New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures

STUDY DESIGN

Literature review.

OBJECTIVES

To describe new treatments for painful osteoporotic compression fractures in light of available scientific literature and clinical experience.

SUMMARY OF BACKGROUND DATA

Painful vertebral osteoporotic compression fractures lead to significant morbidity and mortality. This relates to pulmonary dysfunction, eating disorders (nutritional deficits), pain, loss of independence, and mental status change (related to pain and medications). Medications to treat osteoporosis (primarily antiresorptive) do not effectively treat the pain or the fracture, and require over 1 year to reduce the degree of osteoporosis. Kyphoplasty and vertebroplasty are new techniques that help decrease the pain and improve function in fractured vertebrae.

METHODS

This is a descriptive review of the background leading to vertebroplasty and kyphoplasty, a description of the techniques, a review of the literature, as well as current ongoing studies evaluating kyphoplasty.

RESULTS

Both techniques have had a very high acceptance and use rate. There is 95% improvement in pain and significant improvement in function following treatment by either of these percutaneous techniques. Kyphoplasty improves height of the fractured vertebra, and improves kyphosis by over 50%, if performed within 3 months from the onset of the fracture (onset of pain). There is some height improvement, though not as marked, along with 95% clinical improvement, if the procedure is performed after 3 months. Complications occur with both and relate to cement leakage in both, and cement emboli with vertebroplasty.

CONCLUSION

Kyphoplasty and vertebroplasty are safe and effective, and have a useful role in the treatment of painful osteoporotic vertebral compression fractures that do not respond to conventional treatments. Kyphoplasty offers the additional advantage of realigning the spinal column and regaining height of the fractured vertebra, which may help decrease the pulmonary, GI, and early morbidity consequences related to these fractures. Both procedures are technically demanding.

Initial outcome and efficacy of "kyphoplasty" in the treatment of painful osteoporotic vertebral compression fractures

STUDY DESIGN

An Institutional Review Board-approved Phase I efficacy study of inflatable bone tamp usage in the treatment of symptomatic osteoporotic compression fractures.

OBJECTIVES

To evaluate the safety and efficacy of inflatable bone tamp reduction and cement augmentation, "kyphoplasty," in the treatment of painful osteoporotic vertebral compression fractures.

SUMMARY OF BACKGROUND DATA

Osteoporotic compression fractures can result in progressive kyphosis and chronic pain. Traditional treatment for these patients includes bed rest, analgesics, and bracing. Augmentation of vertebral compression fractures with polymethylmethacrylate, "vertebroplasty," has been used to treat pain. This technique, however, makes no attempt to restore the height of the collapsed vertebral body. Kyphoplasty is a new technique that involves the introduction of inflatable bone tamps into the vertebral body. Once inflated, the bone tamps restore the vertebral body back toward its original height while creating a cavity that can be filled with bone cement.

PATIENTS AND METHODS

Seventy consecutive kyphoplasty procedures were performed in 30 patients. The indications included painful primary or secondary osteoporotic vertebral compression fractures. Mean duration of symptoms was 5.9 months. Symptomatic levels were identified by correlating the clinical data with MRI findings. Perioperative variables and bone tamp complications or issues were recorded and analyzed. Preoperative and postoperative radiographs were compared to calculate the percentage height restored. Outcome data were obtained by comparing preoperative and latest postoperative SF-36 data.

RESULTS

At the completion of the Phase I study there were no major complications related directly to use of this technique or use of the inflatable bone tamp. In 70% of the vertebral bodies kyphoplasty restored 47% of the lost height. Cement leakage occurred at six levels (8.6%).SF-36 scores for Bodily Pain 11.6-58.7, (P = 0.0001) and Physical Function 11.7-47.4, (P = 0.002) were among those that showed significant improvement.

CONCLUSIONS

The inflatable bone tamp was efficacious in the treatment of osteoporotic vertebral compression fractures. Kyphoplasty is associated with early clinical improvement of pain and function as well as restoration of vertebral body height in the treatment of painful osteoporotic compression fractures.

Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology

The advent of 'biological internal fixation' is an important development in the surgical management of fractures. Locked nailing has demonstrated that flexible fixation without precise reduction results in reliable healing. While external fixators are mainly used today to provide temporary fixation in fractures after severe injury, the internal fixator offers flexible fixation, maintaining the advantages of the external fixator but allowing long-term treatment. The internal fixator resembles a plate but functions differently. It is based on pure splinting rather than compression. The resulting flexible stabilisation induces the formation of callus. With the use of locked threaded bolts, the application of the internal fixator foregoes the need of adaptation of the shape of the splint to that of the bone during surgery. Thus, it is possible to apply the internal fixator as a minimally invasive percutaneous osteosynthesis (MIPO). Minimal surgical trauma and flexible fixation allow prompt healing when the blood supply to bone is maintained or can be restored early. The scientific basis of the fixation and function of these new implants has been reviewed. The biomechanical aspects principally address the degree of instability which may be tolerated by fracture healing under different biological conditions. Fractures may heal spontaneously in spite of gross instability while minimal, even non-visible, instability may be deleterious for rigidly fixed small fracture gaps. The theory of strain offers an explanation for the maximum instability which will be tolerated and the minimal degree required for induction of callus formation. The biological aspects of damage to the blood supply, necrosis and temporary porosity explain the importance of avoiding extensive contact of the implant with bone. The phenomenon of bone loss and stress protection has a biological rather than a mechanical explanation. The same mechanism of necrosis-induced internal remodelling may explain the basic process of direct healing.

Management of the fractured scaphoid using a new bone screw

A new and simple operative technique has been developed to provide rigid internal fixation for all types of fractures of the scaphoid. This involves the use of a double-threaded bone screw which provides such good fixation that, after operation, a plaster cast is rarely required and most patients are able to return to work within a few weeks. A classification of scaphoid fractures is proposed. The indications for operation included not only acute unstable fractures, but also fractures with delayed healing and those with established non-union; screw fixation was combined with bone grafting to treat non-union. In a prospective trial, 158 operations using this technique were carried out between 1977 and 1981. The rate of union was 100 per cent for acute fractures and 83 per cent overall. This method of treatment appears to offer significant advantages over conventional techniques in the management of the fractured scaphoid.

Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial

BACKGROUND

Open reduction and internal fixation is the treatment of choice for displaced intra-articular calcaneal fractures at many orthopaedic trauma centers. The purpose of this study was to determine whether open reduction and internal fixation of displaced intra-articular calcaneal fractures results in better general and disease-specific health outcomes at two years after the injury compared with those after nonoperative management.

METHODS

Patients at four trauma centers were randomized to operative or nonoperative care. A standard protocol, involving a lateral approach and rigid internal fixation, was used for operative care. Nonoperative treatment involved no attempt at closed reduction, and the patients were treated only with ice, elevation, and rest. All fractures were classified, and the quality of the reduction was measured. Validated outcome measures included the Short Form-36 (SF-36, a general health survey) and a visual analog scale (a disease-specific scale).

RESULTS

Between April 1991 and December 1997, 512 patients with a calcaneal fracture were treated. Of those patients, 424 with 471 displaced intra-articular calcaneal fractures were enrolled in the study. Three hundred and nine patients (73%) were followed and assessed for a minimum of two years and a maximum of eight years of follow-up. The outcomes after nonoperative treatment were not found to be different from those after operative treatment; the score on the SF-36 was 64.7 and 68.7, respectively (p = 0.13), and the score on the visual analog scale was 64.3 and 68.6, respectively (p = 0.12). However, the patients who were not receiving Workers' Compensation and were managed operatively had significantly higher satisfaction scores (p = 0.001). Women who were managed operatively scored significantly higher on the SF-36 than did women who were managed nonoperatively (p = 0.015). Patients who were not receiving Workers' Compensation and were younger (less than twenty-nine years old), had a moderately lower Böhler angle (0 degrees to 14 degrees ), a comminuted fracture, a light workload, or an anatomic reduction or a step-off of < or =2 mm after surgical reduction (p = 0.04) scored significantly higher on the scoring scales after surgery compared with those who were treated nonoperatively.

CONCLUSIONS

Without stratification of the groups, the functional results after nonoperative care of displaced intra-articular calcaneal fractures were equivalent to those after operative care. However, after unmasking the data by removal of the patients who were receiving Workers' Compensation, the outcomes were significantly better in some groups of surgically treated patients.

Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology

The advent of 'biological internal fixation' is an important development in the surgical management of fractures. Locked nailing has demonstrated that flexible fixation without precise reduction results in reliable healing. While external fixators are mainly used today to provide temporary fixation in fractures after severe injury, the internal fixator offers flexible fixation, maintaining the advantages of the external fixator but allowing long-term treatment. The internal fixator resembles a plate but functions differently. It is based on pure splinting rather than compression. The resulting flexible stabilisation induces the formation of callus. With the use of locked threaded bolts, the application of the internal fixator foregoes the need of adaptation of the shape of the splint to that of the bone during surgery. Thus, it is possible to apply the internal fixator as a minimally invasive percutaneous osteosynthesis (MIPO). Minimal surgical trauma and flexible fixation allow prompt healing when the blood supply to bone is maintained or can be restored early. The scientific basis of the fixation and function of these new implants has been reviewed. The biomechanical aspects principally address the degree of instability which may be tolerated by fracture healing under different biological conditions. Fractures may heal spontaneously in spite of gross instability while minimal, even non-visible, instability may be deleterious for rigidly fixed small fracture gaps. The theory of strain offers an explanation for the maximum instability which will be tolerated and the minimal degree required for induction of callus formation. The biological aspects of damage to the blood supply, necrosis and temporary porosity explain the importance of avoiding extensive contact of the implant with bone. The phenomenon of bone loss and stress protection has a biological rather than a mechanical explanation. The same mechanism of necrosis-induced internal remodelling may explain the basic process of direct healing.

