Open fractures of the tibia treated by immediate intramedullary tibial nail insertion without reaming: a prospective study

OBJECTIVE

Does immediate tibial nail insertion without reaming as part of protocol-driven management provide a safe and effective treatment for open tibia fractures?

STUDY DESIGN

Prospective cohort.

SETTING

Level 1 trauma center.

PATIENTS

A consecutive series of 161 patients with Gustilo grade I-IIIb open tibia fractures.

INTERVENTION

Emergent incision and debridement of the wound with immediate tibial nail insertion without reaming, repeat incision and debridement, and soft-tissue coverage within 14 days.

MAIN OUTCOME MEASUREMENTS

Time to union, number of secondary procedures performed to obtain union, implant failures, and the type and incidence of complications.

RESULTS

One hundred and forty-three fractures were followed to union. Follow up averaged 2.2 years (0.6-5.5 years). Seventy-six fractures united in less than 6 months, 35 took between 6 and 9 months, and 32 took longer than 9 months. Twenty-five additional procedures were needed to obtain union in 16 of the delayed unions (12 nail exchanges, 4 bone grafts, 9 dynamizations). Complications included 3 patients with cellulitis, 1 superficial infection, 4 deep infections (1 grade I, 2 grade II, 1 grade IIIb), 3 loose screws, 2 broken screws, 5 malunions greater than 5 degrees, and 30 patients with decreased ankle motion when compared with the uninjured side. Not counting the ankle loss of motion, 18 complications occurred in 143 fractures (13%). Twenty-nine patients (20%) had complaints of minor knee pain and 30 (21%) had occasional fracture site pain after activity despite clinical and radiographic evidence of union. Eleven patients (8%) considered themselves completely disabled. Five patients were not treated by the standard protocol and are not included in the previously listed statistics; 3 were grade IIIB that did not have adequate coverage by 14 days, and 2 were grade II injuries that did not have a second debridement. Four of these 5 patients developed a complication.

CONCLUSIONS

Protocol-driven management emphasizing meticulous soft-tissue management and the use of immediate tibial nailing without reaming appears to be safe and effective in the treatment of open tibia fractures. The deep infection rate for the patients who were treated by protocol was 3% and the implant failure rate was lower than has been previously reported, most likely attributable to attempts to obtain cortical contact and avoid fracture gaps. Overall satisfaction was good, but approximately 41% of the patients had complaints of knee or fracture site pain or both well after union.

Type-II error rates (beta errors) of randomized trials in orthopaedic trauma

BACKGROUND

Although an investigator may limit bias through randomization, concealment of patient allocation, and blinding, the results of randomized trials may be less convincing when the sample size is not sufficiently large to reveal a true difference between treatment groups. When the sample size is small, randomized trials are subject to beta errors (type-II errors)--that is, the probability of concluding that no difference between treatment groups exists when, in fact, there is a difference. The purpose of this study of randomized trials involving fracture care published between 1968 and 1999 was twofold: (1) to evaluate type-II error rates and study power (1 - beta) for the primary outcomes and (2) to identify whether investigators clearly identified the primary and secondary outcomes.

METHODS

To be eligible, studies were required to (1) be published in English, (2) be described as a randomized trial, (3) involve the care of adult patients with fractures, treated either operatively or nonoperatively, and (4) contain sufficient outcome information to enable study power to be calculated. Computer database searches were performed independently by two investigators to identify all potentially relevant study titles. Additional strategies to identify articles included (1) hand searches of selected orthopaedic journals from 1989 to 1999, (2) searches of the bibliographies of potentially relevant articles, and (3) review by content experts to identify missing studies. For each study, a standard power calculation was performed on the primary and secondary outcomes. For those studies in which the primary outcome was not explicitly reported, the most clinically relevant measure was chosen by consensus. Acceptable study power was agreed a priori to be > or = 80% (type-I error of < or = 0.20).

RESULTS

We identified 620 potentially relevant citations from MEDLINE, of which only 187 were potentially eligible. We identified nine more articles with other searches, and application of the eligibility criteria to the 196 articles eliminated seventy-nine. Thus, we analyzed 117 studies in which a total of 19,942 patients with orthopaedic trauma had been randomized. Sample sizes ranged from ten to 662 patients (mean and standard deviation, 95 79 patients). The majority (34%) of trials involved the treatment of hip fractures. The mean overall study power among the 117 trials was 24.65% (range, 2% to 99%). The type-II error rate for primary outcomes was 90.52%.

CONCLUSIONS

Mean type-II error rates in the orthopaedic trauma trials that we analyzed exceeded accepted standards. Investigators can reduce type-II error rates by performing power and sample-size calculations prior to conducting a trial.

Overtightening of the ankle syndesmosis: is it really possible?

BACKGROUND

Many surgeons and orthopaedic references recommend that fixation of a disrupted distal tibiofibular syndesmosis be performed with the ankle in dorsiflexion to avoid overtightening and subsequent restriction of ankle dorsiflexion. This recommendation is based in large part on one cadaveric study without clinical correlation. The purpose of the present study was to examine whether overtightening of the syndesmosis limits maximal ankle dorsiflexion.

METHODS

Nineteen cadaveric ankles were used for the study. Each ankle was tested for the initial range of motion after release of the Achilles tendon proximal to the ankle joint. All capsular and ligamentous structures remained intact. Kirschner wires were placed in the tibia and talus. The angle between the wires with the ankle maximally dorsiflexed was measured before and after syndesmotic compression. Syndesmotic compression was achieved with a 4.5-mm lag screw with the ankle in plantar flexion.

RESULTS

There was no difference between the values for maximal dorsiflexion before and after syndesmotic compression.

CONCLUSIONS

Syndesmotic compression in and of itself does not diminish ankle dorsiflexion in a cadaveric model.

CLINICAL RELEVANCE

Maximal dorsiflexion of the ankle during syndesmotic fixation is not required in order to avoid loss of dorsiflexion. It is likely that the most important aspect of syndesmotic fixation is anatomic reduction of the syndesmosis and that the degree of ankle dorsiflexion during fixation is not important.

Technical considerations in the surgical management of tibial fractures

The surgical treatment of tibial shaft fractures is generally successful. However, significant controversy exists regarding the indications for specific types of fixation and the techniques used to apply them. Advances to meet the technical challenges of tibial fracture fixation continue to be made, and orthopaedic surgeons should have these new techniques at their disposal for application to each individual patient's injury.

