Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing.

OBJECTIVE: To observe and report the clinical results of indirect plating techniques in the treatment of femoral shaft nonunions originally treated with intramedullary nailing. DESIGN: Prospective consecutive. SETTING: Regional trauma center. PATIENTS: A consecutive series of twenty-three patients with nonunion of femoral shaft fractures previously treated with intramedullary nailing. INTERVENTION: Surgical treatment with indirect plating techniques using the AO 95-degree condylar blade plate in nonunions of the distal and proximal one thirds and broad large-fragment dynamic compression plating in nonunions of the middle one third, with selective autologous cancellous bone grafting. Emphasis was placed on preoperative planning, intraoperative attention to soft tissue sparing and selection of the appropriately applied implant to correct deformity and obtain union. MAIN OUTCOME MEASUREMENTS: Healing rate and time, operative blood loss and time, and incidence of complications, including hardware failure, loss of fixation, infection, and postoperative malalignment. RESULTS: Twenty-one of the twenty-three nonunions healed without further intervention at an average of twelve weeks (range 10 to 16 weeks) postoperatively. The two remaining patients (9 percent) had early breakage of their hardware, requiring repeat plating. Union in both of these cases occurred within sixteen weeks of the revision (12 and 16 weeks). Including the two patients requiring reoperation, all twenty-three nonunions healed at an average of seventeen weeks (range 10 to 24 weeks) from the initial plating procedure. There were no intraoperative complications. Average operative time was 164 minutes (range 120 to 240 minutes), and blood loss was 340 milliliters (range 200 to 700 milliliters). There were no cases of significant postoperative axial or rotational malalignment (more than 5 degrees), limb length discrepancy (more than 1 centimeter), or deep infections. CONCLUSIONS: Modern plating techniques are effective in the treatment of femoral shaft nonunions after intramedullary fracture fixation. The authors consider this method particularly valuable in the presence of deformity. Union occurred reliably with few complications.

Distraction external fixation in lateral compression pelvic fractures.

OBJECTIVE: To observe the results and describe the technique of closed reduction and placement of a two-pin supra-acetabular external fixator, followed by immediate weight bearing, in the treatment of displaced vertically stable lateral compression pelvic fractures. DESIGN: Prospective, consecutive SETTING: Regional trauma center PATIENTS: A consecutive series of fourteen patients with displaced, vertically stable lateral compression pelvic fractures who were transported to a regional trauma center. INTERVENTION: Surgical treatment with closed reduction and maintenance of the distraction force with a two-pin, single-bar, supra-acetabular external fixator, followed by immediate weight bearing. MAIN OUTCOME MEASUREMENTS: Healing rate and time, operative blood loss and time, quality of reduction, time to full weight-bearing, and incidence of complications, including neurovascular deficits, loss of reduction, nonunion, pin tract infections, and chronic pain. RESULTS: A symmetric reduction of both hemipelves was achieved in all fourteen patients. Time to healing averaged 8.2 weeks (seven to twelve weeks), and no fixator required removal before healing. There were no delayed unions or nonunions, and none of the fractures displaced significantly after initial reduction. Average surgical time was thirty-seven minutes (range, twenty-five to sixty minutes) with an estimated blood loss of less than fifty milliliters. Patients were allowed to bear full weight immediately and were able to do so without ambulatory assistive devices within an average of twelve days (range, three to eighteen days). Complications consisted of three minor pin tract infections, one temporary lateral femoral cutaneous nerve palsy, one late pin tract abscess, and one patient with chronic low-back pain. CONCLUSIONS: Treatment of type B lateral compression injuries of the pelvic ring with anterior distraction external fixation is a highly effective yet relatively simple and minimally invasive treatment method. Surgical time and blood loss are minimal, and patients can be effectively and rapidly mobilized. Based on our experience, we believe this method to be a valuable tool in the treatment of these fractures.

Biomechanical evaluation of the dynamic hip screw with two- and four-hole side plates.

