Republication of "Primary Ankle Arthrodesis vs ORIF for Severely Comminuted Pilon Fractures: A Comparative Retrospective Study"

Background

The treatment for highly comminuted pilon fractures remains controversial. The goal of this retrospective cohort study was to compare functional outcomes of primary arthrodesis of the tibiotalar joint (fusion) and open reduction internal fixation (ORIF).

Methods

Patients who underwent primary ORIF or fusion for pilon fractures at our institution since 2000 were identified by Current Procedural Terminology (CPT) code. Inclusion criteria for the ORIF cohort were patients with an AO/Orthopaedic Trauma Association type C3 pilon fracture. Additional inclusion criteria for the fusion cohort were patients whose fractures were deemed non-reconstructable by the treating surgeon. Outcome assessment was determined by the Foot and Ankle Outcome Score (FAOS) and Short Form 36-item health survey (SF-36), time to radiographic union or fusion, and wound-healing complications at a minimum of 2 years after their surgery.

Results

Nineteen ORIF and 16 fusion patients completed the study's outcome assessments. A higher rate of nonunion was observed in patients treated by primary ORIF than primary fusion (5/19 vs 1/16). Posttraumatic arthritis was observed in 11 of 19 primary ORIF patients. Primary fusion patients exhibited increased symptoms, pain, and physical role limits but were equivalent to primary ORIF patients on all other functional metrics examined.

Conclusions

Primary ankle arthrodesis achieves a lower rate of nonunion and comparable functional outcomes to ORIF in patients with severely comminuted pilon fractures. The higher rate of nonunion observed in the primary ORIF group suggests that primary fusion should be considered an effective procedure for severe injuries to decrease the need for further operative intervention.

Level of Evidence

Therapeutic Level III, retrospective cohort.

Probable Delirium as a Risk Factor for Adverse Surgical Outcomes in Geriatric Patients With Acute Hip Fracture: Preoperative Assessment Using a Short Screening Tool

Hip fractures in geriatric patients are associated with substantial morbidity and mortality including postoperative delirium. Few data are available regarding preoperative identification of patients at risk of postoperative delirium before surgical repair of hip fracture. We used the Ultrabrief Two-Item Bedside Test, a proxy for delirium, to identify patients who are likely to have adverse outcomes postoperatively. This prospective pilot study included patients 65 years and older with an acute hip fracture. The questionnaire was administered preoperatively, and patients were followed up for 30 days postoperatively. We enrolled 30 patients, with a mean age of 78 years. The 12 patients with an abnormal test result had a significantly lower body mass index, a trend in descriptive statistics for pulmonary disease, and a higher ASA physical status. In addition, hospital stay following fracture repair was longer for patients with an abnormal test result, although not significantly (mean [SD]=8.8 [4.2] days vs 6.4 [2.0] days, median=8 vs 6 days, log-rank P=.052). A 2-item questionnaire could help identify patients who have sustained hip fracture who are likely to have a longer hospitalization. Future studies are needed to confirm these findings and determine whether interventions can reduce risk.

Primary Ankle Arthrodesis vs ORIF for Severely Comminuted Pilon Fractures

Background:

The treatment for highly comminuted pilon fractures remains controversial. The goal of this retrospective cohort study was to compare functional outcomes of primary arthrodesis of the tibiotalar joint (fusion) and open reduction internal fixation (ORIF).

Methods:

Patients who underwent primary ORIF or fusion for pilon fractures at our institution since 2000 were identified by Current Procedural Terminology ( CPT) code. Inclusion criteria for the ORIF cohort were patients with an AO/Orthopaedic Trauma Association type C3 pilon fracture. Additional inclusion criteria for the fusion cohort were patients whose fractures were deemed non-reconstructable by the treating surgeon. Outcome assessment was determined by the Foot and Ankle Outcome Score (FAOS) and Short Form 36-item health survey (SF-36), time to radiographic union or fusion, and wound-healing complications at a minimum of 2 years after their surgery.

Results:

Nineteen ORIF and 16 fusion patients completed the study’s outcome assessments. A higher rate of nonunion was observed in patients treated by primary ORIF than primary fusion (5/19 vs 1/16). Posttraumatic arthritis was observed in 11 of 19 primary ORIF patients. Primary fusion patients exhibited increased symptoms, pain, and physical role limits but were equivalent to primary ORIF patients on all other functional metrics examined.

Conclusions:

Primary ankle arthrodesis achieves a lower rate of nonunion and comparable functional outcomes to ORIF in patients with severely comminuted pilon fractures. The higher rate of nonunion observed in the primary ORIF group suggests that primary fusion should be considered an effective procedure for severe injuries to decrease the need for further operative intervention.

Level of Evidence:

Therapeutic Level III, retrospective cohort.