Clubfeet and tarsal coalition

Tarsal coalition was noted in 18 cases of rigid equinovarus deformity. Sixteen cases were encountered at surgery and two at morbid dissection. There were 14 patients in the series; six had associated pathologic conditions that might have caused their clubfeet to be deemed "teratologic," whereas eight did not and were considered to have congenital clubfeet. Four patients in the series had bilateral coalitions. Preoperative radiographs demonstrated the coalition in only one case. A presurgical magnetic resonance image (MRI) clearly showed the coalition in another case. Nonoperative treatment was unsuccessful. Two patients with tibial dysplasia had ankle disarticulations. The remaining 16 feet required extensive soft-tissue releases, internal fixation, and coalition excision. The vast majority of cases showed cartilaginous subtalar coalition at the medial facet. The patients were followed for an average of 6 years, and two recurrences were noted. Remaining feet were painless and plantargrade, but were rather stiff. This anomaly may be more common than previously described. It is usually not suspected preoperatively and may likewise be difficult to recognize at surgery. A preoperative MRI scan may also be helpful.

Amputation versus limb salvage

The decision to attempt salvage or to amputate a severely injured leg in among the most difficult that the orthopaedist must face. Even surgeons with tremendous trauma experience cannot agree on standard course of action. In the face of such injuries, physician consultation regarding the treatment decision, including all of those members of the team that are needed for a successful salvage, is necessary. In the best circumstances, the trauma surgeon, vascular surgeon, orthopaedist, and a soft-tissue specialist are all involved. From a psychological perspective, the timing of an amputation is important. Although each patient's case is unique, immediate amputation is often viewed by the patient and family as a result of the injury. Conversely, a delayed amputation may be viewed as a failure of treatment. It is imperative that the surgeon have a detailed discussion with the patient and the family whenever possible before making the decisions. Scoring systems are of some help in estimating the chances of a successful salvage. However, the ultimate decision to amputate or attempt salvage is based on such patient factors as preinjury function and social situation, and of associated injuries, surgeon experience, available resources, projected physical abilities, and the patient's projected physical requirements. These decisions are difficult and tax the judgment and emotions of the patient, family, and physician.

Tibial portal placement: the radiographic correlate of the anatomic safe zone

OBJECTIVE

To identify the radiographic correlate of the anatomic safe zone for tibial portal placement.

DESIGN

Cadaveric, anatomic, and radiographic study using twenty cadaveric knees. Kirschner wires were placed in the anatomic safe zone. Anteroposterior and lateral radiographs were taken to evaluate the portal placement.

SETTING

Anatomy laboratory.

OUTCOME MEASUREMENTS

Radiographic measurements of Kirschner wires placed in the anatomic safe zone.

RESULTS

The safe zone for tibial nail placement as seen on radiographs is just medial to the lateral tibial spine on the anteroposterior radiograph and immediately adjacent and anterior to the articular surface as visualized on the lateral radiograph. There is some variance on the anteroposterior radiograph but no variance on the lateral radiograph.

CONCLUSIONS

The placement of tibial nails in the superior portion of the tibia in the documented position generates the least risk to the intraarticular structures of the knee.

Lag screw only fixation of the lateral malleolus

OBJECTIVES

To evaluate the use of lag screw only fixation of noncomminuted oblique fractures of the lateral malleolus in patients younger than fifty years of age.

DESIGN

Prospective evaluation.

SETTING

Level I trauma center.

PATIENTS AND PARTICIPANTS

Forty-seven ankle fractures with simple oblique patterns and no comminution that were long enough to accept two lag screws placed at least 1 centimeter apart were prospectively evaluated. All patients were younger than fifty years of age. There were twenty-three ligamentous SE4, eighteen bimalleolar SE4, and six PE4 fractures.

INTERVENTION

Open reduction and internal fixation with lag screw only fixation of the lateral malleolus.

MAIN OUTCOME MEASUREMENTS

Radiographic and clinical outcome parameters were compared with those of a cohort of patients previously treated at the same institutions using different techniques.

RESULTS

Thirty-five patients' ankles were fixed with two lag screws, ten with three lag screws, and two with four lag screws. The incision for lag screw placement was 30 percent shorter and slightly more anterior than that in the comparison group. No patient lost reduction and there were no soft-tissue complications in the group. Follow up averaged 1.6 years for forty-two patients. One patient (2 percent) had complaints of lateral pain in the study, compared with 17 percent in the plate group. No patient fixed with lag screws had palpable hardware, as compared with 56 percent in the plate group. None had any restrictions in shoe wear, as compared with 15 percent in the plate group. No patient required screw removal, as compared with 31 percent in the plate group. There was no difference in radiographic outcome between the two groups.

CONCLUSIONS

Lag screw only fixation is a useful and successful method for appropriately selected lateral malleolar fractures.

Meta-analyses in orthopaedic surgery. A systematic review of their methodologies

BACKGROUND

The number and quality of well-designed scientific studies in the orthopaedic literature are limited. The purpose of this review was to determine the methodological qualities of published meta-analyses on orthopaedic-surgery-related topics.

METHODS

A systematic review of meta-analyses was conducted. A search of the Medline database provided lists of meta-analyses in orthopaedics published from 1969 to 1999. Extensive manual searches of major orthopaedic journals, bibliographies of major orthopaedic texts, and personal files identified additional studies. Of 601 studies identified, forty met the criteria for eligibility. Two investigators each assessed the quality of the studies under blinded conditions, and they abstracted relevant data.

RESULTS

More than 50% of the meta-analyses included in this review were published after 1994. We found that 88% had methodological flaws that could limit their validity. The main deficiency was a lack of information on the methods used to retrieve and assess the validity of the primary studies. Regression analysis revealed that meta-analyses authored in affiliation with an epidemiology department and those published in nonsurgical journals were associated with higher scores for quality. Meta-analyses with lower scores for quality tended to report positive findings. The meta-analyses that focused upon fracture treatment and degenerative disease (hip, knee, or spine) had significantly lower mean quality scores than did meta-analyses that examined thrombosis prevention and diagnostic tests (p < 0.05).

