Femoral nailing with transverse locking screws through the femoral neck.

We treated 55 patients with subtrochanteric or comminuted femoral fractures with a transverse locking femoral nail (Alta, Howmedica). This nail was positioned more cephalad than usual so that at least one fixation screw was located in the femoral neck or head. Forty-seven fractures (20 subtrochanteric and 27 diaphyseal) were available for follow-up averaging 12 months (3-35). The time to radiographic healing averaged 7 months (3-21). There was one delayed union, one non-union, two superficial infections, one broken proximal screw, one compartment syndrome of the thigh, and one peroneal nerve palsy. There were no femoral neck fractures, avascular changes of the femoral head, or gluteal irritation at the most recent follow up. The described technique appears safe and effective, is technically easy, and avoids intra-articular screws.

Comparison of antibiotic beads and intravenous antibiotics in open fractures.

This study compared the efficacy of antibiotic impregnated beads with conventional intravenous antibiotics in the treatment of open fractures. A randomized prospective study was designed and conducted during a 29-month period. Sixty-seven patients with 75 open fractures were treated similarly, with the exception of the method of antibiotic administration, and were followed up for at least 1 year after injury. Infection occurred in two of 24 (8.3%) fractures treated with antibiotic beads alone and in two of 38 (5.3%) fractures treated with conventional intravenous antibiotics. In an unanticipated nonrandomized third cohort group, patients received antibiotic beads and intravenous antibiotics administered for nonorthopaedic reasons or limb threatening injury, or both. Two of 13 (15.4%) fractures in this high risk group became infected. Infection ultimately resolved in all fractures treated with antibiotic beads alone or antibiotic beads in conjunction with conventional intravenous antibiotics. This study was unable to achieve statistical significance; however, the data suggest antibiotic beads may be useful in preventing infection in open fractures. Thus, a larger multicenter randomized prospective study of isolated open fractures, eliminating other variables, is justified.

Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus.

Using a computer database, we conducted a retrospective review of all ankle fractures treated at our institution from March 1985 to October 1996. Twenty-one patients with diabetes mellitus and isolated ankle fractures that were treated operatively met all inclusion criteria. Seven had insulin-dependent diabetes, and 14 had non-insulin-dependent diabetes. A randomly selected control group of 46 patients without diabetes who also underwent operative treatment of ankle fractures during this same time period were matched for age, sex, and fracture severity. The complication rate was 43% with 13 complications in nine patients with diabetes. There were seven (15.5%) complications in the control group. Complications in the diabetic group included seven infections (five deep, two superficial) and three losses of fixation. The complications were more severe in our diabetic population, requiring seven additional procedures including two below-knee amputations; a third patient refused an amputation. No additional procedures were required in our control group. All complications in our control group resolved with treatment. The relative risk for postoperative complications in patients with diabetes who sustained ankle fractures that were treated operatively was 2.76 times greater than the control group's (95% confidence interval, 1.57-3.97).

Treatment of supracondylar nonunions of the femur with plate fixation and bone graft.

BACKGROUND: The purpose of this study was to review the results of single and double-plate fixation combined with grafting with bone from the iliac crest performed by one surgeon as treatment for supracondylar nonunion of the femur. METHODS: We performed a retrospective study of eighteen adult patients in whom a nonunion of the supracondylar region of the femur had been treated with single or double-plate fixation and autologous bone graft. The average time from the initial treatment of the fracture or the osteotomy to the index repair of the nonunion was fifteen months (range, five to thirty-six months), and nine patients had had a total of fifteen operations between the initial treatment and the repair of the nonunion. Two of these patients had had at least three procedures. Thirteen double plates, four single plates, and one interfragmentary screw were used for fixation of the nonunions, with onlay autologous bone graft used in all patients. The average time from the repair of the nonunion to the latest follow-up examination was twenty-six months (range, six to 120 months). RESULTS: By the time of the latest follow-up examination, all eighteen nonunions had healed. One patient had needed repeat double-plate fixation and autologous bone-grafting to obtain union. Two patients had had the hardware removed because of pain or infection, one patient had had an implanted electrical bone stimulator removed, and one patient had had a quadricepsplasty to treat restricted motion of the knee. There were only three complications. These included one infection, which resolved with irrigation and debridement and the use of antibiotics; loss of motion of one knee; and one malunion. The average range of motion of the knee at the latest follow-up examination was 101 degrees (range, 10 to 135 degrees). CONCLUSIONS: Rigid plate fixation and autologous bone-grafting is an effective technique for the treatment of nonunions of the supracondylar region of the femur.