Foreign-body reactions to fracture fixation implants of biodegradable synthetic polymers

Biodegradable rods of polyglycolide or lactide-glycolide copolymer were used in the internal fixation of a variety of fractures and osteotomies in 516 patients. A clinically manifest foreign-body reaction occurred in 41 patients (7.9%), producing a fluctuant swelling at the implantation site after an average of 12 weeks. Spontaneous sinus formation or surgical drainage yielded a sterile exudate containing liquid remnants of the degrading implants. After prompt drainage this discharge subsided within three weeks. Histological examination showed a typical nonspecific foreign-body reaction with abundant giant cells both in patients with the reaction and in some patients with an uneventful clinical course. The factors determining the nature of the reaction were probably related to the local capacity of the tissues to clear the polymeric debris. The reactions did not influence the clinical or radiographic results, but recognition of the incidence and the features of the reaction is necessary in view of the increasing use of such implants.

Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report

Using a volar approach to avoid the soft tissue problems associated with dorsal plating, we treated a consecutive series of 29 patients with 31 dorsally displaced, unstable distal radial fractures with a new fixed-angle internal fixation device. At a minimal follow-up time of 12 months the fractures had healed with highly satisfactory radiographic and functional results. The final volar tilt averaged 5 degrees; radial inclination, 21 degrees; radial shortening, 1 mm; and articular incongruity, 0 mm. Wrist motion at final follow-up examination averaged 59 degrees extension, 57 degrees flexion, 27 degrees ulnar deviation, 17 degrees radial deviation, 80 degrees pronation, and 78 degrees supination. Grip strength was 79% of the contralateral side. The overall outcome according to the Gartland and Werley scales showed 19 excellent and 12 good results. Our experience indicates that most dorsally displaced distal radius fractures can be anatomically reduced and fixed through a volar approach. The combination of stable internal fixation with the preservation of the dorsal soft tissues resulted in rapid fracture healing, reduced need for bone grafting, and low incidence of tendon problems in our study.

The biomechanics of vertebroplasty. The effect of cement volume on mechanical behavior

STUDY DESIGN

Ex vivo biomechanical study using osteoporotic cadaveric vertebral bodies.

OBJECTIVE

To determine the association between the volume of cement injected during percutaneous vertebroplasty and the restoration of strength and stiffness in osteoporotic vertebral bodies, two investigational cements were studied: Orthocomp (Orthovita, Malvern, PA) and Simplex 20 (Simplex P with 20% by weight barium sulfate content; Stryker-Howmedica-Osteonics, Rutherford, NJ).

SUMMARY OF BACKGROUND DATA

Previous biomechanical studies have shown that injections of 8-10 mL of cement during vertebroplasty restore or increase vertebral body strength and stiffness; however, the dose-response association between cement volume and restoration of strength and stiffness is unknown.

METHODS

Compression fractures were experimentally created in 144 vertebral bodies (T6-L5) obtained from 12 osteoporotic spines harvested from female cadavers. After initial strength and stiffness were determined, the vertebral bodies were stabilized using bipedicular injections of cement totaling 2, 4, 6, or 8 mL and recompressed, after which post-treatment strength and stiffness were measured. Strength and stiffness were considered restored when post-treatment values were not significantly different from initial values.

RESULTS

Strength was restored for all regions when 2 mL of either cement was injected. To restore stiffness with Orthocomp, the thoracic and thoracolumbar regions required 4 mL, but the lumbar region required 6 mL. To restore stiffness with Simplex 20, the thoracic and lumbar regions required 4 mL, but the thoracolumbar region required 8 mL.

CONCLUSION

These data provide guidance on the cement volumes needed to restore biomechanical integrity to compressed osteoporotic vertebral bodies.