CONCLUSIONS

The majority of meta-analyses on orthopaedic-surgery-related topics have methodological limitations. Limitation of bias and improvement in the validity of the meta-analyses can be achieved by adherence to strict scientific methodology. However, the ultimate quality of a meta-analysis depends on the quality of the primary studies on which it is based. A meta-analysis is most persuasive when data from high-quality randomized trials are pooled.

Displaced acetabular fractures: indications for operative and nonoperative management

Displaced acetabular fractures are a challenging problem. In contradistinction to most conditions in which surgery is based on specific operative indications, displaced acetabular fractures should be considered an operative problem unless specific criteria for nonoperative management are met. These include a congruent hip joint on the anteroposterior and oblique (Judet) radiographs, an intact weight-bearing surface (as defined by roof arc and subchondral arc measurements on computed tomographic scans), and a stable joint. The final decision about the treatment method must also consider the patients functional demands, expectations, and physical condition and the physicians experience and institutional support for dealing with this type of injury. Displaced both-column fractures with secondary congruence may have better results than other displaced fractures. In older patients, nonoperative management may be effectively utilized. Understanding the current criteria for effective use of nonoperative treatment will help the surgeon make these difficult decisions.

Hybrid external fixation of tibial pilon fractures

Although external fixation reduces drastically the number of iatrogenic complications compared with acute open reduction and plate fixation, the prognosis for functional recovery after a pilon fracture remains guarded. Many authors have applied validated patient outcome measures to patients who have had pilon fractures. These studies confirmed that there are significant decreases in general health perceptions, physical and emotional role function, pain, and energy levels in patients who have suffered pilon fractures, regardless of the treatment modality. The high-energy tibial pilon fracture with soft tissue compromise remains a treatment dilemma. Hybrid external fixation with limited open reduction has proved to be a safe, reproducible, and effective treatment modality for this complex fracture.

Tension wire position for hybrid external fixation of the proximal tibia

OBJECTIVE

To compare a new configuration of proximal wires for hybrid external fixation with the standard configuration.

DESIGN

Biomechanical testing of five matched pairs of fresh cadaveric tibia.

INTERVENTION

The authors compared the standard tension wire configuration of the three proximal wires with a more sagittal orientation of the oblique wires. A second study compared the new configuration with two wires and an offset half-pin. A two-centimeter segmental defect was created just distal to the tibial tubercle and the tibias fixed in a Montecelli Spinelli (Howmedica, NJ, U.S.A.) hybrid frame. The constructs were biomechanically tested using an Instron servohydraulic biaxial testing machine.

RESULTS

There was a significant 67 percent decrease in displacement during anterior posterior bending and a significant 40 percent decrease in displacement in posterior bending with the new configuration compared with the standard configuration (p < 0.05). The differences in stability in all other testing modes were not significant. There was no significant difference between the new configuration and the two wire and off-set half-pin configuration.

CONCLUSION

We recommend anterior placement of the oblique tension wires in the proximal tibia to more effectively resist bending in the sagittal plane, which is the most common deforming force on proximal metaphyseal fractures.

Antegrade or retrograde reamed femoral nailing

Retrograde femoral nailing is gaining in popularity. We report a prospective, randomised comparison of antegrade and retrograde procedures in 68 patients with 69 fractures of the femoral shaft. All nails were inserted after appropriate reaming. There was no difference in operating time, blood loss, technical complications, size of nail or reamer, or transfusion requirements. There were more problems of length and rotation using a retrograde technique on a radiolucent table than with an antegrade approach on a fracture table. All fractures in both groups healed and there was no difference in the time taken to achieve union. Although retrograde nailing is a promising technique the skills required need practice. A longer period of follow-up is necessary to determine whether there are long-term problems in the knee after such surgery.

Accidental and nonaccidental femur fractures in children

A retrospective review of 207 patients younger than 6 years of age who sustained nonpathologic diaphyseal femur fractures was done, which emphasized the characteristics of accidental versus nonaccidental injury. There were 214 fractures in 123 boys and 83 girls (the gender of one patient was unknown). The average age of the patients was 2.73 years. Mechanisms of injury were pedestrian struck by a car (62 patients), falls (92 patients), and motor vehicle accidents (10 patients). Nineteen patients did not have a history of trauma. Seventy-six cases were investigated for child abuse. The results of 13 investigations were positive. Overall, the morphologic features of the fractures were transverse (38%), spiral (27%), and oblique (17%). In the investigated group, 27% of the fractures were transverse, 39% were spiral, and 15% were oblique. In those cases with positive results of the investigation, 36% of the fractures were transverse, 36% were spiral, and 7% were oblique. Although transverse fractures are most common in accidental and nonaccidental injuries, many practitioners think spiral fractures are pathognomonic of abuse. The current data show that although spiral fractures were less common than transverse fractures overall, and no more common in the cohort of patients in whom the results of the child abuse investigations were positive, they were overrepresented in the cohort that was investigated. This suggests that spiral fractures are viewed as particularly suspicious, which may lead to missed cases of nonaccidental injury in children with transverse fractures.

Ender rod fixation of femoral shaft fractures in children

Ender rod fixation for femoral shaft fractures in children was evaluated in a prospective study at two Level 1 trauma centers. Fifty-seven fractures in 52 patients were evaluated. Criteria for inclusion in the study included age younger than 14 years, femoral shaft fractures occurring in the middle 3/5, canal size greater than 7 mm, and parental consent. Hip and knee motion, gait, leg length discrepancy, and rotational asymmetry were evaluated by clinical examination. Standard radiographs were used to measure any residual angulation. A subset of patients whose injuries occurred more than 12 months previously was evaluated using scanograms. Followup averaged 20 months. There were no delayed unions and all fractures healed within 12 weeks. Clinically significant leg length discrepancy, malunion, or loss of motion did not occur. Functional results were excellent and complications were minor. Ender rod fixation of femur fractures in children allows the advantages of surgical fixation with minimal risk of complications.