The effect of reamed and nonreamed intramedullary nailing on fracture healing.

Intramedullary nailing has revolutionized the treatment of fractures. It is important to be aware of the biological and mechanical effects of reaming and nailing on bone. Most nails are substantially stiffer than bone, but because of their location in the medullary canal do not have nearly as adverse an effect on callus strength as plates. Reaming and nailing embolizes marrow contents into the systemic circulation and reduces blood flow to the total bone and cortex by 30% to 80%. This results in a hyperemic reaction that revascularizes the cortex depending on the type of nail used. Preservation of the soft tissue envelope around the fracture enhances this response resulting in fracture healing ratio of 98% when closed nailing techniques are used. The primary advantage of nonreamed nailing is better preservation of the blood supply to the cortex whereas the major advantage of reamed nailing is a more rigid construction, stronger implants, and earlier fracture union.

Education in orthopaedic trauma.

Education of the orthopaedic surgeon in trauma care presents a unique challenge because of the need to acquire knowledge about the overall resuscitation of the patient as well as having a sound working knowledge of the treatment of injuries to other organ systems and how that treatment interplays with orthopaedic care in such complex disorders such as adult respiratory distress syndrome. The orthopaedic trauma educator requires special dedication and skill because much teaching occurs at night and on holidays and weekends in the context of emergency surgery where immediate decisions are required and procedures must be executed expeditiously and with minimal morbidity. An ideal educational program in trauma provides ready availability of the attending with close supervision of a team of residents lead by an experienced chief or fellow to whom appropriate graduated responsibility for decision making and execution of surgery is provided. A formal didactic course with a complete multidisciplinary curriculum is essential. The managed healthcare movement has the potential to disrupt the educational process and clinical research in orthopaedic trauma by reducing referrals to major trauma centers; by making high quality trauma treatment, particularly in the indigent population economically impractical; and by interfering with the patient care and educational and research process by early transfer of patients to other providers removed from the trauma center environment. Orthopaedic trauma educators must work with their institutions, national organizations, government, and the healthcare industry to develop methods to preserve and advance the education and research in trauma care which has served our population so well and is so important for the health and productivity of society in the future.

Reamed femoral nailing in patients with multiple injuries. Adverse effects of tourniquet use.

Limb reperfusion after tourniquet ischemia causes pulmonary microvascular injury. Similarly, microembolization, like that associated with reamed femoral nailing, can induce pulmonary microvascular injury. Both processes result in increased pulmonary capillary membrane permeability and edema. However, the association between femoral nailing followed by tourniquet ischemia and clinical lung injury has not been described. The authors reviewed 72 patients with femoral shaft fractures and tibial or ankle fractures requiring internal fixation between 1987 and 1993. All femoral shaft fractures were treated with reamed intramedullary nails. Patients were divided into groups, based on whether the tibial or ankle injury was managed surgically with (Group T, 34 patients) or without (Group NT, 38 patients) a tourniquet. Group T was subdivided based on tourniquet time: T1, less than or equal to 90 minutes; T2, greater than 90 minutes. Groups were matched for injury severity. Group NT had fewer ventilator dependent days and intensive care days than Group T (NT: ventilator dependent days, 2.5 +/- 5.2; intensive care days, 3.9 +/- 6.5; T: 5.1 +/- 6.4; intensive care days, 6.7 +/- 6.6). Ventilator dependent days and intensive care days increased with increasing tourniquet time (T1: ventilator dependent days, 3.2 +/- 3.6; intensive care days, 5.4 +/- 4.6; T2: ventilator dependent days, 7.5 +/- 8.5; intensive care days, 8.5 +/- 8.5), suggesting that in patients with multitrauma, combining reamed femoral nailing with fracture fixation under tourniquet control increases pulmonary morbidity. Further investigation to measure pulmonary injury associated with ischemia reperfusion and intramedullary nailing in patients with multitrauma is warranted.

Nonreamed locking intramedullary nailing for open fractures of the tibia.