OBJECTIVES: To determine the biomechanical strength and stiffness of a dynamic hip screw (DHS; Synthes USA, Paoli, PA, U.S.A.) with a two-hole side-plate as compared with a four-hole side-plate design for the reconstruction of unstable three-part intertrochanteric fractures. DESIGN: Eight matched pairs of embalmed human femurs were tested in two modes: (a) 2,000 cycles of simulated physiologic loading; (b) test to failure. SETTING: Laboratory. Simulated single leg stance using a simulated pelvic loading mechanism with abductor loading. Strain and displacement sensors were used to measure fragment shear and distraction and surface strain in the proximal side plate. SPECIMENS: Eight pairs of skeletonized embalmed cadaveric specimens were selected on the basis of femoral neck angle and absence of old fracture, anatomic anomaly, or pathology. INTERVENTION: The specimens were divided into two groups: (a) left femurs received the two-hole side-plate design; (b) right femurs received the four-hole side-plate design. All fractures were reconstructed by the same surgeon using the manufacturer's instructions. MAIN OUTCOME MEASUREMENTS: Implant placement was verified by radiographic measurement of tip-to-apex distance. In cyclic testing, the amount of femoral neck fragment migration in both distraction and shear was quantified. Strain magnitude in the side plate was measured in both cyclic and failure testing. The peak load withstood by the reconstruction was quantified in the failure test. RESULTS AND CONCLUSIONS: Peak load in the failure test was not found to be statistically different between the two-hole and four-hole designs. In cyclic testing, the two-hole configuration exhibited statistically smaller fragment migration in both shear and distraction than the four-hole design (p < 0.05). The strain magnitude in the side plate was not statistically different in the cyclic or failure tests. The femurs with a greater neck angle failed by crushing of the bone in the neck. The femurs with a lesser neck angle failed due to bending of the hardware. The results of this investigation revealed that the two-hole DHS is biomechanically as stable as the four-hole DHS in cyclic and failure loads under the conditions tested. These results, in concert with clinical experience, can be used to support the use of the two-hole DHS for the reconstruction of intertrochanteric fractures without a diaphyseal extension.

Results of intertrochanteric femur fractures treated with a 135-degree sliding screw with a two-hole side plate.

OBJECTIVE: To observe and report the clinical results of the treatment of intertrochanteric hip fractures treated with a 135-degree hip screw with a two-hole side plate. DESIGN: Prospective consecutive. SETTING: Community private practice. PATIENTS: A consecutive series of seventy primarily older patients with intertrochanteric hip fractures treated in a community hospital setting. INTERVENTION: Surgical treatment with a 135-degree sliding hip screw and a two-hole side plate. MAIN OUTCOME MEASUREMENTS: Healing rate and time, operative blood loss and time, incidence of hardware failure, and complications including loss of side plate fixation and amount of collapse. RESULTS: Sixty-nine patients, with seventy intertrochanteric hip fractures, underwent surgical treatment with a 135-degree sliding hip screw and a two-hole side plate. There were twenty-one (30 percent) A1.1, sixteen (23 percent) A1.2, twenty-one (30 percent) A2.1, and twelve (17 percent) A2.2 fractures in twenty-three (33 percent) men and forty-six (67 percent) women. Average age was seventy-nine years. The average estimated blood loss was seventy-seven cubic centimeters (range 10 to 300 cubic centimeters), and the average surgical time was thirty-one minutes (range 8 to 90 minutes). The average time to union was fifteen weeks (range 8 to 17 weeks). There were three failures: two from screw cut-out and one from screw plate dissociation. No cases failed due to loss of fixation of the two-hole side plate. Collapse was minimum in fifty-five patients (79 percent), moderate in twelve patients (17 percent), and severe in two patients (3 percent). CONCLUSIONS: Use of the 135-degree sliding hip screw with a two-hole side plate produces satisfactory healing and results in relatively low blood loss and short surgical times without the loss of side plate fixation.

The results of open reduction and Internal fixation of distal femur fractures using a biologic (indirect) reduction technique.

The results of 57 A-O type A or C supracondylar femur fractures treated by open reduction and internal fixation using indirect reduction techniques are reported. No bone grafting or dual plating was used. All patients were placed in a continuous passive motion (CPM) machine postoperatively. Patients were followed at 4-week intervals until fracture healing had occurred. All patients were followed for at least 1 year after injury. All fractures were treated by a single surgeon. The average time for fracture healing was 10.7 weeks (range 8-16). Hardware failure did not occur in this series. Outcomes were assessed using a modified Schatzker scoring method. Using the scale, there were 84% good to excellent results, 11% fair results, and 5% poor outcomes. Fair and poor results tended to occur in more severe fractures and were primarily due to limited knee motion. Complications included two broken screws, one deep infection, and one malunion. No fractures failed to unite. In conclusion, holding the surgical skill factor constant, it appeared that biologic reduction techniques, although they provided excellent bone healing capability, did not guarantee universally satisfactory outcomes.

Indirect reduction and composite fixation of extraarticular proximal tibial fractures.