Acetabular fractures in children and adolescents

A retrospective study of 29 acetabular fractures in children 2 to 16 years of age with an average followup of 14 years is presented. Nineteen patients had an additional dislocation of the femoral head and 14 patients had an associated neurologic injury. Surgical treatment was performed in 16 patients and consisted of open reduction and internal fixation in 14 patients and a simple arthrotomy in two patients. Thirteen patients were treated nonoperatively with traction or bedrest. The outcome was satisfactory in all patients with undisplaced fractures and fractures with disruption of a small fragment. Eight patients with linear fractures with instability all were treated surgically. All but one of the patients had a satisfactory functional outcome; one patient had early degenerative changes develop after an open pelvic and acetabular fracture. Patients with central fractures and dislocations had a relatively poor outcome, and congruency was achieved in only one of the four patients who were treated surgically. Results may deteriorate with time, as was seen when the results of the current study were compared with those published 10 years previously.

Antegrade or retrograde reamed femoral nailing. A prospective, randomised trial

Retrograde femoral nailing is gaining in popularity. We report a prospective, randomised comparison of antegrade and retrograde procedures in 68 patients with 69 fractures of the femoral shaft. All nails were inserted after appropriate reaming. There was no difference in operating time, blood loss, technical complications, size of nail or reamer, or transfusion requirements. There were more problems of length and rotation using a retrograde technique on a radiolucent table than with an antegrade approach on a fracture table. All fractures in both groups healed and there was no difference in the time taken to achieve union. Although retrograde nailing is a promising technique the skills required need practice. A longer period of follow-up is necessary to determine whether there are long-term problems in the knee after such surgery.

Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation

BACKGROUND

The stability of the ankle joint is provided by the medial and lateral malleoli and ligaments. Recent studies of cadaveric ankles have demonstrated that injury to the medial structures of the ankle is necessary to allow lateral subluxation of the talus after fracture. However, cadaveric models are limited by the fracture pattern chosen for the model. We sought to investigate the competency of the deltoid ligament in vivo in patients with an operatively treated bimalleolar ankle fracture.

METHODS

Twenty-seven patients with a bimalleolar ankle fracture were evaluated. In each patient, the medial malleolus was anatomically reduced and fixed. A radiograph of the ankle was then made with application of an external rotation load to the joint. All lateral malleolar injuries were then reduced and fixed. The radiographs were evaluated for restoration of the competence of the deltoid ligament according to established criteria.

RESULTS

Seven (26 percent) of the twenty-seven patients had radiographically evident incompetence of the deltoid ligament after medial malleolar fixation. This finding was associated with a small medial malleolar fragment.

CONCLUSIONS

In bimalleolar fractures, the medial injury may be an osseous avulsion, leaving the deltoid intact on the displaced fragment, or it may be a combination of ligamentous and osseous injury with disruption of the deep portion of the deltoid ligament.

Percutaneous treatment of calcaneal fractures

Percutaneous fixation of calcaneal fractures has limited indications. It is most useful for tongue-type fractures in which the displaced portion of posterior facet remains intact to the tuberosity. This allows the tuberosity to be used as a reduction tool for the posterior facet. The technique has been used successfully in 41 patients. In the current study, the indications and technique are reviewed in detail.

Superior gluteal artery in the extended iliofemoral approach

OBJECTIVE

To determine the incidence of superior gluteal artery injury following fracture of the acetabulum and to determine whether the combination of a superior gluteal artery injury and the use of an extended iliofemoral approach to the acetabulum creates abductor muscle necrosis.

DESIGN

Prospective protocol, consecutive cases.

SETTING

A consecutive series from the referral practice of the senior author plus seven cases from the practices of two other authors.

PATIENTS

Two hundred twenty-seven patients with fractures of the acetabulum were treated operatively between November 1992 and January 1995. Forty-one were treated with the use of the extended iliofemoral approach. Preoperative angiograms were not performed for any of the patients. All fractures involved the posterior column, and all but two fractures had displacement of the greater sciatic notch. The average displacement of the notch was 2.5 centimeters (range 6 to 60 millimeters).

INTERVENTION

All patients were treated with open reduction and internal fixation via the extended iliofemoral approach. Intraoperative Doppler examination of the superior gluteal artery was performed before and after reduction and fixation of the posterior column.

MAIN OUTCOME MEASURE

Wound complications, abductor manual muscle testing, hip range of motion.

RESULTS

Pulsatile flow was confirmed in forty of forty-one patients. All patients were followed for a minimum of six months with an average follow-up of 1.4 years. At most recent follow-up, no patients had evidence of complete loss of abductor function. Sixty-three percent of patients had achieved Grade 4 of 5 motor strength, and 25 percent of them had achieved normal motor strength.

CONCLUSIONS

No instances of superior gluteal artery laceration and only one instance of superior gluteal artery thrombosis were encountered in these forty-one patients despite significant fracture displacement involving the sciatic notch. The incidence of superior gluteal artery injury was significantly less than would be expected from previous studies. Massive abductor necrosis resulting from superior gluteal artery injury combined with an extended approach has been described primarily in animal and cadaver studies. Although arteriograms are useful in the control of hemodynamic instability, we cannot support the recommendation of preoperative angiographic study of all patients undergoing acetabular fracture surgery via an extended approach. In one case, an extended iliofemoral approach was tolerated in a patient with absent superior gluteal artery flow.

Radial and axillary nerves. Anatomic considerations for humeral fixation

Because the axillary and radial nerves can be injured during operative exposure and fixation of the humerus, accurate delineation of their location is vital to avoid complications. The authors investigated the relationship of the radial and axillary nerves for radiographically and surgically identifiable bony landmarks. Fifty fresh human cadaveric upper extremities were dissected to identify the nerves as they crossed the lateral intermuscular septum and the humeral surgical neck, respectively. Longitudinal distances between the nerves and the superior aspect of the humeral head, the surgical neck, the superior extent of the olecranon fossa, and the distal aspect of the trochlea were measured with calipers. The average distance from the axillary nerve to the proximal humerus was 6.1 +/- 0.7 cm (range, 4.5-6.9 cm) and 1.7 +/- 0.8 cm (range, 0.7-4.0 cm) from the surgical neck. The radial nerve traversed the lateral intermuscular septum 17 +/- 2.3 cm (range, 13-22 cm) from the proximal humerus, 12 +/- 2.3 cm (range, 7.4-16.6 cm) from the olecranon fossa, and 16 +/- 0.4 cm (range, 9.0-20.5 cm) from the distal humerus, representing the approximate midpoint of the bone. Anteroposterior locking screws placed into the proximal humerus endanger the axillary nerve because it lies directly over the posterior cortex as little as 0.7 cm from the surgical neck. As the radial nerve crosses the lateral intermuscular septum more proximal than generally was thought, it is at risk during implant insertion in the distal half of the humerus. Using measurements calculated from preoperative and intraoperative imaging, the approximate position of the nerve could be determined to better plan fixation method and implant location.