Total Hip Arthroplasty Complicated by a Gluteal Hematoma Resulting in Acute Foot Drop

Total hip arthroplasty is a prevalent orthopedic intervention in the United States. Massive postoperative hematomas are a rare albeit serious complication of the procedure. Sequelae of these hematomas can include lower extremity paralysis from compression of the sciatic nerve. A 66-year-old woman taking aspirin and clopidogrel for coronary stents presented with a complete foot drop, paresthesias, and lower extremity pain 10 days after a total hip arthroplasty. The patient was initially seen by a neurology service at another hospital and thought to have lateral recess stenosis. At the authors' center, magnetic resonance imaging of the lumbar spine failed to show lateral recess stenosis. Urgent pelvic computed tomography showed a large hematoma and raised suspicion of sciatic nerve compression. Hip magnetic resonance imaging showed a right gluteal hematoma compressing the sciatic nerve. The patient was then taken to the operating room for the clot to be evacuated and was later referred for rehabilitation. Massive hematomas after total hip arthroplasty are an important consideration in the differential diagnosis of nontraumatic acute foot drop. Prompt diagnosis may correlate with improved neurological outcome and help reduce overall morbidity.

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

OBJECTIVES

To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach.

DESIGN

Retrospective review.

SETTING

Two level one trauma centres.

PATIENTS

Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up.

INTERVENTION

Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients).

MAIN OUTCOME MEASUREMENTS

Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

RESULTS

Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p=0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p<0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p=0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p=0.333).

CONCLUSIONS

A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome.

LEVEL OF EVIDENCE

Level III.

Primary Arthrodesis of the Tibiotalar Joint in Severely Comminuted High-Energy Pilon Fractures

BACKGROUND

The treatment of highly comminuted tibial pilon fractures is controversial. The aim of this study was to determine the effectiveness and outcomes of primary arthrodesis following highly comminuted tibial plafond fractures.

METHODS

A database search was performed to identify all patients who underwent blade plate arthrodesis at our institution over a sixteen-year period. Inclusion criteria included patients with an Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association type-C2 or type-C3 pilon fracture that was deemed to be non-reconstructable by the treating surgeon. Outcomes were measured using the Short-Form 36-Item Health Survey, time to independent walking, time to consolidation of the arthrodesis, and wound-healing complications.

RESULTS

A total of twenty patients were included in this study, and seventeen patients (85%) were available for follow-up at a minimum of two years after their surgery. Wound infections or wound dehiscence did not occur in this series. All patients were walking without crutches or a walker at their latest follow-up. One patient developed an aseptic nonunion and healed successfully after revision surgery.

CONCLUSIONS

Blade plate ankle fusion using a posterior approach is a reliable method for the treatment of a small subset of patients with severely comminuted, non-reconstructable pilon fractures.

LEVEL OF EVIDENCE

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

The associations between OPRM 1 and COMT genotypes and postoperative pain, opioid use, and opioid-induced sedation

Previous studies have associated mu-opioid receptor (OPRM1) genotype with pain and analgesia responses in postoperative and patient populations. This study investigates the role of catechol-O-methyltransferase (COMT) and OPRM1 genotypes in acute postoperative pain scores, opioid use, and opioid-induced sedation after surgical procedures for orthopedic trauma in an otherwise healthy patient population. Verbal pain/sedation scores, opioid use, and physiologic responses in the immediate postoperative period were examined for association with genetic variants in Caucasians genotyped for OPRM1 single nucleotide polymorphisms (SNPs) A118G and C17T and COMT SNPs. The OPRM1 A118G genotype was associated with patients' postoperative Numerical Pain scale (NPS) ratings at 15 min in the postanesthesia care unit (PACU) (p = .01) and patients' sedation scores at 15 min in the PACU (p = .02). COMT genotype (rs4818) was associated with opioid consumption in the first 45 min in the PACU (p = .04). NPS ratings at 45 min were also higher in the group of patients with A/A genotype of rs4680 than in patients with the other two genotypes at this SNP (p = .03). Our haplotype trend analysis identified a COMT haplotype "GCGG" significantly associated with NPS at 15 min (p = .0013), amount of opioids consumed in the first 45 min (p = .0024), and heart rate at 45 min in the PACU (p = .017). The results indicate that genetic variations in COMT contribute to the acute postoperative pain and analgesia responses and physiologic responses in this group of otherwise healthy postoperative orthopedic trauma patients.

The association of CYP2D6 genotype and postoperative nausea and vomiting in orthopedic trauma patients

The CYP2D6 gene encodes for an enzyme that is involved in the metabolism of more than 25% of all medications, including many opioids and antiemetics. It may contribute to the risk of postoperative nausea and vomiting (PONV), a common surgical complication. However, little research has been conducted in this area. The purpose of this study was to explore the association of CYP2D6 genotypes with PONV in adult surgical trauma patients. Data from 112 patients (28% female) with single extremity fractures, aged 18-70 years, were analyzed. PONV was defined as present if patients reported nausea, were observed vomiting, or received medication for PONV. Saliva samples collected for DNA extraction and Taqman(®) allele discrimination and quantitative real time polymerase chain reaction (qRT-PCR) were used to collect genotype data that were then used to assign CYP2D6 phenotype classification. The incidence of PONV was 38% in the postanesthesia care unit and increased to 50% when assessed at 48 hr. CYP2D6 classification results were 7 (6%) poor metabolizers, 34 (30%) intermediate metabolizers, and 71 (63%) extensive metabolizers. No ultrarapid metabolizers were identified. Patients who were classified as poor metabolizers had less PONV and higher pain scores. Gender and history of PONV, but not smoking, were also significant risk factors. Findings suggest variability in CYP2D6 impacts susceptibility to PONV.