The use of nonreamed interlocking tibial nails in the management of open fractures of the tibial shaft has gained wide acceptance. This technique has been reported to have reproducible good results with a low incidence of complications in Type I, Type II, and Type IIIA open tibial shaft fractures. The use of nonreamed nails in Type IIIB fractures continues to be a source of controversy. The treatment of 72 open fractures of the tibial shaft with nonreamed interlocking intramedullary nailing is detailed. There were 27 Type I, 22 Type II, 11 Type IIIA, and 12 Type IIIB open tibial shaft fractures. There were three (4.2%) deep infections; one Type II, one Type IIIA, and one Type IIIB. Forty-nine fractures (68%) united by 6 months, all fractures had united by 12 months. The use of nonreamed locking intramedullary nailing in Types I, II, IIIA, and IIIB open fractures of the tibial shaft is supported.

Modified transverse locking nail fixation of proximal femoral fractures.

It was hypothesized that transverse locking screws of intramedullary nails, seated above the lesser trochanter, provide equal strength to that of reconstruction nails, and that screws placed through the medial cortex of the femoral neck do not have adverse biomechanical effects during physiologic loading. Synthetic femurs (n = 10) and paired anatomic specimen femurs (n = 14) were tested intact and with an intramedullary device in place. Intact specimens were loaded nondestructively, then a segmental subtrochanteric defect was created and either a high seated transverse locking nail or a reconstruction nail was inserted and statistically locked. Axial and torsional stiffness were determined followed by axial failure testing. Mechanical parameters evaluated were stiffness, displacement, and energy. The implanted specimens did not show any statistically significant difference between transverse or reconstruction screw constructs with any of the measured parameters (stiffness, displacement, and energy). Failure tests in implanted specimens also did not show any statistically significant difference in yield load, yield displacement, or energy to failure between implant constructs. All anatomic specimens failed, with fractures of the proximal fragment involving medial and lateral cortices. Synthetic specimens did not fracture but showed failure with implant deformation at the level of the skeletal defect. The use of high seated transverse locking nails for complex proximal femoral fractures is a viable option and has comparable in vitro mechanical performance with reconstruction nails. Although not shown to be a problem in the present study, clinical evaluation of screws through the medial femoral neck cortex is required.

Irreducible intertrochanteric fractures of the femur.

A retrospective study during a 3-year interval revealed that four of 112 patients had intertrochanteric fractures that were irreducible by the usual closed manipulation and traction techniques at the time of surgery. Each of these patients' preoperative radiographs showed a fracture line that bisected the lesser trochanter and was relatively uncomminuted. Although longitudinal traction and appropriate closed manipulation provide acceptable reduction for most intertrochanteric fractures, the few with the described fracture pattern may require open reduction with removal of interposed soft tissue to achieve satisfactory alignment.

Treatment of acute fractures with a collagen-calcium phosphate graft material. A randomized clinical trial.

A prospective, randomized clinical trial was conducted concurrently at eighteen medical centers in order to compare the safety and efficacy of two types of graft material for the treatment of fractures of long bones: autogenous bone graft obtained from the iliac crest, and a composite material composed of purified bovine collagen, a biphasic calcium-phosphate ceramic, and autogenous marrow. Two hundred and thirteen patients (249 fractures) were followed for a minimum of twenty-four months to monitor healing and the occurrence of complications. We observed no significant differences between the two treatment groups with respect to rates of union (p = 0.94, power = 88 per cent) or functional measures (use of analgesics, pain with activities of daily living, and impairment in activities of daily living; p > 0.10). The prevalence of complications did not differ between the treatment groups except for the rate of infection, which was higher in the patients who were managed with an autogenous graft. Twelve patients who were managed with a synthetic graft had a positive antibody titer to bovine collagen; seven of them agreed to have intradermal challenge with bovine collagen. One patient had a positive skin response to the challenge but had no complications with regard to healing of the fracture. We concluded that, for traumatic defects of long bones that necessitate grafting, use of the composite graft material appears to be justified on the grounds of safety, efficacy, and elimination of the increased operative time and risk involved in obtaining an autogenous graft from the iliac crest.

Limb lengthening over an intramedullary nail. An animal study and clinical report.