Reamed versus nonreamed anterograde femoral nailing

OBJECTIVE

To compare reamed femoral nailing with unreamed femoral nailing.

DESIGN

Prospective, randomized.

SETTING

Two Level One trauma centers.

PATIENTS

One hundred seventy patients with 172 femur fractures were randomized to an unreamed or reamed group. MAIN OOUTCOME MEASURES: Data included demographics, Injury Severity Score (ISS), operative time, blood loss, blood and fluid requirements, technical complications, time to callus formation, time to union, and complications.

RESULTS

There was no statistical difference in operative time, transfusion requirements, or hypoxic episodes between the groups. Intraoperative blood loss was greater in the reamed group. The time to union was 80 +/- 35 days for the reamed group and 109 +/- 62 days for the unreamed group (p = 0.002). This difference was most dramatic in the distal femur, with union in the reamed group occurring in 80 days compared with 158 days in the unreamed group (p = 0.012). There were more technical complications and delayed unions in the unreamed group.

CONCLUSIONS

There is no advantage to the routine use of nailing without reamed insertion. Fractures treated with reamed nails heal faster than those treated with unreamed nails, especially distal fractures.

Pseudosubluxation of the hip joint. A case report

The case of a 32-year-old man who had a subluxation of his hip joint after open reduction and internal fixation for an acetabular fracture is presented. The subluxation resolved without surgical intervention. It is thought that the subluxation, herein termed pseudosubluxation, is similar to pseudosubluxation seen in the shoulder. The patient had sustained significant trauma to the abductor musculature and lateral hip region with a Morel-Lavelle lesion and a hip fracture coincident with his acetabular fracture. This entity has not been reported previously.

Intraarticular anatomic risks of tibial nailing

OBJECTIVE

To identify the risks to intraarticular structures of the knee during tibial portal creation and to identify the safe zone for tibial nail placement.

STUDY DESIGN

Cadaveric anatomic.

LOCATION

University trauma center.

METHODS

Forty fresh frozen cadaveric knees were studied to elaborate the risks of tibial portal creation and nail placement to the intraarticular structures of the knee. Nails were placed through medial and lateral parapatellar approaches, and the distance from the nail portal to the intraarticular structures of the knee was measured. A safe zone for portal placement was determined.

RESULTS

The tibial portal location averaged 4.4+/-3 millimeters lateral to the midline of the plateau. Actual intraarticular structural damage occurred in 20 percent of the specimens; however, an additional 30 percent demonstrated the nail to be subjacent to one of the menisci. A lateral paratendinous approach placed the lateral articular surface at most risk, and a medial paratendinous approach placed the medial meniscus at most risk. The safe zone for nail placement was identified and is located 9.1+/-5 millimeters lateral to the midline of the plateau and three millimeters lateral to the center of the tibial tubercle. The width of the safe zone averaged 22.9 millimeters and was as narrow as 12.6 millimeters.

CONCLUSION

Damage to the intraarticular structures of the knee is possible during tibial nailing with a superior portal. The safe zone for nail placement is small and can be exceeded if a reamed nail is used. The safest starting point for tibial nailing should be slightly lateral to the center of the tibial tubercle.

Morbidity and mortality in elderly trauma patients

BACKGROUND

Despite an increasing incidence, relatively few studies have examined the factors that predict morbidity and mortality in older patients and several reports have found standard predictors such as the Injury Severity Score to be less useful in this patient population. Similarly, the effect of skeletal injury has not been examined with regard to complications and mortality. The purpose of this study was to review a large multicenter experience with elderly trauma patients to isolate factors that might predict morbidity and mortality. The potential effect of skeletal long-bone injury was of particular interest.

METHODS

The charts of all patients older than 60 years who were admitted to one of four Level I trauma centers after sustaining blunt trauma were reviewed. Mechanisms of injury included in the study were motor vehicle crash, pedestrian struck, fall from a height, and crush injury. Slip-and-fall injuries were excluded. A total of 326 patients met inclusion criteria. Variables studied included age, sex, mechanism of injury, Injury Severity Score (ISS), Revised Trauma Score, Glasgow Coma Scale (GCS) score, blood transfusion, fluid resuscitation, surgery performed (laparotomy, long-bone fracture stabilization, both), and timing of surgery. Outcome variables measured included incidence of adult respiratory distress syndrome, pneumonia, sepsis, myocardial infarction, deep venous thromboembolism, gastrointestinal complications, and death. chi2, logistic regression, t test, and nonparametric analyses were done as appropriate for the type of variable.

RESULTS

The average age of the patients was 72.2+/-8 years. Overall, 59 patients (18.1%) died, of whom 52 of 59 survived at least 24 hours. Statistical significance for continuous variables (p < 0.05) using univariate analysis was reached for the following factors for the patients who died: higher ISS (33.1 vs. 16.4), lower GCS score (11.5 vs. 13.9), greater transfusion requirement (10.9 vs. 2.9 U), and more fluid infused (12.4 vs. 4.9 L). Logistic regression analysis was performed to determine the factors that predicted mortality. They included (odds ratios and p values in parentheses) transfusion (1.11, p = 0.01), ISS (1.04, p = 0.008), GCS score (0.87, p = 0.007), and fluid requirement (1.06, p = 0.06). Regarding surgery, orthopedic surgery alone had an odds ratio of 0.53, indicating that orthopedic patients was less likely to die than patients who did not undergo any surgery. Patients who underwent only a general surgical procedure were 2.5 times more likely to die (p = 0.03) and patients who underwent both general and orthopedic procedures were 1.5 times more likely to die (p = 0.32) than patients who did not require surgery. Early (< or =24 hours) versus late (>24 hours) surgery for bony stabilization did not have a statistical effect on mortality (11% early vs. 18% late). Two patients in need of bony stabilization, however, died before these procedures were performed. With regard to complications, regression analysis revealed that ISS predicted adult respiratory distress syndrome, pneumonia, sepsis, and gastrointestinal complications; fluid transfusion predicted myocardial infusion; and need for surgery and transfusion requirements predicted sepsis. These complications, in turn, were significant risk factors for mortality. This large series of elderly patients demonstrates that mortality correlates closely with ISS and is influenced by blood and fluid requirements and by GCS score. The institution-specific mortality was the same when adjusted for ISS. The need for orthopedic surgery and the timing of the surgery was not a risk factor for systemic complications or mortality in this series.