Advancements in percutaneous fixation for foot and ankle trauma

Operative fixation of foot and ankle trauma can be challenging. Often times, the soft tissue envelope can have extensive damage as a result of the fracture. In these cases, percutaneous fixation may be used. Percutaneous fixation can benefit both soft tissue and osseous healing when used correctly. Many techniques have been described in the literature that may help to preserve blood supply, minimize soft tissue dissection, and restore a functional limb. This article reviews general guidelines for fracture and soft tissue management, osseous healing of fractures, and how certain techniques influence fracture healing. It also illustrates certain techniques for specific fracture reduction.

Early complications following the operative treatment of pilon fractures with and without diabetes

BACKGROUND

An increased rate of complications has been clearly shown in diabetic patients undergoing operative treatment for displaced ankle fractures. To date, no studies have specifically looked at the complication rates following the operative management of pilon fractures in this difficult patient population. We performed a retrospective review to determine the rates of complications in diabetic patients undergoing operative fixation of tibial pilon fractures compared with a control group of patients without diabetes.

MATERIALS AND METHODS

The trauma registry was utilized to identify all patients who underwent primary treatment for a tibial pilon fracture between January 2005 and June of 2007 at a single Level 1 trauma center. A minimum of 6-month followup was required for inclusion. A chart and radiographic review was completed to identify the complications seen in each patient population. Specifically, we looked at the rate of infection (superficial and deep), the rate of nonunion or delayed union, and the rate of surgical wound complications.

RESULTS

A total of 14 fractures in 13 diabetic patients, and 69 fractures in 68 non-diabetic patients met inclusion criteria. In the diabetic patient group, the average age was 48 years, the average BMI was 35, and 36% of the fractures were open. In the non-diabetic group, the average age was 47 years, the average BMI was 29, and 35% of the fractures were open. Only the difference in BMI was statistically significant. The infection rate was 71% for diabetic patients (43% deep infection), and 19% for non-diabetic patients (9% deep infection) [p < 0.001, odds ratio 10.719 (95% confidence interval 2.914 to 39.798)]. Overall, the rate of non-union/delayed union was 43% in the diabetic group versus 16% in the non-diabetic group [p = 0.02, odds ratio 3.955 (95% confidence interval 1.145 to 13.656)]. The rate of surgical wound complications was 7% in both the non-diabetic and diabetic patient groups.

CONCLUSION

The management of tibial pilon fractures in diabetic patients is difficult, with a high rate of complications compared to non-diabetic patients. These results mirror those previously reported for ankle fractures in diabetic patients.

External adjuncts to enhance fracture healing: what is the role of ultrasound?

Current methods of fracture care use various adjuncts aimed at decreasing time to fracture union and improving fracture union rates. Among the most commonly used modalities, low-intensity pulsed ultrasound is emerging as a safe, cost-effective and reliable treatment for both fresh fractures and fracture nonunions. Both in vivo and in vitro basic science studies have helped to elucidate potential mechanisms of ultrasound action and a number of prospective, randomised, double-blind, placebo-controlled trials exist demonstrating the clinical efficacy of low-intensity pulsed ultrasound. This article will review the evidence for the use of low-intensity pulsed ultrasound in fracture care.

Sacroiliac joint dysfunction: evaluation and management

Sacroiliac joint dysfunction is believed to be a significant source of low back and posterior pelvic pain.

METHODS

To assess the clinical presentation, diagnostic testing, and treatment options for sacroiliac joint dysfunction, a systematic literature review was performed using MEDLINE.

RESULTS

Presently, there are no widely accepted guidelines in the literature for the diagnosis and treatment of sacroiliac instability. Establishing management guidelines for this disorder has been complicated by the large spectrum of different etiologic factors, the variability of patient history and clinical symptoms, limited availability of objective testing, and incomplete understanding of the biomechanics of the sacroiliac joint.

CONCLUSIONS

A reliable examination technique to identify the sacroiliac joint as a source of low back pain seems to be pain relief following a radiologically guided injection of a local anaesthetic into the sacroiliac joint. Most patients respond to non-operative treatment. Patients who do not respond to non-operative treatment should be considered for operative sacroiliac joint stabilization.

Scapulothoracic dissociation: evaluation and management

Scapulothoracic dissociation is an infrequent injury with potentially devastating outcomes. Knowledge of this injury is based on small patient series and case reports. The aim of this article is to review the evaluation, management and functional outcomes following scapulothoracic dissociation. Often caused by high traction forces applied to the shoulder girdle, there is a complete loss of the scapulothoracic articulation with lateral scapular displacement and intact skin. This is frequently associated with muscular, ligamentous and osseous injuries to the shoulder girdle, vascular injuries to the subclavian, or axillary, vessels and brachial plexus lesions. In the acute setting, the timely diagnosis of the associated neurovascular injuries is crucial. Severe neurovascular and soft tissue compromise often requires an early above-elbow amputation. Further, complete brachial plexus avulsions are associated with a limited potential for functional recovery.

Exchange reamed nailing for aseptic nonunion of the tibia

BACKGROUND

Exchange reamed nailing of the tibia is a common procedure in the treatment of an aseptic tibial nonunion. However, reports in the literature supporting this technique are limited.

METHODS

Forty patients with a tibial nonunion after initial unreamed intramedullary nailing were retrospectively assessed after an exchange reamed nailing. The main outcome measurements included radiographic and clinical union as well as time from exchange reamed nailing to union.

