our young, active military population was commonly performing a traction neurectomy as described by the authors, but over time, we have transitioned to performing a neuroma excision followed by burying the nerve end within muscle when able because our results seemed very similar to what the authors have presented. In addition, with our typical treatment algorithm consisting of initial medical management followed by prosthetic modification for off-loading if feasible and/or ultrasound guided neuroma injection, fewer and fewer patients seem to be requiring surgical intervention for painful neuromas.

Daniel J. Stinner, MD

Medical Director, The Center for the Intrepid

Department of Orthopaedics and Rehabilitation

Brooke Army Medical Center

Fort Sam Houston, Tx

Wound Vacs versus Compressive Dressings for Skin Grafts

Increased Cost of Negative Pressure Dressings Is Not Justified for Split-Thickness Skin Grafting of Low-Risk Wounds

Kempton, Laurence B. MD*; Larson, Timothy B. MD*; Montijo, Harvey E. MD*; Seymour, Rachel B. PhD*; Getz, Stanely B. MD; Bosse, Michael J. MD*

July 2015 JOT

These authors should be congratulated for a nice study that shows us all that new technologies (in this case negative-pressure dressings (NPD)) are not always better than tried and true “old-fashioned” methods (compressive dressing).  This study is especially valuable because it also indicates that the substantial added expense of the new technology is not justified.  I agree with the invited comments of Dr.’s Sanders and Sagi that advantages of the compressive dressing protocol for STSG’s are limited if inpatient management is required.  Their proposed alternative, outpatient use of NPD, would certainly reduce costs associated with the inpatient stay but still have associated costs of the NPD device.  Our protocol is to use a compressive dressing and overlying splint that are removed in the outpatient setting 5-7 days after application.  Patients are not required to have an inpatient stay nor do they have the expense of a NPD.  The dressing is critical and consists of multiple layers: Xeroform; moist fluffed 4×4’s to fill all nooks and crannies; dry 4×4’s; ABD pad(s); Webril; then an ACE wrap.  A splint is then applied over this ACE.  We have been very pleased with the results of this protocol, however, a rigorous study would be required to substantiate virtually 100% take.

William M. Ricci, MD
Professor of Orthopaedic Surgery
Vice-Chair, Department of Orthopaedic Surgery
Chief, Orthopaedic Trauma Service
Director, Orthopaedic Clinical Operations
Washington University Orthopedics

Tibial Plateau Fractures and Meniscal Tears

Stahl et al have published an article in the July 2015 JOT titled “Operatively Treated Meniscal Tears Associated With Tibial Plateau Fractures: A Report on 661 Patients.”

The authors presented a series of patients with tibial plateau fractures and meniscal injuries. They found the rate of fractures with meniscal injuries requiring repair to be 30% and 45% with split depressed fractures. They felt this rate was lower than previously reported and that advanced imaging of tibial plateau fractures to overstate the true incidence of meniscal tears requiring intervention.
The information on the rate of meniscal injuries requiring repair at 30% and most often with split depressed fractures (45%) is more good information to maintain an index of suspicion for this injury.
What is not acknowledged as was noted in Gardner et al (J Orthop Trauma. 2005;19:79–84) was there can be medial meniscus injuries especially with significant depressed lateral fractures and the higher energy injuries. With a Schatzker IV essentially being a knee dislocation, there can be an expected incidence of soft tissue injury accompanying this. And often times a medial arthrotomy is not completed with fixation of IV, V, VI fractures so one must maintain a high index of suspicion or consider advanced imaging in appropriate, select cases.
I agree with the authors that direct visualization of the meniscus is useful to guide the treatment.

Lisa K. Cannada, MD
Associate Professor
Department of Orthopaedic Surgery
Saint Louis University

A Biomechanical Study of Posteromedial Tibial Plateau Fracture Stability: Do They All Require Fixation?

The biomechanical study in the July JOT evaluating posterior medial fragment stability in complex tibial plateau fractures emphasizes the importance of this fracture component when considering fixation strategies for the treatment of these intricate fracture patterns. The authors provide valuable data on the morphology of the critical posterior medial fragment size and at which point the fragment is likely displace with motion. The authors state ‘Certain sizes of posteromedial fragments may be inherently stable through a defined arc of motion and may not require direct surgical attention.” However, I would urge the readers to be very cautious if actually considering any non op management of these coronal plane components based on the authors results. The 10mm post medial fracture fragment evaluated was essentially an extra articular fragment. Contact pressure results largely demonstrated no significant differences between an intact condyle and the idealized 10-mm fracture fragment when tested in compression, internal rotation, and posterior shear loading.
These small coronal plane fractures are rare and occur infrequently in the clinical setting when treating these complex fracture patterns. The larger 20 mm fracture fragment specimens were thru the weight bearing portion of the medial condyle and displacement of this fragment increased progressively for all loading conditions, demonstrating the requirement for fragment stabilization. These larger fragments are the clinical norm. I would encourage clinicians to employ the column classification with transverse CT cuts to evaluate the size and overall morphology of these specific components with the realization that very few of these will be amenable to non op management.

J. Tracy Watson, MD

Professor and Chief of Orthopaedic Traumatology

Saint Louis University

The Anterior Intrapelvic (AIP) Approaches For ORIF Of The Acetabulum – Where Are We Going?