CONCLUSION

Mortality is predicted by ISS and by complications in older patients. Seventy-seven percent of the orthopedic injuries were stabilized early, but the timing of surgery did not have any statistical effect on the incidence of complications or mortality. (ABSTRACT TRUNCA

Non-operative management of acetabular fractures

To assess the stability of the hip after acetabular fracture, dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management. These included roof arcs of 45°, a subchondral CT arc of 10 mm, displacement of less than 50% of the posterior wall, and congruence on the AP and Judet views of the hip. There were three unstable hips which were treated by open reduction and internal fixation. The remaining 38 fractures were treated non-operatively with early mobilisation and delayed weight-bearing. At a mean follow-up of 2.7 years, the results were good or excellent in 91% of the cases. Three fair results were ascribed to the patients’ other injuries. Dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment.

Non-operative management of acetabular fractures. The use of dynamic stress views

To assess the stability of the hip after acetabular fracture, dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management. These included roof arcs of 45 degrees, a subchondral CT arc of 10 mm, displacement of less than 50% of the posterior wall, and congruence on the AP and Judet views of the hip. There were three unstable hips which were treated by open reduction and internal fixation. The remaining 38 fractures were treated non-operatively with early mobilisation and delayed weight-bearing. At a mean follow-up of 2.7 years, the results were good or excellent in 91% of the cases. Three fair results were ascribed to the patients' other injuries. Dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment.

The Essex-Lopresti reduction for calcaneal fractures revisited

OBJECTIVES

To evaluate the reduction and outcome of selected intraarticular calcaneal fractures treated with percutaneous Essex-Lopresti reduction and fixation.

DESIGN

Prospective consecutive series.

SETTING

Level one trauma center and tertiary university hospital.

PATIENTS/PARTICIPANTS

Twenty-six consecutive patients with an Essex-Lopresti tongue-type, Sanders type 2C calcaneus fracture.

INTERVENTION

Modified percutaneous Essex-Lopresti type spike reduction and fixation of the posterior facet.

OUTCOME MEASUREMENTS

Clinical and radiographic analysis.

METHODS

Twenty-six consecutive patients with calcaneal fractures meeting the criteria had an attempted percutaneous reduction performed under fluoroscopic control with the patient in the lateral position. Twenty-three of the twenty-six feet had an acceptable reduction, and the remaining three were treated with open reduction and internal fixation (ORIF). The first seventeen cases were stabilized by two Steinmann pins, which were removed at ten to twelve weeks. The last six cases were fixed with two cannulated 6.5-millimeter screws, which were left in place. Early motion was encouraged in all cases

RESULTS

Of the twenty-three patients with an acceptable reduction, twenty had no angulation between the posterior facet of the talus and the calcaneus and three had <5 degrees. The tuberosity reduction was <5 degrees in seventeen cases and <10 degrees in all cases. The calcaneal height was restored to normal in twenty cases, and the width (axial view) averaged 119 percent of the contralateral side. Follow-up averaged 2.9 years. Using the Maryland foot score there were twelve (55 percent) excellent, seven (32 percent) good, and three (13 percent) fair results.

CONCLUSIONS

The Essex-Lopresti spike reduction is a useful method for the treatment of tongue-type Sanders type 2C fractures of the calcaneus. Results are superior to those in previous series of intraarticular fractures treated with ORIF.

Publication rates for the scientific sessions of the OTA. Orthopaedic Trauma Association

OBJECTIVES

To determine the publication rate of the scientific papers presented at the Orthopaedic Trauma Association (OTA) meetings from 1990 to 1995 inclusive.

DESIGN

A Medline search was performed on abstracts presented at the OTA sessions from 1990 through 1995 using both authors and key text words within the OTA abstract. The publication rate for each meeting, journal of publication, and time to publication were tabulated.

RESULTS

The publication rate for papers presented at the OTA meetings from 1990 through 1994 was 64 percent. This was significantly better than publication rates reported for American Academy of Orthopaedic Surgeons (AAOS) meetings in 1990 through 1992. The average time to publication was sixteen months. The most common journals in which papers derived from the OTA abstracts were published include the Journal of Orthopaedic Trauma (JOT), Journal of Bone and Joint Surgery combined volumes (JBJS). and Clinical Orthopaedics and Related Research (CORR).

CONCLUSION

OTA meetings are an excellent source of high-quality information, which is generally subsequently published in peer-reviewed journals. The Journal of Orthopaedic Trauma is the single best source for information presented at the OTA meetings. Allowing more papers to be presented did not affect the publication rate for the meetings.

Neurologic and vascular structures at risk during anterior-posterior locking of retrograde femoral nails

OBJECTIVE

To evaluate the neurovascular structures at risk with the placement of anterior-posterior locking screws in the proximal femur.

DESIGN

Cadaveric study.

MAIN OUTCOME MEASURE

Anatomic relationships.

RESULTS

The femoral artery lies medial to the femur, and its branches cross the anterior femur more than four centimeters distal to the lesser trochanter. Branches of the femoral nerve cross the anterior femur proximal to the lesser trochanter and start four centimeters distal to the piriformis fossa.

CONCLUSIONS

Risks to the neurovascular structures during anterior-posterior locking in the proximal femur are diminished if locking is performed above the level of the lesser trochanter.

Operative treatment of hip fractures in patients with renal failure

The conditions of a hip fracture and renal failure cause particularly high mortality. Eight patients (average age, 63 years) who had operative treatment for nine hip fractures were studied retrospectively. Three had intertrochanteric fractures fixed with sliding compression screws, and five had femoral neck fractures (bilateral in one patient): two nondisplaced femoral neck fractures were fixed with percutaneous screws, and four displaced femoral neck fractures were treated with arthroplasties in three and percutaneous screws in one. Operative treatment was done when the patient was in medically stable condition (average, 8 days). Full weightbearing was allowed on the injured limb after surgery. Early morbidity analysis showed no wound infections, thromboembolic events, or hemorrhagic complications. The first year mortality was three (38%). Late morbidity included one nonunion and one sliding screw penetration. Total mortality at 6 years was seven (88%) patients, with an average postoperative survival time of 28 months. Preoperative ambulation was preserved in five of seven (71%) patients. One the basis of this study, it appears that a team approach to operative management including nephrologist and surgeon helps to reduce short term complications and mortality and allows such patients to be mobilized and regain ambulation.