RESULTS

Thirty-eight patients achieved union of their fracture (95%). The average time from exchange nailing to union was 29 +/- 21 weeks. Complications included one deep vein thrombosis (2.5%) and two hardware failures (5%).

CONCLUSION

Exchange reamed nailing for nonunions of the tibia results in a high union rate and is associated with a low complication rate. This technique is recommended as a standard procedure for aseptic tibial nonunions after initial unreamed intramedullary nailing.

Sacral fractures with neurological injury: is early decompression beneficial?

During a 6-year period, 177 patients with a displaced sacral fracture were treated at our level-one trauma centre. At the initial presentation, 13 patients demonstrated a neurological deficit as a result of their sacral fracture. Six patients underwent surgical decompression, and seven patients were managed without surgical decompression. All patients were re-assessed at an average follow-up of 27.1 (range 12-84) months using the modified SOFCOT Index and the SF-36. Patients undergoing surgical decompression had a significantly better neurological improvement as measured by the modified SOFCOT Index (p=0.014). Moreover, patients undergoing surgical decompression had a significantly better physical function than the patients that were managed without surgical decompression, as measured by the SF-36 (p=0.044). We therefore believe that patients undergoing surgical decompression achieve better neurological improvement and better functional results.

Feasibility of percutaneous gene transfer to an atrophic nonunion in a rabbit

Treatment of atrophic nonunions is a challenge to orthopaedic surgeons. Growth factors potentially are valuable factors for improvement of tissue healing. The use of growth factors, however, is limited by their short half-lives. Gene therapy has the potential to improve the treatment. This study aimed to establish and validate an atrophic nonunion model in a rabbit for the use of a percutaneous in vivo gene therapy protocol. An atrophic tibial nonunion was established in 24 New Zealand White rabbits. Radiologic and histologic followup was for 64 weeks. The rabbit tibias showed no radiologic or histologic signs of healing. In addition, an adenoviral vector carrying a marker gene was injected percutaneously into the nonunion site in 12 rabbits. Expression of the marker gene was assessed for as many as 4 weeks. The percutaneous gene delivery resulted in transgene expression in the nonunion site for as many as 4 weeks. The described model reliably leads to an atrophic tibial nonunion in rabbits. Adenoviral percutaneous gene delivery into the nonunion site is feasible and leads to transgene expression locally for at least 1 month. This study provides investigators with a reliable and reproducible model of an atrophic nonunion.

Anticardiolipin antibody associated arterial thrombosis following fibula fracture

A case is described of a 20-year-old college student in whom open reduction and internal fixation of a Weber B fibula fracture was complicated by arterial thrombosis and gangrene of the foot. The patient subsequently required a below-knee amputation. A hypercoagulability workup revealed the presence of an anticardiolipin antibody. Although this is an extremely unusual complication, young female patients with a positive personal or family history of early thrombotic events, such as DVT, multiple pregnancy loss, or early myocardial infarction, should be viewed as being at increased risk. Additional risk factors such as oral contraceptive use, should be sought during the initial history.

Validating the Functional Capacity Index as a measure of outcome following blunt multiple trauma

BACKGROUND

The validity of the Functional Capacity Index (FCI) is evaluated by examining its distributional characteristics, its correlation with other well-known measures of outcome and its ability to discriminate among persons with injuries of varying type and severity.

METHODS

A telephone survey which included the FCI and the SF-36 was administered 1 year post-injury to 1240 blunt trauma patients discharged from 12 trauma centers. A subsample of 656 patients also completed the Sickness Impact Profile (SIP) by mail.

RESULTS

FCI scores correlated well with the physical health subscores of the SIP and SF-36. They also correlated well with self-reported change in health status and return to work. The FCI, when compared to either the SF-36 or the SIP, however, appears to discriminate better among patients according to the presence and severity of head trauma.

CONCLUSIONS

While further testing of the FCI is needed, it holds promise as a preference based measure for assessing the physical impact of trauma.

The surgical treatment of internal snapping hip

BACKGROUND

Internal snapping hip is an underdiagnosed cause of hip pain that sidelines many recreational and competitive athletes. It originates from a taut iliopsoas tendon that snaps across bony prominences when the hip is extended from a flexed position. When nonoperative treatment methods fail, fractional tendon-lengthening procedures may be used.

HYPOTHESIS

Surgical tendon lengthening through a true ilioinguinal approach, which has not been previously reported, will achieve good results in patients with internal snapping hip.

STUDY DESIGN

Retrospective cohort study.

METHODS

In 30 patients with symptoms in their anterior hip, internal snapping hip was diagnosed by history and physical examination. All patients were initially treated nonoperatively; 19 (63%) improved and did not require further intervention. Eleven patients (12 hips) whose symptoms were recalcitrant to physical therapy were offered the surgical option of iliopsoas tendon lengthening. The procedure was performed via an ilioinguinal intrapelvic approach. Patients were followed up for an average of 3 years.

RESULTS

All 11 surgically treated patients (100%) had complete postoperative mitigation of their snapping hip. Nine (82%) reported excellent pain relief. Moreover, nine patients thought that they had greatly benefited from the tendon lengthening and would repeat the surgery.