Guidelines for the clinical application of the LCP

The Locking Compression Plate (LCP), in combination with the LISS and the PHILOS, is part of a new plate generation requiring an adapted surgical technique and new thinking about commonly used concepts of internal fixation using plates. The following guidelines are needed to avoid failures and possible complications in the hands of surgeons not yet confident with the new implant philosophy. The importance of the reduction technique and minimal-invasive plate insertion and fixation is addressed to keep bone viability undisturbed. Understanding of mechanical background for choosing the proper implant length and the type and number of screws is essential to obtain a sound fixation with a high plate span ratio and a low plate screw density. A high plate span ration decreases the load onto the plate. A high working length of the plate in turn reduces the screw loading, thus fewer screws need to be inserted and the plate screw density can be kept low. Knowledge of the working length of the screw is helpful for the proper choice of monocortical or bicortical screws. Selection is done according to the quality of the bone structure and is important to avoid problems at the screw thread bone interface with potential pullout of screws and secondary displacement. Conclusive rules are given at the end of this chapter.

A staged protocol for soft tissue management in the treatment of complex pilon fractures

OBJECTIVE

To determine whether open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol results in minimal surgical wound complications.

DESIGN

Retrospective.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Between January 1991 and December 1996, 226 pilon fractures (AO types 43A-C) were treated, of which 108 were AO type 43C. Fifty-six fractures were included in a retrospective analysis of a treatment protocol. Injuries were divided into Group I, thirty-four closed fractures, and Group II, twenty-two open fractures (three Gustilo Type 1, six Type II, eight Type IIIA, and five Type IIIB).

METHODS

The protocol consisted of immediate (within twenty-four hours) open reduction and internal fixation of the fibula when fractured, using a one-third tubular or 3.5-millimeter dynamic compression plate and application of an external fixator spanning the ankle joint. Patients with isolated injuries were discharged after initial stabilization and readmitted for the definitive reconstruction. Polytrauma patients remained hospitalized and were observed. Formal open reconstruction of the articular surface by plating was performed when soft tissue swelling had subsided. Complications were defined as wound problems requiring hospitalization. All affected limbs were then evaluated via chart and radiograph review, patient interviews, and physical examination until surgical wound healing was complete, for a minimum of twelve months.

RESULTS

Group 1 (closed pilon): Follow-up was possible in twenty-nine out of thirty fractures (97 percent). Average time from external fixation to open reduction was 12.7 days. All wounds healed. None exhibited wound dehiscence or full-thickness tissue necrosis requiring secondary soft tissue coverage postoperatively. Seventeen percent (five out of twenty-nine patients) had partial-thickness skin necrosis. All were treated with local wound care and oral antibiotics and healed uneventfully. There was one late complication (3.4 percent), a chronic draining sinus secondary to osteomyelitis, which resolved after fracture healing and metal removal. Group II (open pilon): Follow-up was possible in seventeen patients with nineteen fractures (86 percent). Average time from external fixation to formal reconstruction was fourteen days (range 4 to 31 days). By definition, all Gustilo Type IIIB fractures required flap coverage for the injury. Two patients experienced partial-thickness wound necrosis. These were treated with local wound care and antibiotics. All surgical wounds healed. There were two complications (10.5 percent), both deep infections. One Type I open fracture developed wound dehiscence and osteomyelitis requiring multiple debridements, intravenous antibiotics, subsequent removal of hardware, and re-application of an external fixator to cure the infection. One Type IIIA open fracture of the distal tibia and calcaneus developed osteomyelitis and required a below-knee amputation.

CONCLUSION

Based on our data, it appears that the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotation flaps, or free tissue transfers in our series. This technique appears to be effective in closed and open fractures alike.

Effects of bone cement volume and distribution on vertebral stiffness after vertebroplasty

STUDY DESIGN

The biomechanical behavior of a single lumbar vertebral body after various surgical treatments with acrylic vertebroplasty was parametrically studied using finite-element analysis.

OBJECTIVES

To provide a theoretical framework for understanding and optimizing the biomechanics of vertebroplasty. Specifically, to investigate the effects of volume and distribution of bone cement on stiffness recovery of the vertebral body.

SUMMARY OF BACKGROUND DATA

Vertebroplasty is a treatment that stabilizes a fractured vertebra by addition of bone cement. However, there is currently no information available on the optimal volume and distribution of the filler material in terms of stiffness recovery of the damaged vertebral body.

METHODS

An experimentally calibrated, anatomically accurate finite-element model of an elderly L1 vertebral body was developed. Damage was simulated in each element based on empirical measurements in response to a uniform compressive load. After virtual vertebroplasty (bone cement filling range of 1-7 cm3) on the damaged model, the resulting compressive stiffness of the vertebral body was computed for various spatial distributions of the filling material and different loading conditions.