With the goal of reducing the duration of external fixation in limb lengthening, the authors investigated the feasibility of limb lengthening over an intramedullary nail that could be statically locked when the desired length was achieved, permitting early removal of the external fixation device. In a preliminary study, 8 minigoats underwent 2.0-cm lengthening of the tibia by means of a uniplanar external fixator. Half of the goats had a reamed nail placed in the tibia at the initial surgery. By 10 weeks after lengthening, there no difference in radiographic, histologic, or biomechanical evidence of bone regeneration was found between the tibiae that were nailed and those that were not. In a following clinical series, 15 patients underwent tibial or femoral lengthening by means of a circular frame fixator with a reamed intramedullary nail in place. The postoperative course was uneventful except for 1 infection. The distraction gaps became ossified from 6 months to 1 year, and only 2 patients needed additional bone graftings. The joint function of the lengthened limb at last followup was good. Gradual limb lengthening with a reamed intramedullary nail in place is safe and effective and allows for early removal of the external fixation device.

Removal of intramedullary nails from the femur: a review of 45 cases.

The excellent biocompatibility of titanium and its alloys may result in osseointegration. In order to determine if this presents an obstacle to removal of intramedullary nails, we retrospectively reviewed a series of 45 cases of isolated removal of a femoral nail. Indications for removal were persistent pain and discomfort, request of an asymptomatic patient, or skeletal immaturity. Twenty-three nails were titanium, and 22 were stainless steel. Although removal of the titanium nails had a significantly longer operative time (110 vs. 84 min), analysis of variance indicated that this was due to a greater number of crosslocking screws in the titanium nails (2.2 vs. 0.6) and a tendency to set the titanium nails deeper in the femur. The use of the titanium material per se did not pose a risk factor for difficulty in late removal of an intramedullary nail.

Biomechanical consequences of fracture and repair of the posterior wall of the acetabulum.

We measured the distribution of contact area and pressure between the acetabulum and the femoral head of cadaveric pelves in three different conditions: intact, with an operatively created fracture of the posterior wall, and after anatomical reduction and fixation of the fracture with a buttress plate and interfragmentary screws. The study involved eight cadaveric hip joints from five pelves loaded to 2000 newtons in simulated single-limb stance. Measurements were made with pressure-sensitive film. The acetabulum was divided into three areas--the anterior wall, the superior aspect, and the posterior wall--for the analysis of the data. Creation of a fracture of the posterior wall was followed by an increase in contact area, maximum pressure, and contact force in the superior aspect of the acetabulum. A concomitant decrease in these parameters was observed in the anterior and posterior walls. Anatomical reduction and fixation of the fracture with a plate and screws did not restore the pattern of loading to pre-injury levels.

Open tibia fractures in the splenectomized trauma patient: results of treatment with locking, intramedullary fixation.

OBJECTIVE: To confirm our clinical impression that patients with traumatic splenectomy had more complications in the treatment of open tibia fractures, we retrospectively reviewed the records of patients with open tibia fractures treated between 1989 and 1992. MATERIALS AND METHODS: Eight patients with open tibia fractures and traumatic splenectomies were compared to 43 patients with open tibia fractures and intact spleens. The latter group typically underwent either exploratory laparotomy or peritoneal lavage. The two groups were similar with respect to age, mechanism of injury, fracture wound classification, and injury severity score (22.4 in the splenectomized patients, 18.6 in the control). All tibia fractures were treated with a nonreamed, cross-locked, titanium intramedullary nail, and all patients were treated according to the same protocol of antibiotic therapy. Patients were followed for two years or until roentgenographic and clinical union. RESULTS: The splenectomized patients had a significantly higher incidence of chronic osteomyelitis (25% vs. 4.6%), and the need for additional tibial surgeries to achieve union (75% vs. 16%). Time to union averaged 11.3 months in the splenectomized group and 7.6 months in the patients with intact spleens. CONCLUSIONS: The increased risk for chronic osteomyelitis and other complications of tibial fracture in the splenectomized patients should be taken as an argument favoring splenic, repair, when possible, rather than splenectomy in victims of blunt multiple trauma.

Traumatic anterior dislocation of the radial head in an adult.

We report an isolated anterior dislocation of the radial head in an adult after sustaining a fall on the outstretched arm. Based on history and presentation, we speculate that the injury occurred in a position of hyperextension and supination. Reduction was achieved by a pronation maneuver.