CONCLUSION

Although nonoperative measures are usually successful in the treatment of internal snapping hip, surgical tendon lengthening is a viable approach in cases refractory to nonoperative therapy.

Using the SF-36 for characterizing outcome after multiple trauma involving head injury

BACKGROUND

The purpose of this study was to evaluate the validity of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) for examining outcomes after multiple trauma and to investigate whether the addition of items selected to measure cognitive function could improve the sensitivity of the SF-36 for identifying differences in outcomes for patients with and without head injury.

METHODS

One thousand two hundred thirty patients discharged from 12 trauma centers were interviewed 1 year after injury. The interview included the SF-36 supplemented with four items chosen to assess cognitive function.

RESULTS

The resulting cognitive function scale is internally consistent and measures a component of health that is independent of the dimensions incorporated in the SF-36. It correlates well with established measures of brain injury severity and discriminates among patients with and without brain injury.

CONCLUSION

This study underscores the need to supplement the SF-36 with a measure of cognitive function when evaluating outcome from multiple trauma involving head injury. Further studies are needed to validate the specific items chosen for measuring cognitive function.

Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures: does correction of Bohler's angle alter outcomes?

The study reviewed in this article evaluated a group of patients who underwent surgical therapy for calcaneal fractures at a Level I trauma center. One group of patients was treated after outpatient referral to the center, whereas the other group was admitted to, and underwent surgery at, the center. This study attempted to determine which patient risk factors or injury characteristics might lead to an increased rate of wound-healing complications. Bohler's angle is a classic radiographic method of determining the severity of calcaneal injury in this group of patients. The question posed by the authors of this study was: Does a drastic correction in Bohler's angle lead to an increased incidence of wound-healing complications? The authors do not recommend undercorrection of Bohler's angle but urge avoidance of overcorrection and stress the importance of early surgical fixation after lateral skin wrinkling is found.

Transsacral versus modified pelvic landmarks for percutaneous iliosacral screw placement--a computed tomographic analysis and cadaveric study

The alar roots of the first sacral body are the usual confines for iliosacral screw (IS) placement when stabilizing a sacroiliac joint injury or sacral fracture. The traditional transsacral method of IS placement aligns the screw horizontally through the sacral ala on both the inlet and outlet views of the sacrum. A modified oblique method of IS placement aligns the screw in an oblique fashion, directed inferiorly to superiorly and posteriorly to anteriorly. The purpose of this investigation was to first define the S-1 segment boundaries for both methods of placement by analyzing the 3-dimensional (3-D) composites of 40 pelvic computed tomography (CT) scans, and then to evaluate the actual placement of ISs under fluoroscopy in 10 cadaveric pelves comparing the transsacral with the modified oblique techniques. Critical dimensions of 7.3 mm and 14.6 mm were considered as the diameter sizes of one and two cannulated screws, respectively. From the 3-D CT composites, the mean anterior/posterior (A/P) measurements were 10.9 mm and 18.0 mm, comparing transsacral with modified oblique methods, respectively. Moreover, 9/40 (22.5%) of the transsacral A/P measurements were <7.3 mm, while all of the modified oblique A/P measurements were >7.3 mm. The mean superior/inferior (S/I) measurements were 18.0 mm for transsacral and 26.2 mm for modified oblique placement. Out of 40 transsacral S/I measurements, 4 (10%) were <14.6 mm, while all the modified oblique S/I measurements were >14.6 mm. In the second part of this study, 10 uninjured cadaveric pelves had unilateral percutaneous IS placed under fluoroscopic guidance (inlet, outlet, and lateral projections) by one orthopedic traumatologist. The final position of all 10 screws was confirmed on fluoroscopy by two independent orthopedic trauma surgeons. The first 5 screws were placed by using transsacral pelvic landmarks. Modified landmarks guided the other 5 screws. The accuracy of final screw position was determined by "postoperative" CT scans interpreted by a blinded musculoskeletal radiologist. The screws inserted using transsacral pelvic landmarks were errant in 3 of the 5 cases. Neurovascular complications could be expected from the extraosseous position of all 3 screws. All 5 screws were located within the confines of the S-1 segment by means of the modified oblique technique. Thus, the modified oblique placement technique allowed greater accuracy and reliability over transsacral landmarks in placing percutaneous ISs. The use of the modified oblique pelvic landmarks is warranted during percutaneous iliosacral screw stabilization of the posterior pelvis.

Ankle arthrodesis: indications and techniques

Patients with ankle arthritis and deformity can experience severe pain and functional disability. Those patients who do not respond to nonoperative treatment modalities are candidates for ankle arthrodesis, provided pathologic changes in the subtalar region can be ruled out. Several techniques are available for performing the procedure; the most successful combine an open approach with compression and internal fixation. The foot must be positioned with regard to overall limb alignment and in the optimal position for function. A nonunion rate as high as 40% has been reported. Osteonecrosis of the talus and smoking are known risk factors for nonunion. When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain.