RESULTS

Vertebral stiffness recovery after vertebroplasty was strongly influenced by the volume fraction of the implanted cement. Only a small amount of bone cement (14% fill or 3.5 cm3) was necessary to restore stiffness of the damaged vertebral body to the predamaged value. Use of a 30% fill increased stiffness by more than 50% compared with the predamaged value. Whereas the unipedicular distributions exhibited a comparative stiffness to the bipedicular or posterolateral cases, it showed a medial-lateral bending motion ("toggle") toward the untreated side when a uniform compressive pressure load was applied.

CONCLUSION

Only a small amount of bone cement ( approximately 15% volume fraction) is needed to restore stiffness to predamage levels, and greater filling can result in substantial increase in stiffness well beyond the intact level. Such overfilling also renders the system more sensitive to the placement of the cement because asymmetric distributions with large fills can promote single-sided load transfer and thus toggle. These results suggest that large fill volumes may not be the most biomechanically optimal configuration, and an improvement might be achieved by use of lower cement volume with symmetric placement.

Responsiveness of the short form-36, disability of the arm, shoulder, and hand questionnaire, patient-rated wrist evaluation, and physical impairment measurements in evaluating recovery after a distal radius fracture

We evaluated the responsiveness of patient questionnaires and physical testing in the assessment of recovery after distal radius fracture. Patients (n = 59) were assessed at their baseline clinic visit and again 3 and 6 months after injury. At each visit patients completed a short form-36, Disability of the Arm, Shoulder, and Hand questionnaire, and patient-rated wrist evaluation (PRWE). At 3 and 6 months grip strength, range of motion, and dexterity were analyzed. Standardized response means (SRM) and effects sizes were calculated to indicate responsiveness. The PRWE was the most responsive. Both the PRWE (SRM = 2.27) and the Disability of the Arm, Shoulder, and Hand (SRM = 2.01) questionnaire were more responsive than the short form-36 (SRM = 0.92). The physical component summary score of the short form-36 was similar to that of the physical component subscales. Questionnaires were highly responsive during the 0- to 3-month time period when physical testing could not be performed. Of the physical tests, grip strength was most responsive, followed by range of motion. Responsive patient-rating scales and physical performance evaluations can assist with outcome evaluation of patients with distal radius fracture.

Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient

PURPOSE

Increased incidence of falls and osteoporosis combine to make distal radius fractures a major cause of morbidity for the elderly patient. This report presents our experience treating distal radius fractures in the elderly population using a volar fixed-angle internal fixation plate.

METHODS

We reviewed retrospectively all patients older than 75 years treated during a period of 4 years and 7 months at our centers for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, and a wrist splint used for an average of 3 weeks. Standard radiographic fracture parameters were measured and final functional results where assessed by measuring finger motion, wrist motion, and grip strength.

RESULTS

Of 26 patients that fit the inclusion criteria, we were able to evaluate 23 patients with 24 unstable distal radius fractures for an average of 63 weeks. Final volar tilt averaged 6 degrees and radial tilt 20 degrees, and radial shortening averaged less than 1 mm. The average final dorsiflexion was 58 degrees, volar flexion 55 degrees, pronation 80 degrees, and supination 76 degrees. Grip strength was 77% of the contralateral side. There were no plate failures or significant loss of reduction, although there was settling of the distal fragment in 3 patients (1-3 mm).

CONCLUSIONS

The treatment of unstable distal radius fractures in the elderly patient with a volar fixed-angle plate provided stable internal fixation and allowed early function. This technique minimized morbidity in the elderly population by successfully handling osteopenic bone, allowed early return to function, provided good final results, and was associated with a low complication rate.

Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation

Odontoid fractures, especially unstable type II fractures have a poor prognosis in respect to healing. Therefore, operative stabilization (posterior fusion C1/2 or anterior screw fixation) has been suggested for the treatment of unstable type II and for some unstable type III fractures. Compared to posterior fusion C1/2, anterior screw fixation has proven to be effective; it has the advantage of leaving the motion segment C1/2 intact, therefore preserving at least some C1/2 rotation. However, in some instances, this method of stabilization is not indicated. In these cases, posterior fusion C1/2 is the treatment of choice. Primary posterior fusion C1/2 is indicated in (a) odontoid fracture associated with comminution of one or both atlanto-axial joints; (b) fracture of the odontoid associated with an unstable Jefferson fracture; (c) unstable type III odontoid fracture, when immobilization in a halo jacket or plaster cast is not suitable, as in elderly people or polytraumatized patients; (d) atypical type II fractures (comminuted or with oblique fracture in the frontal plane); (e) irreducible fracture dislocation C1/2, e.g., several-weeks-old fracture; (f) unstable type II or shallow and unstable type III odontoid fracture, when marked thoracic kyphosis is associated with limited extension of the cervical spine; (g) unstable type II or shallow type III odontoid fracture in elderly people with degenerative narrow spinal canal; (h) pathologic fracture of the odontoid. In all these instances, posterior fusion C1/2 is the treatment of choice. We prefer the transarticular screw fixation technique. Compared to other posterior fusion techniques, it has the advantage of increased stability and allows effective stabilization of C1/2 in a reduced position as well as immediate ambulation with minimal head support. This technique can also be performed when the posterior arch of the atlas is fractured or absent. Our experience of 12 acute odontoid fractures, managed by this technique, is presented. At follow-up, all C1/2 fusions were united in reduced position.

Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius

PURPOSE

Despite the recent popularity of volar plating for dorsally displaced distal radius fractures there is a paucity of data documenting the results of this treatment method. The purpose of this study was to determine the functional outcome of patients treated with volar fixed-angle plating for dorsally displaced, unstable distal radius fractures.

METHODS

We reviewed the records of all patients treated at our institution with internal fixation using volar plates for dorsally displaced, comminuted distal radius fractures. Patients with follow-up periods shorter than 12 months were excluded from the study. Outcomes were evaluated at the latest follow-up examination with the Disabilities of the Arm, Shoulder, and Hand and the Gartland and Werley scoring systems.

RESULTS

We studied 41 patients with a mean age of 53 years. The average follow-up period was 17 months. All fractures were stabilized with volar locking plates. Radiographs in the immediate postoperative period showed a mean radial height of 11 mm, mean radial inclination of 21 degrees , and mean volar tilt of 4 degrees. At fracture healing the mean radial height was 11 mm, mean radial inclination was 21 degrees, and mean volar tilt was 5 degrees. The average score on the Disabilities of the Arm, Shoulder, and Hand questionnaire was 14 and all patients achieved excellent and good results on the Gartland and Werley scoring system, indicating minimal impairment in activities of daily living. Nine patients experienced postoperative complications. There were 4 instances of loss of reduction with fracture collapse, 3 patients required hardware removal for tendon irritation, 1 patient developed a wound dehiscence, and 1 patient had metacarpophalangeal joint stiffness.

CONCLUSIONS

Patients with unstable, dorsally displaced fractures of the distal radius treated with volar fixed-angle devices have good or excellent functional outcomes despite a high complication rate. When compared with previous reports on dorsal plating volar plates appear to have a higher incidence of fracture collapse but a lower rate of hardware-related complications. Complex fracture patterns thus mandate a careful and individualized approach.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level III.

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.

Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique

OBJECTIVES

Single incision open reduction and double plate fixation of complex tibial plateau fractures has been associated with high wound complication rates. Minimally invasive methods have been recommended to decrease the wound complication rates as compared with open techniques. Additionally, laterally applied fixed-angle devices appear to minimize late varus deformity without the need for additional medial stabilization. Accurate reduction of comminuted lateral and/or medial articular surfaces, however, often requires visualization through an open reduction. This study reports the complications, infection rate, and radiographic assessment of reduction associated with double plating complex AO/OTA 41-C3 tibial plateau fractures utilizing 2 incisions.

DESIGN

Retrospective clinical review.

SETTING

Urban level 1 university trauma center.

PATIENTS

Over a 77-month period, 83 patients were treated for a complex bicondylar tibial plateau fracture at our institution utilizing a 2-incision technique.

INTERVENTION

Dual plating using anterolateral and posteromedial incisions.

MAIN OUTCOME MEASURE

Type and incidence of septic and non-septic complications and radiographic assessment of articular reduction and axial alignment.

RESULTS

Eleven fractures were open (13.3%) and classified according to Gustilo as type II (1 patient), type III-A (7 patients), type III-B (2 patients), and type III-C (1 patient). Compartment syndrome was diagnosed and treated with fasciotomies in 12 patients (14.5%). The average time interval from injury to definitive surgical treatment was 9 days. Seven patients developed deep wound infections (8.4%). Three of these had an associated septic arthritis (3.6%). Clinical resolution of infection occurred after an average of 3.3 additional procedures. The presence of a dysvascular limb requiring vascular reconstruction was statistically associated with a deep wound infection (P = 0.006). Secondary procedures for complications included 13 patients who required removal of implants secondary to local discomfort, 5 patients who required a knee manipulation, 2 patients that were managed with excision of heterotopic ossification to improve knee motion, 1 patient that required an equinus contracture release, and 1 patient treated for a metadiaphyseal nonunion. Sixteen patients (19.3%) incurred deep venous thromboses. No patient was diagnosed with pulmonary embolism. Sixty-two percent of patients demonstrated satisfactory articular reductions, 91% demonstrated satisfactory coronal alignment, 72% demonstrated satisfactory sagittal alignment, and 98% demonstrated satisfactory condylar width.