Use of an interlocked cephalomedullary nail for subtrochanteric fracture stabilization

Forty-five Russell-Taylor Type 1B subtrochanteric femoral fractures were stabilized using an interlocked cephalomedullary nail. The intraoperative complication rate was 13.5%; the most frequent complication was a varus malreduction. The union rate was 100% at an average of 13.5 weeks after surgery; there were no implant failures. Forty-three of 45 (96%) patients regained greater than 120 degrees knee motion. Based on these results it is thought that an interlocked cephalomedullary nail may be the implant of choice for stabilization of Russell-Taylor Type 1B fractures; however, its proper use requires careful intraoperative technique, with particular attention given to avoid a varus malreduction.

Intraarticular findings after gunshot wounds through the knee

OBJECTIVES

To compare the radiographic findings in patients with a low-velocity gunshot wound through the knee with the intraarticular pathology as documented by arthroscopy, and to evaluate arthroscopic management of these injuries.

STUDY DESIGN

Retrospective review of a protocol.

MATERIALS AND METHODS

Thirty-three patients with low-velocity gunshot wounds through the knee, no significant soft tissue injury, and no fracture requiring repair were studied. Radiographs were evaluated for bullet fragments, loose bodies, and debris. All patients were treated with arthroscopic evaluation and management of intraarticular pathology. The arthroscopic findings were compared with the radiographic findings.

RESULTS

Five chondral injuries and fourteen meniscal injuries not suspected on the basis of plain films were found during arthroscopic evaluation. Seven patients had no radiographic evidence of debris, loose bodies, or bullet or bone fragments in the joint. Five of these seven (71%) had debris and meniscal damage. Debridement of all loose bodies was possible using arthroscopy and occasional miniarthrotomy. No patient in the series had an infection.

CONCLUSIONS

Patients who sustain a low-velocity gunshot through the knee have soft tissue injuries not visible on plain radiographs in most cases, and therefore operative treatment is warranted. Arthroscopic management of these injuries appears to be a safe and effective method of treatment.

Damage control for devastating pelvic and extremity injuries

This article focuses on some general principles of care and then discusses devastating pelvic injury secondary to both blunt and penetrating trauma. The authors describe the current approach to the mangled extremity and discuss indications for primary amputation.

The risks of Kirschner wire placement in the distal radius: a comparison of techniques

A comparison of percutaneous and limited open insertion of Kirschner wires (K-wires) in the distal radius was conducted in an effort to determine which technique has the lower rate of iatrogenic injury. Eighty-eight K-wires were inserted in the distal radii of 44 fresh cadaveric arms: 44 at Lister's tubercle and 44 at the tip of the radial styloid. No incision was used for the percutaneous technique. The limited open technique included a 1.5-cm incision with blunt dissection and use of a soft tissue protector. To define the incidence of nerve or tendon damage secondary to pin placement, the cadaveric wrists were subsequently dissected under 3.5x loupe magnification. The distances from the K-wires to the branches of the superficial radial nerve and to the first 3 extensor compartments were recorded. Structures pierced or displaced by a K-wire were considered potentially injured. Chi-square analysis demonstrated a significantly higher rate of potentially injured nerves and tendons in the percutaneous group. Thus, to reduce the risk of potential injuries, limited open incision, blunt dissection down to bone, and the use of a soft tissue protector for K-wire placement into the distal radius is recommended.

Open fractures of the humerus treated with external fixation

Twenty-three patients with open fractures of the humerus who had been treated with immediate external fixation were reviewed retrospectively. Eighteen patients had adequate followup and were included in this study. Four patients (22%) had Gustilo and Anderson Grade I injury; 1 (5%), Grade II; and 13 (72%), Grade III (1 IIIA, 2 IIIB, and 10 IIIC). Fourteen patients (78%) had associated neurologic injury, of which 9 involved multiple nerves. A unilateral external fixation frame with half pins proximal and distal to the fracture site was used in all but 1 case. In 8 patients (44%) with distal humerus fractures, the external fixator crossed the elbow joint. All upper extremities in this series were salvaged. The duration of external fixation averaged 11 weeks. Complications included 3 malunions, 1 delayed union, 8 (44%) pin tract infections, 2 pin tract sequestrum formation, and 2 late fractures after removal of the external fixator. At followup (average, 34 months), function was rated as good or excellent in 12 patients (70%). There were 1 fair and 4 poor results. External fixation of complicated fractures of the humerus allowed associated injuries to the nerves, arteries, and soft tissues to be treated adequately while maintaining skeletal stability.

The treatment of femoral shaft fractures using intramedullary interlocked nails with and without intramedullary reaming: a preliminary report

OBJECTIVE

To compare operative and postoperative variables in the treatment of femur fractures using interlocked intramedullary nails with and without reaming.

DESIGN

Prospective and randomized.

METHODS

81 consecutive patients with femur fractures treated with a stainless steel statically locked intramedullary nail. Whether or not reaming was done was randomized. There were 42 nails placed without reaming and 39 placed with reaming. There were no demographic differences between the two groups. Intraoperative and postoperative variables were studied. Interval healing was assessed by one observer on bimonthly radiographs.

RESULTS

There were more intraoperative technical complications in the group without reaming. There was no statistical difference in operative time, transfusion requirement, or time to union between the groups. In the reamed group callus formation occurred faster and there was slightly more blood loss (247 cc vs. 396 cc) (p < 0.05). However, when distal fractures were analyzed separately, the time to union was faster in the reamed group (< 0.05). Two patients in the unreamed group and none in the reamed group developed delayed unions. Pulmonary complications occurred in two patients, one in each group and did not appear to be related to the nailing.

CONCLUSION

Reamed canal preparation led to faster healing of distal fractures treated with statically locked intramedullary nails. Blood loss was greater in the reamed group but this did not translate into increased transfusion requirements. In this series, there was no advantage to nail insertion without reaming.

