Intramedullary nailing of multiple long-bone fractures of the lower extremity at the same surgery: a single-center experience

Intramedullary nailing of concurrent ipsilateral fractures of the tibia and femur: primary synchronous nailing versus staged osteosynthesis with temporizing external fixation

INTRODUCTION

The optimal timing to definitive osteosynthesis in the polytraumatized patient remains an unanswered question. Early total care, damage control orthopaedics, and early appropriate care have been described to manage the fractures in these patients, but there is a paucity of literature specific to ipsilateral tibial and femoral fractures. We sought the perioperative outcomes of primary simultaneous intramedullary nailing (IMN) versus temporizing external fixation (EF) of both fractures.

METHODS

A chart review of all patients who sustained fractures of the ipsilateral femur and tibia that were definitively treated with (IMN) from January 2010 to December 2020 was performed. Patients who underwent initial EF and those that were primarily treated with IMNs were examined.

RESULTS

IMNs and EF were the initial treatment in 23 and 16 patients, respectively. The mean (range) injury severity score (ISS) was 23.3 (33) in the EF group vs. 18.5 (34) in the IMN group, (p = 0.0686). The EF group had a higher total transfused units of packed red blood cells 7.4 vs. 2.8, the mean initial operative time was 236 vs. 282.6 (min), (p = 0.7399), a longer mean total operative time 601.78 vs. 236 (min), and longer mean length of stay 15.6 vs. 11 (days), (p < 0.5). Rates of complications were not significantly different between groups.

CONCLUSION

Primary IMN is as safe as provisional EF in the adequately resuscitated patient with ipsilateral femoral and tibial fractures. This implies the fixation of both fractures into a single surgery without increasing perioperative complications, and decreasing total hospital stay in patients with sufficient preoperative resuscitation.

Tranexamic Acid in Orthopaedic Trauma Surgery: A Meta-Analysis

AIM

To systematically review and quantify the efficacy of tranexamic acid (TXA) use in reducing the risk of receiving a blood transfusion in patients undergoing orthopaedic trauma surgery, in reducing blood loss, and risk of thromboembolic events.

METHODS

A systematic literature search was performed using MEDLINE, Embase, ClinicalTrials.gov, and conference proceeding abstracts from 2014 to 2016. A minimum of 2 reviewers screened each study and graded quality. The primary outcome measure was the risk of receiving a blood transfusion in the TXA group versus control. A meta-analysis was performed to construct a combined odds ratio (OR) of receiving a blood transfusion, mean difference (MD) of blood loss, and OR of thromboembolic events.

RESULTS

Twelve studies were included in the quantitative analysis (1,333 patients). The risk of blood transfusion was significantly less in patients who were administered TXA compared with controls [OR 0.407; 95% confidence interval (CI) 0.278-0.594, I = 34, Q = 17, P ≤ 0.001]. There was significantly less blood loss in the TXA group compared with controls, as the mean difference was 304 mL (95% CI, 142-467 mL) (I = 94, Q value = 103, P < 0.001). There was no significant difference in risk of symptomatic thromboembolic events (OR 0.968; 95% CI, 0.530-1.766, I = 0, Q value = 5, P = 0.684).

CONCLUSIONS

In patients with orthopaedic trauma, TXA reduces the risk of blood transfusion, reduces perioperative blood loss, and has no significant effect on the risk of symptomatic thromboembolic events. More high-quality studies are needed to ensure the safety of the drug in these patients.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Epidemiology of acute transfusions in major orthopaedic trauma

OBJECTIVES

The orthopaedic trauma-related blood product usage is largely unknown. Aim of this study was to describe the epidemiology of early (<24 hours of arrival) blood component use in major orthopaedic trauma.

DESIGN

12-month prospective observational study.

SETTING

John Hunter Hospital, Level 1 Trauma Center, New South Wales, Australia.

PATIENTS

64 consecutive trauma admissions identified, who had an orthopaedic injury and required at least 1 unit of packed red blood cells (PRBC) <24 hours of arrival.

INTERVENTION

Epidemiological study.

MAIN OUTCOME MEASURES

Demographics, orthopaedic injury type, procedure type, injury severity score, timing, place of first unit of transfusion, and blood component volumes were collected. Activation of the massive transfusion protocol was recorded. Primary outcome measures were intensive care unit admission and mortality.