Outcomes in acute orthopaedic trauma: a review of 130,506 patients by age

There is a paucity of large cohort studies that address outcomes after acute orthopaedic trauma. The regional trauma registry is a powerful tool to study trends of large populations over long periods of time. We used such a regional trauma registry to review retrospectively a large subset of orthopaedic trauma patients over a long period of time and to evaluate the relationship between initial presentation, hospital course, hospital charges, and outcomes as a function of age. A retrospective review of 130,506 level I and II trauma admissions with acute orthopaedic injuries over 10 years (1985-1995) was conducted. Aggregate data were analyzed among five age groups. Descriptive analyses were conducted for mechanism of injury, mortality, time to death, injury type, injury severity score (ISS), Glasgow Coma Scale (GCS) on presentation, length of stay (LOS), discharge destination, and hospital charges. Forty-six percent of the patients were in the 18-35-year-old age group; however, 21% of all patients were older than 65 years of age at the time of injury. There were no differences in GCS or ISS on admission. Injury types were similar across all age groups, mostly extremity fractures. Younger patients were much more likely to be injured in a motor vehicle accident (MVA), whereas older patients were injured in a fall. Penetrating trauma was seen almost exclusively in the young. LOS in the hospital was longer in the elderly; however, LOS in the intensive care units were similar across all age groups. Time to death from initial presentation differed across age groups. Elderly patients who eventually died were much more likely to survive more than 24 h in the hospital as compared with young patients. Hospital charges per hospitalization increased with age, although the total charges to the youngest age group were higher due to the group's high volume. Younger American trauma patients with acute orthopaedic injuries are much more likely than their older counterparts to sustain penetrating trauma and pass the socioeconomic burden to society by way of large opportunity costs, lack of insurance, and high rates of recidivism. Elderly patients fared as well as younger patients after acute orthopaedic trauma, although their hospital stays were longer and resulted in increased hospital charges. The excessive costs of trauma, $100 billion and more than 150,000 deaths annually, necessitate study of general population trends. Indirect costs, including rehabilitation costs and opportunity costs, as well as direct costs, are incurred during the post-trauma hospitalization. Attention must focus on prevention of penetrating injuries in the young and falls in the elderly to reduce morbidity, mortality, and the costs of trauma.

Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures

This retrospective study investigated outcomes of wound healing in a series of 63 consecutive patients with 64 fractures of the calcaneus who underwent open reduction and internal fixation done by two surgeons experienced in this fracture during a 3-year period. Thirty-nine patients were managed preoperatively as outpatient referrals before surgery. Twenty-four patients were admitted directly to the trauma service and were managed as inpatients preoperatively. Minimum patient follow-up was 6 months, with an average follow-up of 18 months. A trend correlating the time between injury and operative intervention with the incidence of complications in wounds was noted; the incidence rose in patients who underwent surgery >5 days after their injury. Two-layered closures had a lower incidence of dehiscence compared to single-layered tension-relieving sutures. Patients with a higher body-mass index (BMI) (kg/ m2) took longer to heal their wounds. Strong trends were noted to link BMI and severity of fractures. In the outpatient group, a history of active smoking preoperatively correlated with increased time to wound healing. In 43 patients, there were no wound-healing complications. In 21 feet, there were varying degrees of wound dehiscence. Average wound healing took 47 days. Risk factors for complications in the wound after calcaneal open reduction and internal fixation include single layered closure, high BMI, extended time between injury and surgery, and smoking. Age, type of immobilization, medical illness (including diabetes), type of bone graft, or use of a Hemovac did not influence wound healing.

Outcome of distal radius fractures using the short form 36 health survey

The Short Form 36, a survey designed to accurately study subjective findings, was applied to analyze the outcome of distal radius fractures and its' relation to extrinsic and intrinsic factors. The survey was administered to 50 adults (mean age, 49.6 years) requiring fixation of a distal radius fracture with a mean followup of 2.4 years. Treatment included external fixation and pins in 24 patients, buttress plating in 20 patients, pins alone in four patients, and external fixation alone in two patients. The Short Form 36 scores were correlated with components possibly affecting outcome and compared with those of the general population. There was no correlation with residual radial height, radial tilt, or palmar tilt. No differences were observed between treatment or fracture groups. Intraarticular incongruence of 1 mm or greater correlated with a lower Short Form 36 score and with the development of arthrosis. Those injured while working were more than four times less likely to return to work than those injured while away from work. The Short Form 36 was found an effective and precise tool for measuring subjective patient information.

Ipsilateral proximal and shaft femoral fractures: spectrum of injury involving the femoral neck

Medical records and radiographs of 52 patients were studied after inclusion/exclusion criteria were met. The anatomical location of proximal femoral fractures that involved the femoral neck were examined after the primary fracture planes were drawn onto templates of the proximal femur. The AO classification is comprehensive and widely accepted. It has not been used in this injury combination in a large series of patients. Therefore, we classified each fracture by the AO method and then the AO classes were tabulated and analysed. Only three patterns of proximal femoral fractures appeared. The inferior aspect of the fracture line clustered in the inferomedial aspect of the femoral neck above an intact lesser trochanter in each separate pattern: 55 per cent were AO B2.1 (basilar); 35 per cent AO B2.3 (intracapsular); and 10 per cent AO A1.2 (pertrochanteric) fractures). Eleven fractures (21 per cent) were not detected initially. None of these were A1.2, eight were B2.1 and three were B2.3. Despite many proximal femoral fracture types reported in the literature only three fracture patterns were noted in this large study group. A new finding of clustering of these fractures in the inferomedial femoral neck was noted. AO class B2.1 fractures were the most common fractures missed at initial presentation and were the most common type seen.