Compartment pressures during nonreamed tibial nailing without traction

OBJECTIVE

To assess the intracompartmental pressure changes during the nailing of acute tibia fractures with the extrinsic factors of 90 degrees/90 degrees positioning, posterior thigh posts, continuous traction, and remaining removed.

STUDY DESIGN

Prospective case control.

METHODS

Fifty-eight acute tibia fractures were nailed using an unreamed technique without leg elevation, thigh post, or continuous traction. Two presented with compartment syndrome and had fasciotomy before nailing. Thirty of the remaining fifty-six tibias had continuous intracompartmental pressure monitoring of the anterior compartment.

RESULTS

The highest pressures were routinely seen during manual reduction of the fracture (20-58mms Hg; avg = 34mm Hg) and during nail passage (15-56mms Hg; avg = 26mms Hg). In fifteen tibias, the pressure rose to within 30mmg Hg of the diastolic pressure and in 12 tibias the pressure exceeded 40mmg Hg. The pressures in all cases returned to baseline immediately following nail passage (avg = 13.8mms Hg). No sequelae of compartment syndrome was found in any of the 56 tibias presenting without compartment syndrome. There were no iatrogenic compartment syndromes in the series.

CONCLUSION

When extrinsic factors that increase intramedullary pressures are avoided, then intramedullary nailing raises the intramedullary pressure only momentarily. The pressure peaks during manual reduction and nail passage, and then returns to normal before the patient is awakened. Intramedullary nailing performed without reaming or traction is safe with respect to compartment syndromes and continuous pressure is not required.

Angiographic findings in pelvic fractures

Pelvic fractures are high energy injuries indicative of significant trauma. Hypotension and significant blood loss is common in skeletally unstable pelvic fractures. Potential sites of intrapelvic bleeding include fractured bone edges, venous injuries and/or arterial vascular injuries. In an attempt to define the relationship of fracture pattern to arterial injury, a specific subset of 39 patients with pelvic fractures who underwent angiography for hemodynamic instability or ongoing blood loss were reviewed retrospectively. In 35 patients with definable arterial injuries, 20 (57%) had multiple bleeding sites. Posterior arterial bleeding (internal iliac or its posterior branches) was statistically more common in patients with unstable posterior pelvic fractures, and anterior arterial bleeding (pudendal or obturator) was more common in patients with lateral compression injuries. The pudendal artery was the most commonly injured vessel in this series. The superior gluteal artery was the most commonly injured vessel associated with posterior pelvic fractures. There was no correlation between fracture pattern and survival. The injury severity score however, did indirectly correlate to survival. In addition, the presence of hypotension (systolic blood pressure < or = 90) at the time of arrival to the trauma center was found to significantly increase mortality.

Radiologic evaluation of the pelvis

Careful radiographic assessment is essential in the diagnosis of pelvic fractures. The standard radiographic assessment of the pelvis includes the anteroposterior, inlet, outlet, Judet views, and axial computed tomography images. The different radiographic projections of the pelvis and their corresponding anatomic landmarks and the anatomy of the pelvis and the different anterior and posterior pelvic lesions are discussed. Description of the proper views and their uses are included.

Corona mortis. Incidence and location

Fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. The distance from the symphysis to the anastomotic vessels averaged 6.2 cm (range, 3-9 cm).

Outcome of operatively treated unstable posterior pelvic ring disruptions

Forty-six patients with 48 operatively fixed unstable posterior pelvic ring disruptions were observed for an average of 44 months. Two thirds of the patients returned to their original jobs and 16% changed jobs because of an associated injury. Sixty-three percent of the patients had no pain or pain only on strenuous activity and ambulated without limitation. However, 35% of the patients had significant neurologic injuries that compromised their final result. Properly performed open reduction and internal fixation of unstable posterior pelvic ring injuries may he expected to yield good functional results in the majority of patients. Associated injuries continue to be a major source of disability.

Internal fixation of unstable pelvic ring injuries

One hundred and seven unstable pelvic fractures were treated operatively. Reductions were graded by the maximal displacement measured on the 3 standard views of the pelvis. Criteria were: excellent 4 mm or less, good 5 to 10 mm, fair 10 to 20 mm, and poor more than 20 mm. Overall there were 72 excellent, 30 good, 4 fair, and 1 poor reduction. Ninety-five percent of all reductions were excellent or good. Open reduction and internal fixation within 21 days were associated with a higher percentage of excellent reductions than in reductions performed after 21 days (70% versus 55%). These differences were not statistically significant, however. Complications were infrequent using the techniques described.

Outcome of rotationally unstable pelvic ring injuries treated operatively

Twenty-nine patients with unstable rotational injuries treated operatively were observed for an average of 39 months. There were 24 associated orthopaedic injuries. Twenty-seven patients had symphysis disruption (4 with rami fractures) and 2 had rami fractures associated with an acetabular fracture. Followup evaluation of those who could be evaluated in each category revealed that 96% had no pain or pain only on strenuous activity, ambulated without assistance or limitations, and returned to work. Open reduction and internal fixation of rotationally unstable pelvic fractures results in a high functional success rate.

Semiextended position of intramedullary nailing of the proximal tibia

Over a 24 month period, 30 patients with proximal tibia fractures who were reviewed consecutively were treated by nonreamed, statically locked, intramedullary nailing. There were 16 open, 13 segmental, and 7 comminuted fractures (Winquist III, IV). The average distance from the fracture to the proximal locking screws was 24 mm (range, 0-65 mm). All procedures were performed while the patient's affected leg was on a radiolucent table without traction. The last 25 fractures were nailed using a partial (2/3) medial parapatellar incision while the leg was semiextended. This approach allowed the patella to be subluxed laterally availing the trochlear groove for use as a conduit for nail placement. Using only 15 degrees knee flexion eliminated the extension force of the quadriceps on the proximal fragment, which otherwise would have tended to cause anterior angulation at the fracture site. In the first 5 patients, the average anterior angulation was 8 degrees (range, 5 degrees-15 degrees). Of the 25 patients who were treated while in the semiextended position, none had more than 5 degrees anterior angulation and 19 had no anterior angulation. Fractures of 3 of the 25 patients had greater than 5 degrees angulation in the coronal plane, 2 of which were nailed in the semiextended position. This technique greatly facilitates intramedullary nailing of proximal tibia fractures.