Forty-one extraarticular comminuted proximal tibial fractures were treated during a 7-year period. The fractures were proximal tibial metaphyseal injuries or metaphyseal-diaphyseal junction injuries with extension proximally and distally but not involving the knee joint. All fractures were treated surgically with open reduction and internal fixation using an indirect reduction technique with a lateral plate, and a medial substitution external fixator concomitantly. All fractures were seen for followup until they healed (average healing time, 12.1 weeks). The timing of internal fixation was based on the status of the soft tissue (average time to surgery, 8.5 days after injury). A temporary spanning external fixator was used in 17 (41.5%) fractures to allow for further assessment, demarcation, and improvement of the anterior soft tissues. There were 3 (7%) delayed unions, 1 (2%) malunion, and no nonunions. There were 2 (5%) wound infections and 5 (12%) pin track problems. One postsurgical soft tissue problem was encountered. Through this technique, reliable healing and alignment were achieved in this often difficult fracture pattern, particularly for fractures that were difficult or impossible to treat with an intermedullary nail.

Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results.

Between March 1991 and December 1992 the authors surgically treated 55 acetabular fractures using a modified Stoppa anterior intrapelvic extensile approach. Indications for utilization of this approach included displaced anterior column or wall fractures, transverse fractures, T shaped fractures, both column fractures and anterior column or wall fractures associated with a posterior hemitransverse component. The approach involves a transverse skin incision 2 cm above the pubic symphysis followed by a midline split of the rectus abdominis. Access to the intrapelvic aspect of the pelvis and acetabulum is gained by retraction of the muscular, neurovascular and urological structures. This modified Stoppa approach affords excellent visualization of the pelvic ring, facilitating the development and utilization of improved reduction and plating options. Patients were followed for an average of 17.7 months. All fractures united 6-12 weeks postoperatively. Radiographic grades were excellent (64%), good (25%), fair (7%) and poor (4%). Fixation and subsequent reduction were lost in 1 patient. Two transient obturator nerve palsies were diagnosed. There was 1 infection and 1 inguinal hernia. Posttraumatic arthritic changes were noted in 6 patients within the first postoperative year. There was no significant heterotopic ossification, major vascular injury iatrogenic palsy or intraarticular hardware placement. Clinical results were excellent (47%), good (42%), fair (9%) and poor (2%). The modified Stoppa incision offers the experienced trauma surgeon a new approach for fixation of displaced acetabular fractures. The approach offers improved reduction and fixation possibilities and may decrease the rate of complications associated with extrapelvic or extensile approaches.

Motorcycle accident injury severity, blood alcohol levels, insurance status, and hospital costs: a 4-year study in St. Petersburg, Florida.

Clinical, demographic, and financial information for 337 patients injured in motorcycle accidents who were admitted to a community hospital over a 4-year period was reviewed for injury severity, prevalence and degree of alcohol intoxication, and effects of insurance status on hospital, patient, and community costs. Ninety percent of the patients were males (average age 31 years), and 52% had some form of insurance. Of those tested at the time of admission, 36% had blood alcohol levels of > or = 100 mg%. Uninsured patients had higher blood alcohol levels (p = 0.0001), as did older patients (p = 0.01). Forty percent of patients had injury severity scores of > or = 16. Uncompensated costs to the hospital of caring for the uninsured totalled > $850,000 over the 4 years. The need to enforce existing statutes and to increase awareness through education is discussed, and statutory changes are recommended.

Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate.

The results were retrospectively analyzed of 47 subtrochanteric fractures of the femur treated with a 95 degrees condylar blade-plate to establish whether two different surgical techniques yielded different results. Before 1981, treatment consisted of extensive visualization of the fracture lines, permitting anatomic reduction of all fragments, stable internal fixation with the blade-plate, and optional autologous bone grafting as recommended by the AO group. Twenty-four fractures were treated accordingly and constituted Group I of this study. In 1981, visualization of the fracture lines was abandoned, especially at the medial cortex; an indirect reduction technique was used to gain optimal alignment and stability without aiming at anatomic reduction, and bone grafting was discontinued. Twenty-three patients were treated accordingly and constituted Group II. The use of prophylactic antibiotics as a routine for all major trauma was instituted at the time the surgical technique was changed. Thus, only two of the 24 patients in Group I received antibiotics as opposed to 20 of the 23 patients in Group II. Average time to bony union for those fractures that healed primarily was 5.4 months in Group I and 4.2 months in Group II. Delayed or nonunion was 16.6% in Group I and 0% in Group II, and the infection rate was 20.8% versus 0% in the two groups. The four cases with a delayed union were aseptic, but three of the four nonunions were infected. The functional end result was comparable for both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of medical complications in orthopedic trauma.

In severely traumatized patients, morbidity and mortality can be reduced by early management of the skeletal injuries. However, prevention of the complications of shock, pulmonary distress syndrome, embolic phenomena, blood disorders, and immunologic, neuroendocrine, and metabolic problems have a very high priority in overall patient management.