The anterior intrapelvic (AIP) approach (also known as the modified Stoppa approach) was pioneered by Cole and Bolhofner as an alternative technique for ORIF of the anterior acetabulum.  The AIP allows less invasive access to the acetabulum from within the pelvis; thus, the goal of this article is to outline the indications for the AIP approach and to stimulate discussion regarding potentially more controversial concepts in light of the increasing popularity of this approach.

The traditional ilioinguinal approach creates three working windows to access the acetabulum with the surgeon standing on the side of fracture and working “down and into” the pelvis.  In contrast, the AIP approach employs a vertical split in the rectus linea alba entering into the retropubic space similar to the approach for symphyseal fixation.  With the surgeon standing on the opposite side of the fracture, dissection is performed along the retro-ramus and quadrilateral surfaces essentially working “up and under” the rectus muscles and neurovascular structures.  This technique provides less direct surgical exposure of the femoral vascular structures while maintaining excellent visualization of the acetabulum, particularly the posterior column, sciatic notch and quadrilateral surface.

Thus, the question: “When is the AIP preferred instead of the traditional or modified ilioinguinal approach?”  The reality is that neither surgical approach is better or more useful, but rather both are tools to accomplish the same goal – anatomic reduction of the acetabulum fracture.  Certainly, based on training and experience, most surgeons will have a preferred approach for anterior acetabulum fractures.  However, a thorough understanding and appreciation for both techniques will better enable the surgeon achieve the goal of anatomic reduction.  The full ilioinguinal approach provides tremendous access to the innominate bone, and for less experienced surgeons or very difficult fractures, this may be preferred.  In contrast, the AIP may serve as a less invasive alternative working mainly through the intra-pelvic window, yet many more complex fractures such as the associated both column and high anterior column fractures may be challenging to reduce via the limited window of the AIP.

As experience grows with the AIP, more and more can be achieved through this single window.  Keys to enhancing the exposure include fully releasing the rectus insertion from the superior aspect of the pubis including release down onto the anterior surface of the pubis.  This allows the rectus to “fold” over and away, dramatically improving the exposure.  Additionally, flexion of the hip and elevation of the iliopsoas as far proximally as the sacroiliac joint greatly enhances both visualization as well as reduction capabilities.  Finally, meticulous dissection and mobilization of the obturator nerve is essential for not only access, but also for protecting the nerve from traction palsy.  The nerve should be freed proximally, almost to its origin and then distally, into the obturator foramen.  This mobility then allows the nerve to remain loose within the operative field under direct vision rather than retracting it out of the field; thus, further protecting the nerve.

This brings us to the subject of alternative tactics for reduction and fixation.  As comfort with the exposure is gained, so does comfort with reduction of more complex fractures.  Traditionally, the posterior column is reduced via a lateral window with either the AIP or a standard ilioinguinal approach.  However, reduction of the posterior column may be achieved by placing an angled jaw pelvic clamps into the greater or lesser sciatic notch or along the quadrilateral surface with the second tine along the pelvic brim or anterior column.  An alternative technique employs a screw reduction clamp such as a Farabouf or Jungbluth applied with screws in the pelvic brim and in the sciatic buttress creating the reduction vector directly for the posterior column.

This leads to the question as to whether the posterior column can be stabilized via the AIP without the traditional anterior to posterior lag screws that are frequently placed from a lateral window.  A plate placed along the sciatic buttress can stabilize the reduced posterior column; however, is a lag screw needed to maintain the reduction?  Finally, one must ask if the reduction can be achieved via the AIP window alone, is stabilization of the iliac components of an associated both column fracture absolutely necessary?  In the classical approach, the iliac components are reduced and stabilized in order to ensure the reduction of the joint surface is anatomic.  Yet, if the fracture is reduced and stabilized at or near the joint itself, are the additional plates and screws for the iliac components needed?

At present, little data exists to answer many of these questions.  However, as more widespread experience is gained, and continued development of the dissection, instruments, reduction tools and implants occurs, these and many more questions will be asked and hopefully answered.

Michael T. Archdeacon, M.D., M.S.E.
Peter J. Stern Professor & Chairman
Department of Orthopaedic Surgery
University of Cincinnati Academic Health Center

Geriatric Acetabular Fractures and Mortality

The geriatric population is a rapidly growing segment of society with longer life expectancies and more active lifestyles than previous generations. More and more geriatric patients are being seen with acetabular fractures, which can have a significant impact on the remainder of an elderly patient’s life.

In the April issue of JOT, Gary et al publish their results from 3 centers in “Effect of Surgical Treatment on Mortality After Acetabular Fracture in the Elderly: A Multicenter Study of 454 Patients.”  The authors conclude that the operative treatment of acetabular fractures does not increase or decrease mortality, once comorbidities are taken into account, and that the decision for operative versus nonoperative treatment of geriatric
acetabular fractures should not be justified based on the concern for increased or decreased mortality alone.  Also of note, the overall one-year mortality for geriatric acetabular fractures was 16%, which is lower than that for elderly patients with proximal femur fractures.

These findings are in line with previous studies, including a single center study by Bible et al (JOT March 2014) that found the 1-year mortality rates for elderly patients with isolated acetabular fractures are significantly lower than those reported previously for hip fractures and acetabular fractures with concurrent injuries.  The authors also found no significant differences in mortality rates between operative and nonoperative patients across all time points.

Please check out article by Gary et al in the April issue of JOT, and share your comments on the treatment of geriatric acetabular fractures.

Hassan R. Mir, MD, MBA, FACS

Editor | OsteoSynthesis – The JOT Online Discussion Forum