CONCLUSIONS

Comminuted bicondylar tibial plateau fractures can be successfully treated with open reduction and medial and lateral plate fixation using 2 incisions. Dysvascular limbs requiring vascular repair are at increased risk for deep sepsis. The use of 2 incisions, temporary spanning external fixation, and proper soft-tissue handling may contribute to a lower wound complication rate than previously reported.

Operative management of displaced femoral neck fractures in elderly patients. An international survey

BACKGROUND

Hip fractures occur in 280,000 North Americans each year. Although surgeons have reached consensus with regard to the treatment of undisplaced fractures of the hip, the surgical treatment of displaced fractures remains controversial. Identifying surgeons' preferences in techniques, and the rationale for their choices, may aid in focusing educational activities to the orthopaedic community as well as planning future clinical trials. Our objective was to clarify current opinion with regard to the operative treatment of displaced fractures of the femoral neck.

METHODS

We used a cross-sectional survey design and a sample-to-redundancy strategy to examine surgeons' preferences in the treatment of displaced femoral neck fractures. We mailed this survey to members of the Orthopaedic Trauma Association and European-AO International-affiliated trauma centers.

RESULTS

Of 442 surgeons who received the questionnaire, 298 (67%) responded. The typical respondent was a North American man over the age of forty years who was in academic practice, supervised residents, had fellowship training in trauma, and worked in a low-volume center (<100 hip fractures per year), treating an equal proportion of displaced and undisplaced femoral neck fractures. Most surgeons believed that internal fixation was the procedure of choice in younger patients (those who are less than sixty years old) with a displaced fracture (Garden type III or IV). For patients over eighty years old with Garden type-III or IV fractures, almost all surgeons preferred arthroplasty. Respondents varied widely in their preferences for the treatment of patients who were sixty to eighty years old with a displaced fracture (Garden type III or IV) or active patients with a Garden type-III fracture. Many surgeons believed there was no difference between arthroplasty and internal fixation when considering mortality (45%), infection rates (30%), and quality of life (37%). Surgeons also revealed variable preferences in their choice of the optimal approach to arthroplasty for patients between sixty and eighty years old with a type-IV fracture (32% preferred unipolar; 41%, bipolar; and 17%, total hip arthroplasty) and in the optimal choice of implant for internal fixation.

CONCLUSIONS

While surgeons prefer internal fixation for younger patients and arthroplasty for older patients, they disagree about the optimal approach to the management of patients between sixty and eighty years old with a displaced fracture and active patients with a Garden type-III fracture. Surgeons also disagree on the optimal implants for internal fixation or arthroplasty.

Open reduction and internal fixation of fractures of the radial head

BACKGROUND

The purpose of this retrospective study was to analyze the functional results following open reduction and internal fixation of fractures of the radial head and to determine which fracture patterns are most amenable to this treatment.

METHODS

Fifty-six patients in whom an intra-articular fracture of the radial head had been treated with open reduction and internal fixation were evaluated at an average of forty-eight months after injury. Thirty patients had a Mason Type-2 (partial articular) fracture, and twenty-six had a Mason Type-3 (complete articular) fracture. Twenty-seven of the fifty-six fractures were associated with a fracture-dislocation of the forearm or elbow or an injury of the medial collateral ligament. Fifteen of the thirty Type-2 fractures were comminuted. Fourteen of the twenty-six Type-3 fractures consisted of more than three fragments, and twelve consisted of two or three fragments. The result at the final evaluation was judged to be unsatisfactory when there was early failure of fixation or nonunion requiring a second operation to excise the radial head, <100 degrees of forearm rotation, or a fair or poor rating according to the system of Broberg and Morrey.

RESULTS

The result was unsatisfactory for four of the fifteen patients with a comminuted Mason Type-2 fracture of the radial head; all four fractures had been associated with a fracture-dislocation of the forearm or elbow, and all four patients recovered <100 degrees of forearm rotation. Thirteen of the fourteen patients with a Mason Type-3 comminuted fracture with more than three articular fragments had an unsatisfactory result. In contrast, all fifteen patients with an isolated, noncomminuted Type-2 fracture had a satisfactory result. Of the twelve patients with a Type-3 fracture that split the radial head into two or three simple fragments, none had early failure, one had nonunion, and all had an arc of forearm rotation of > or =100 degrees.

CONCLUSIONS

Although current implants and techniques for internal fixation of small articular fractures have made it possible to repair most fractures of the radial head, our data suggest that open reduction and internal fixation is best reserved for minimally comminuted fractures with three or fewer articular fragments. Associated fracture-dislocation of the elbow or forearm may also compromise the long-term result of radial head repair, especially with regard to restoration of forearm rotation.