Outcomes of patients with pelvic-ring fractures managed by open reduction internal fixation

The purpose of this multiple-subject case report is to describe the physical impairments, disabilities, and handicaps of patients with multiple traumas and pelvic-ring fractures after management with open reduction internal fixation. Nineteen men and 12 women, with a mean age of 38+/-16 years (chi+/-SD), were interviewed and examined at least 1 year (chi+/-14.5 months) after sustaining multiple traumas, including an unstable pelvic-ring fracture that was repaired by open reduction internal fixation. Disabilities and handicaps were assessed using the Oswestry Low Back Pain Questionnaire and the Sickness Impact Profile (SIP). Assessments of physical performance consisted of lift capacity, the amount of forward bending, and gait. A descriptive analysis by age and pelvic fracture classification is reported. The < or = 50-year-old group had the best physical testing scores, except for the lifting test. The > 50-year-old group had the lowest scores. Subjects with B1-class "open-book" pelvic fractures had a tendency to score higher in individual SIP categories. The average SIP scores of 9.34+/-7.47 for the total SIP score, 7.79+/-6.93 for the physical dimension, and 8.24+/-9.61 for the psychosocial dimension represent mild disability. The mean Oswestry score of 13.26%+/-15.41% also represents mild disability. Some subjects demonstrated impairments, disabilities, and handicaps 1 year postoperatively, but for the most part the subjects recovered almost all lost function. The data and clinical management information can be used as a basis of comparison for treatment and research with these types of patients.

Functional outcome of patients with unstable pelvic ring fractures stabilized with open reduction and internal fixation

An unstable pelvic ring fracture represents a severe injury and is associated with high morbidity and mortality. Little data are available assessing the long-term functional limitations, including disability, in a patient with an unstable pelvic ring fracture. The purpose of this study was to describe the impairment and functional outcome (disability) for patients with unstable pelvic ring fractures managed with open reduction and internal fixation (ORIF). Disability was measured at a minimum of 1 year postinjury using the Sickness Impact Profile (SIP), a measure of the health-related quality of life as perceived by the patient. Of the 230 consecutive patients with a pelvic ring fracture, 54 had unstable fractures requiring ORIF; 48 patients were available at a 1 year follow-up. The follow-up roentgenograms confirmed an osseous union and an anatomic alignment of the pelvis. Thirty-seven (77%) of the patients had mild disability (total SIP < 10); 11 (23%) of the patients had moderate disability (SIP > 10) at 1 year. Of the patients who were employed preinjury, 76% were employed 1 year postinjury; 62% had returned to full time work and 14% had returned with job modification. Of the 7 patients who had been in school, 6 had returned full time and 1 student returned part time. Mean SIP scores for subcategories were: physical health = 6.8 +/- 9.4, psychosocial health = 7.4 +/- 12.7, work = 17.6 +/- 25.5, home management = 8.3 +/- 13.0, ambulation = 10.7 +/- 13.7, and mobility = 5.3 +/- 13.0. Despite the magnitude of the bony injuries, the majority of patients with unstable pelvic ring fractures managed with ORIF had mild disability 1 year postinjury; the majority of the patients had returned to work.

Percutaneous iliosacral screw fixation: early treatment for unstable posterior pelvic ring disruptions

OBJECTIVE

Open reduction and internal fixation of unstable posterior pelvic ring injury provides better bony stability and less long term morbidity than nonoperative treatment. However, open reduction and internal fixation of the posterior pelvis may involve substantial intraoperative blood loss, reported infection rates of 6 to 25%, and wound complications in 25%. Our hypothesis was that percutaneous cannulated iliosacral screws placed by fluoroscopic control would provide early, rapid, definitive stabilization with minimal blood loss, infection, and wound complications.

DESIGN

A retrospective medical record and radiographic study. MATERIALS, METHODS, MEASUREMENTS AND MAIN RESULTS: Twenty consecutive patients with an unstable posterior pelvic ring injury treated by percutaneous fixation (41 screws) under fluoroscopic guidance were reviewed. Average patient age was 34 years, trauma score was 14.4 +/- 3.3, and Injury Severity Score was 22.9 +/- 10.6. Mechanisms were motor vehicle collisions (11), falls (3), crush injury (3), and pedestrian/auto (3). Pelvic injuries were classified as Tile B (5) or Tile C (15). Associated injuries were present in 80%. Seventy-five percent of patients underwent pelvic fixation less than 72 hours after injury with closed percutaneous screw placement achieved in 60%, assisted by open reduction in 25% or aided by anterior external fixation in 15%. Mean operative time was 52 minutes for patients requiring percutaneous screws only (7 of 20 patients, 35%), whereas average blood loss was 233 mL for all cases (including open anterior and posterior procedures). No loss of fixation or wound complications occurred during 9.6 months follow-up.

CONCLUSIONS

Percutaneous iliosacral screw fixation for unstable posterior pelvic disruption provided early fixation with minimal operative time, minimal blood loss, and wound-related morbidity.