RESULTS

From 965 major trauma admissions, 64 had one or more orthopaedic injuries and were transfused <24 hours. Forty-eight percent (31/64) required massive transfusion protocol activation. Average age was 41 ± 21 years, 73% (47/64) men. Eighty-four percent (54/64) required emergent orthopaedic intervention, 41% (22/54) having multiple procedures. Overall mortality was 13% (8/64). Twenty-five percent (16/64) required ≥10 units of PRBC. Average PRBC use was 7.2 ± 6.6 units and fresh frozen plasma use 4.3 ± 5.2 units. Thirty-nine percent (25/64) had a pelvic ring injury or acetabular fracture. Thirty-seven percent (24/64) had at least one femoral shaft fracture. Twenty patients had a total of 23 tibia fractures.

CONCLUSIONS

Orthopaedic trauma patients consume the majority of the blood products <24 hours among blunt trauma patients. This resource-intensive group requires frequent urgent surgical interventions and intensive care unit admission.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A new fluoroscopy-free navigation device for distal interlocking screw placement

During the treatment of tibia fracture with interlocking nails, the most uncomfortable procedure is for an orthopaedic surgeon to find the location for the distal locking screws. In this study, a fluoroscopy-free non-contact navigation device was developed for the placement of distal locking screws in the tibia intramedullary nailing. This device utilizes a 3D digitization arm integrated with spatial coordinate registration module, graphical user interface module and sound-guided navigation module. The 3D digitization arm, a five-DOF passive robotic arm, was used to register the spatial coordinates of proximal and distal landmarks just before placement of the nail. The registered coordinates were then incorporated with the coordinates of the proximal landmarks after nail placement to calculate the coordinate transformation matrix. The transformed spatial coordinates of the distal screw holes were then computed in real time for interlocking nail navigation. A sound-guided navigation module was designed in which a sound with different tones and intermittence frequencies was produced, as the probe of the digitization arm navigates toward the location of distal screw holes. No intra-operative fluoroscopy was required. In vitro assessment was performed successfully with a donor bone, and a clinical case of a young male with tibia fracture was also carried out in the operating theatre. Operation time, distal screw insertion, total radiation time and accuracy of the distal interlocking screw placement were measured. The surgery was conducted under sterile conditions without complication, and the clinical course was smooth with prompt bone healing.

Fracture Strain and Stability with Additional Locking Screws in Intramedullary Nailing: A Biomechanical Study

BACKGROUND

We studied the effect of additional locking screws on fracture strain and stability in tibial intramedullary nailing.

METHODS

We drilled an additional diaphyseal locking hole into 8-mm solid tibial nails 185 mm from the proximal end of the nail, and locked it proximally and distally. An osteotomy was produced 4.5 cm distal to the additional hole, and the construct loaded axially, in flexion, extension, and torsion. The nails were also tested for their fatigue strength.

RESULTS

With the additional locking screw, strain increased proximally during loading in neutral and flexion. Strain decreased on loading in extension. The extra locking screw decreased strain close to the osteotomy site in all loading positions. A significant reduction in angular motion at the osteotomy site occurred with the addition of the extra locking screw. The nails survived the fatigue test, although the stress increased around the additional locking hole

CONCLUSIONS

Nails with additional locking options, by altering strain and motion at the fracture site, may have the clinical potential to affect fracture healing.

[Decision making and and priorities for surgical treatment during and after shock trauma room treatment]

OBJECTIVE

Concepts for optimal surgical treatment of the patient with blunt multiple injuries are being evaluated on the basis of the current literature.

METHODS

Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system).

RESULTS

The posttraumatic clinical course is divided into four different periods: acute-, primary-, secondary- und tertiary period. The first and second period are important for life saving surgery and the stabilization of major fractures. After the cardiorespiratory systems have been stabilized, the following priorities have been formulated: head, face, spine, abdomen, extremities. To restrict the degree of operative burden on the patient it appears to be necessary to limit the duration of initial surgery to less than 6 hours. In patients at high risk to develop posttraumatic complications-"borderline patients"-it appears safer to perform only temporary fixation of major fractures.

CONCLUSIONS

Three different factors determine the clinical course after polytrauma: Trauma represents the first hit, followed by the therapy-induced burden (second hit). In addition, the third hit is represented by the individual response. An evaluation of the clinical status by immunologic monitoring can be performed in order to assess the patient's status.