Hybrid external fixation in the treatment of tibial plafond fractures.

From 1992 to 1994, 37 fractures (36 patients) were treated with hybrid external fixation for tibial plafond or distal tibial fractures. The fractures were classified according to the AO classification: A1 (3), A2 (3), A3 (4), C1 (6), C2 (12), C3 (9). There were 11 open injuries, and in 27 patients (75%) the mechanism of injury was high energy trauma. Results were evaluated based on a subjective and objective rating system. Thirty-four patients were available for followup at an average of 15.2 months. All fractures in this series united with an average time to healing of 4.6 months. Anatomic or good alignment was obtained in all but 1 fracture. There were 12 excellent, 9 good, 7 fair, and 6 poor results. In the 18 C2 and C3 fractures there were 8 good to excellent, 4 fair, and 6 poor results. Degenerative changes were seen on followup radiographs in 4 of these patients. Complications occurred in 12 patients (35%) and included 1 skin slough, 5 pin tract infections, 3 deep infections, 3 nonunions, and 3 loss of reductions necessitating frame revision. This method yielded results comparable with previous studies while decreasing the number of complications resulting from treatment.

Femoral nailing without a fracture table.

This retrospective trail was designed to evaluate the effectiveness and safety of femoral nailing on a radiolucent table with manual traction only. Eighty-three femoral shaft fractures treated by antegrade nailing were included in this study. Group 1 consisted of 24 femur fractures that were reduced and nailed with manual traction. Group 2 consisted of 59 femur fractures treated with the aid of a fracture table. There were 10 patients in Group 1 and 19 patients in Group 2 needing multiple procedures. In Group 1, significantly fewer redrapings and table transfers were necessary. There was no increase in operative time. There were no operative complications in Group 1 and there was 1 operative complication in Group 2--a radial nerve palsy. Postoperative malalignment was minimal in both groups. Intramedullary nailing of femoral shaft fractures on a radiolucent table using manual traction is associated with no increase in morbidity. It also facilitated quicker and more effective treatment of the patient with polytrauma. No undue risks or contraindications were identified; however, the help of an assistant was invaluable.

Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study.

Twenty-three knees in 22 patients with Schatzker type VI tibial plateau fractures were treated with a hybrid ring external fixator using tensioned wires proximally and half-pins distally. All but two injuries were secondary to high-energy trauma. Six were open injuries, and eight patients had other major musculoskeletal trauma. Eight patients were treated with limited open reduction and internal fixation before application of the frame. The remainder received percutaneous cannulated screw fixation to stabilize the articular surface without opening the fracture site. Twenty-three fractures were followed to complete healing. Average time to healing was 4.4 months. Arc of motion averaged 107 degrees, and there were four flexion contractures of 5-15 degrees. Complications consisted of three deep wound infections, one deep venous thrombosis (DVT), one malunion, and one pin tract infection. The average knee score and patient function score were 84.7 and 80.5, respectively (Knee Society Clinical Rating System). There were 13 excellent, three good, one fair, and six poor results. The poor results were in patients who either developed deep wound infections or in those who sustained multiple musculoskeletal trauma compromising the patients' function score and ultimately the average score. This method provides good stabilization and allows early range of motion for complex tibial plateau fractures where extensive dissection and internal fixation are contraindicated due to traumatized soft tissue, osteopenia, and fracture comminution.

Pudendal nerve palsy following fracture table traction.

In separate retrospective and prospective studies at the same Level 1 trauma center, pudendal nerve palsy complicating fracture table cases was analyzed. Incidence was established and pertinent variables categorized and compared. From January 1986 through October 1988, four of 216 fracture table patients (1.9%) were diagnosed with a postoperative pudendal nerve palsy. A subsequent three-month prospective study, ensuring use of preventive measures and incorporating active postoperative screening, resulted in only one of 36 patients (2.8%) developing this complication after fracture table traction. Symptoms associated with this palsy, including genitoperineal hypoesthesia, erectile dysfunction, or both, occurred within the first two postoperative days and resolved spontaneously by six months. No association of variables had any statistical significance. The pathoanatomy of this complication and preventive guidelines are reviewed.

Gunshot wounds to the extremities. Experience of a level I trauma center.

Gunshot wounds to the extremities are more common today, largely because civilian handgun injuries have increased. Such injuries, which are usually caused by low-velocity missiles, should be treated differently from those caused by high-velocity (military) missiles. Bone involvement, including fractures and joint injuries, necessitates orthopaedic management. At the University of Medicine and Dentistry of New Jersey-New Jersey Medical School's (UMDNJ-NJMS) University Hospital, a level I trauma center, 44 gunshot wounds (32 lower-extremity and 12 upper-extremity) with orthopaedic complications were treated between January 1986 and December 1988. The protocol/questionnaire used by the UMDNJ-NJMS is presented here to assist the orthopaedic surgeon in the evaluation and treatment of these problematic injuries.

Pseudarthrosis after spinal fusion for scoliosis. A comparison of autogeneic and allogeneic bone grafts.

This study was undertaken to compare the incidence of pseudarthrosis in fusions supplemented with autogeneic and frozen allogeneic grafts. The records of 208 patients with adolescent idiopathic scoliosis who were treated by posterior fusion and Harrington instrumentation were studied. The fusion was supplemented by an autogeneic iliac bone graft in 114 patients and by an allogeneic bank bone graft in 94 patients. The fusion mass was explored in all patients with suspected pseudarthrosis; therefore, all pseudarthroses reported in this series were proved by surgical exploration. Pseudarthrosis developed in five patients (4.4%) receiving an autogeneic graft and in five patients (5.3%) receiving an allogeneic graft. The incidence of pseudarthrosis was not significantly different at the 95% level of certainty. Average blood loss and operative time were determined for all patients. The decreases in average blood loss and operative time in those patients receiving allogeneic grafts were significant (p less than .01). Thus, based on the incidence of pseudarthrosis, allogeneic frozen bank-stored bone is an attractive alternative to autogeneic iliac bone for fusion supplementation in the treatment of scoliosis. Total operative time and blood loss can be decreased, and possible complications associated with a donor site can be avoided.