A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly

PURPOSE

As the population in developed countries continues to age, the incidence of osteoporotic distal radius fractures (DRFs) will increase as well. Treatment of DRF in the elderly population is controversial. We systematically reviewed the existing literature for the management of DRFs in patients aged 60 and over with 5 common techniques: the volar locking plate system, nonbridging external fixation, bridging external fixation, percutaneous Kirschner wire fixation, and cast immobilization (CI).

METHODS

We reviewed articles retrieved from MEDLINE, Embase, and CINAHL Plus that met predetermined inclusion and exclusion criteria in 2 literature reviews. Outcomes of interest included wrist arc of motion, grip strength, functional outcome measurements, radiographic parameters, and the number and type of complications. We statistically analyzed the data using weighted means and proportions based on the sample size in each study.

RESULTS

We identified 2,039 papers and selected 21 papers fitting the inclusion criteria in the primary review of articles with a mean patient age of 60 and older. Statistically significant differences were detected for wrist arc of motion, grip strength, and Disabilities of the Arm, Shoulder, and Hand score, although these findings may not be clinically meaningful. Volar tilt and ulnar variance revealed significant differences among groups, with CI resulting in the worst radiographic outcomes. The complications were significantly different, with CI having the lowest rate of complications, whereas the volar locking plate system had significantly more major complications requiring additional surgical intervention.

CONCLUSIONS

This systematic review suggests that despite worse radiographic outcomes associated with CI, functional outcomes were no different from those of surgically treated groups for patients age 60 and over. Prospective comparative outcomes studies are necessary to evaluate the rate of functional recovery, cost, and outcomes associated with these 5 treatment methods.

Intertrochanteric femoral fractures. Mechanical failure after internal fixation

In a prospective study we assessed the causes of mechanical failure in a series of 230 intertrochanteric femoral fractures which had been internally fixed with either a sliding hip screw or a Küntscher Y-nail. The overall rate of mechanical failure was 16.5%; cutting-out of the implant from the femoral head was the cause in three-quarters of the instances. Implants placed posteriorly in the femoral head cut out more often (27%) than those placed centrally (7%). The cut-out rate was also determined by the quality of the fracture reduction, but age, walking ability and bone density (assessed by the Singh grade and metacarpal indices) had no significant influence. We conclude that these fractures should be reduced as accurately as possible and it is imperative that the implant is placed centrally within the femoral head.

Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures

OBJECTIVES

The purpose of the present study was to discover any associations between preoperative variables and the occurrence of wound complications in the surgical treatment of calcaneus fractures.

DESIGN

Retrospective review.

SETTING

A Level 1 trauma center.

PATIENTS

One hundred seventy-nine patients, with 190 fractured calcanei, were studied.

INTERVENTION

Each patient underwent open reduction and internal fixation for calcaneus fractures with standard techniques.

MAIN OUTCOME MEASUREMENTS

The age, sex, preexisting medical conditions, social history, and mechanism of injury of each patient were recorded. Note was made of the status of the soft tissue injury, if any. The time from injury to surgical stabilization was recorded, as was the type of incision used, use of preoperative antibiotics, and type of wound closure. The patients' records were reviewed for wound complications. These complications were classified as those that could be treated nonsurgically and those that required surgical management.

RESULTS

Records from July 1992 to July 1998 showed 179 patients who underwent operative stabilization of a calcaneus fracture. Eleven had bilateral fractures, for a total of 190 fractured calcanei. The average age was thirty-five years. Nine patients were diabetics. One hundred eleven of the patients reported current use of cigarettes. Eighteen of the fractures were open. A standard, L-shaped lateral approach to the calcaneus was used in each case. Stabilization was achieved by using standard techniques, with plates and screws. In all cases, a two-layer wound closure was used. Forty-eight patients (25 percent) developed some form of wound complication. Forty (21 percent) of these required surgical treatment. Statistical analysis identified diabetes (p = 0.02; relative risk 3.4), smoking (p = 0.03; relative risk 1.2), and open fractures (p < 0.0001; relative risk 2.8) as risk factors for wound complication. The presence of more than one risk factor increased the relative risk of a wound complication requiring surgery.

CONCLUSION

Smoking, diabetes, and open fractures all increase the risk of wound complication after surgical stabilization of calcaneus fractures. Cumulative risk factors increase the likelihood of wound complications. Patients who have the risk factors identified in this study should be counseled as to the possible complications that may arise after surgery. In patients with multiple risk factors, consideration should be given to nonsurgical management.

Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.