The diagnosis of deep vein thrombosis in the multiply injured patient with pelvic ring or acetabular fractures

Thirty-one patients with unstable displaced pelvic or acetabular fractures were admitted and underwent an open reduction and internal fixation of their fracture. All patients were studied prospectively for the incidence of proximal deep vein thrombosis (DVT) utilizing venous duplex ultrasound. Duplex scans were repeated at 1 week postoperatively in all patients. Additional scans were performed when clinically indicated. A total of 61 scans were completed. DVT developed in three patients (approximately 10%). Two of the three positive scans were noted only on postoperative examination. The third scan was positive on the preoperative phase. Duplex ultrasound was easily applied and well tolerated by the multiply injured patient.

The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fractures

The management of hemodynamically unstable patients with displaced pelvic ring fractures and associated abdominal, thoracic, or head injuries is controversial. We studied 312 consecutive trauma patients with pelvic fractures admitted from July 1, 1989 through June 30, 1993: thirty-six of these patients were in shock (SBP < or = 90 mm Hg) and were treated by a protocol including volume resuscitation, and treatment of the associated injuries, without use of acute external fixation. Evaluation of the pelvic fractures revealed 39% to be rotationally unstable; 61% were both rotationally and vertically unstable. The mean injury Severity Score was 27 +/- 12, the average Glasgow Coma Scale score was 12 +/- 5, and the Abbreviated Injury Scale (AIS) scores stratified for the abdomen and the thorax were 1.9 +/- 1.7 and 1.6 +/- 1.8, respectively. Eighteen patients required thoracotomy, laparotomy, or both. The total blood requirement in the initial 24 hours postinjury was 4.0 +/- 4 Units. Deaths of four patients (11%) were a function of associated injuries and comorbid factors, not the result of uncontrolled pelvic hemorrhage. The data suggest that aggressive resuscitation of these patients and treatment of extrapelvic injuries in conjunction with early or delayed ORIF, without application of acute external fixation, resulted in a low overall mortality rate.

Non-extensile surgical approaches for two-column acetabular fractures

We reviewed the outcome, at a mean follow-up of 14 months, of 21 two-column fractures of the acetabulum treated by operation through one or two non-extensile approaches. Eighteen procedures resulted in reduction of the articular surfaces to within 3 mm. The blood loss and operating time when two combined non-extensile approaches were used were similar to those reported for extended acetabular approaches. The incidence of heterotopic ossification which limited joint motion was low, and the average Harris hip score was 81 points. The use of non-extensile approaches for acetabular fractures in which both columns are involved avoids iatrogenic injury to the abductors, and reduces the incidence of complications.

Arthrodesis of the ankle and subtalar joints

The late reconstruction of a complex nonunion of the distal tibial metaphysis, the ankle, or the subtalar joint was undertaken in five patients through a posterior surgical approach and the application of a blade plate into the os calcis. This technique was preferred as a salvage operation when the surrounding soft tissue envelope was compromised by the initial injury, previous surgical procedures, or infection. Each of the cases was notable for a segmental bone loss, an infected nonunion, or a collapse of the talar body. In the presence of a major soft tissue defect, the internal fixation was accompanied by the application of a microvascular free flap. The postoperative assessment of the posterior arthrodesis with the blade plate fixation was at an average of 33 months. Using a modification of the Boston Children's Hospital ankle scoring system, a preoperative and postoperative assessment was made. The criteria included an objective rating system based on the intensity of pain, the cessation of drainage, the degree of independent ambulation, and the roentgenographic documentation of union. The average preoperative score was 13 (range, 8-16). After arthrodesis, the average score was 44 (range, 40-48), with three patients rated excellent and two rated good.

Three-dimensional angio-computed tomography. New technique for imaging the acetabulum and adjacent vessels in a patient with acetabular protrusio

An arterial injury is an infrequent but potentially lethel occurrence after primary or revision total hip arthroplasty complicated by an acetabular protrusio. Frequently, a plain radiograph and an arteriogram are used to assess the major arteries around the hip. The limitations of these techniques are well documented. A novel technique for documenting the spatial relationships of the external iliac and common femoral arteries to the acetabulum employs an arterial study combined with a three-dimensional computed scan. An angiocatheter is inserted by conventional radiographic technique and a standard computed scan with 3-mm sections is obtained and reconstructed to a three-dimensional image. The scan provides an accurate three-dimensional image of the osseous architecture and arterial images around the acetabulum. Even in the presence of a metallic arthroplastic component, the resolution of the three-dimensional angio-computed scan is sufficient to identify the external iliac artery adjacent to the pelvis.

Distinguishing avascular necrosis from segmental impaction of the femoral head following an acetabular fracture: preliminary report

To distinguish segmental impaction from avascular necrosis of the femoral head, 26 consecutive patients who sustained an acute displaced acetabular fracture were assessed preoperatively with routine radiographs, computed tomography, and radionuclide imaging using pinhole collimation and single photon emission computed tomography (SPECT). The diagnostic criterion for avascular necrosis was a photopenic defect of the femoral head, whereas, the criterion for segmental impaction was an area of impaction of at least 1 cm2 noted at the time of surgery. Of this series, 3 incurred a segmental impaction while 1 showed evidence consistent with avascular necrosis on SPECT imaging. None of the patients possessed diagnostic features of both complications. The distinction between these two complications of an acetabular fracture should contribute to the application of appropriate surgical techniques to correct segmental impaction and avascular necrosis.