Treatment of displaced intra-articular calcaneal fractures with combined transarticular external fixation and minimal internal fixation.

BACKGROUND: The aim of this study was to evaluate clinical outcomes after surgery for displaced intra-articular fractures using an external fixator and minimal internal fixation. METHODS: In this retrospective observational study, a total of 39 patients (32 [82%] men and 7 [18%] women) with 48 displaced intra-articular calcaneal fractures were included. An extended lateral approach was used to stabilize fractures using multiple sagittal plane screws, axial percutaneous threaded Kirschner wires for the frontal fracture plane, and an external fixator for reduction assistance and maintenance. The following variables were assessed: preoperative and postoperative Böhler's angle; calcaneal length, height, and width; postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores; and complications. Mean duration of follow-up was 74 ± 26 months. RESULTS: The mean time from surgery to external fixator removal was 12 ± 1 weeks. The mean preoperative Böhler's angle (-3 ± 21 degrees), calcaneal length (7.9 ± 0.6 cm), and calcaneal height (3.6 ± 0.5 cm) were significantly increased (P < .05) at final follow-up (28.3 ± 6.5, 8.3 ± 0.6, and 4.5 ± 0.5, respectively), whereas the mean preoperative calcaneal width (4.2 ± 0.5) was significantly decreased from the final follow-up mean (3.8 ± 0.5). There were no significant differences between any of the normal and postoperative measures. The mean AOFAS score was 82 ± 12. Complications included superficial pin tract infection (n = 7, 15%), superficial wound edge necrosis (n = 4, 8%), and deep infection (n = 2, 4%). CONCLUSION: Our findings suggest that use of an external fixator with minimal internal fixation is an effective option for treating displaced intra-articular calcaneal fractures. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Anatomical reduction for treatment of displaced midshaft clavicular fractures: Knowles pinning vs. reconstruction plating.

The purpose of this study was to compare Knowles pinning and fixation with cerclage wires vs reconstruction plating and fixation with extraplate wires for the treatment of displaced midshaft clavicular fractures, with anatomical reduction serving as the objective. In this retrospective study, the records of 103 consecutive patients with complete follow-up data (minimum 12 months follow-up) treated operatively for displaced midshaft clavicular fractures between 1997 and 2009 by a single surgeon were reviewed. A total of 53 patients (mean age, 35.2±14.5 years) received Knowles pinning and 50 patients (mean age, 39.9±14.8 years) received reconstruction plating. No differences were observed between the groups with respect to type of fracture, union rate (88.7% vs. 94.0%, respectively; P=.439), and surgical complication rate (13.2% vs. 10.0%, respectively; P=.761). Wound length was significantly shorter in the Knowles pinning group (5.3±0.9 cm vs. 8.4±0.5 cm, respectively; P<.001) and implant-related complications, symptomatic hardware (P<.001), visible implant (P<.001), and palpable implant (P<.015) were significantly higher in the reconstruction plating than in the pinning group. Anatomical reduction is the ultimate objective of anatomical and functional restoration when surgical intervention is indicated, and patient compliance is the major prerequisite for surgical treatment. For treatment of displaced midshaft clavicle fractures, both Knowles pinning with cerclage wires and reconstruction plating with extraplate wires provide rigid fixation and perfect union.

Two-stage reimplantation of infected hip arthroplasties.

BACKGROUND: Although two-stage reimplantation for infected hip arthroplasty has a high success rate, the protocols of the antibiotic therapy after resection arthroplasty have varied in different reports. The purpose of this study was to evaluate the clinical outcomes of two-stage reimplantation for infected hip arthroplasty using our protocol of combined parenteral and oral antibiotic therapy and the criterion for reimplantation. METHODS: Forty-seven patients (48 hips) with infected hip arthroplasty were treated with two-stage reimplantation using interim antibiotic-impregnated cement beads with an average 2.6 weeks of parenteral antibiotic and 6 weeks of oral antibiotic therapy. The timing for reimplantation was determined using the values of erythrocyte-sedimentation rate (ESR) and C-reactive protein (CRP) with no clinical signs of infection. The average follow-up period was 5.6 years. RESULTS: Forty-six (96%) hips were free of recurrent infection according to clinical examination and laboratory tests at the latest follow up. All 48 hips had negative tissue culture results obtained at the second-stage reimplantation except one which resulted in a recurrent infection. The average interim period of time from the first-stage procedure to reimplantation was 5.4 months (range, 2-24 months). Two hips had recurrent infections after reimplantation. The mean Harris hip score improved from 26 points preoperatively to 83 points at the latest follow up. Thirty-five patients (74%) achieved excellent or good results. CONCLUSIONS: Two-stage reimplantation of an infected hip arthroplasty can achieve a high success rate using the protocol of aggressive surgical debridement, local antibiotic-loaded cement beads, combined parenteral and oral antibiotic therapy and reimplantation after normalization of ESR and CRP levels.

The effects of extracorporeal shockwave on acute high-energy long bone fractures of the lower extremity.

INTRODUCTION: High-energy long bone fractures of the lower extremity are at risk of poor fracture healing and high rate of non-union. Extracorporeal shockwave was shown effective to heal non-union of long bone fracture. However, the effect of shockwave on acute fractures is unknown. The purpose of this study was to investigate the effects of shockwave on acute high-energy fractures of the lower extremity. MATERIALS AND METHODS: Between January and October 2004, 56 patients with 59 acute high-energy fractures were enrolled in this study. Patients were randomly divided into two groups with 28 patients with 28 fractures in the study group and 28 patients with 31 fractures in the control group. Both groups showed similar age, gender, type of fracture and follow-up time. Patients in the study group received open reduction and internal fixation and shockwave treatment immediately after surgery on odd-numbered days of the week, whereas, patients in the control group received open reduction and internal fixation without shockwave treatment on even-numbered days of the week. Postoperative managements were similarly performed in both groups including crutch walking with non-weight bearing on the affected limb until fracture healing shown on radiographs. The evaluation parameters included clinical assessments of pain score and weight bearing status of the affected leg and serial radiographs at 3, 6 and 12 months. The primary end-point is the rate of non-union at 12 months, and the secondary end point is the rate of fracture healing at 3, 6 and 12 months. RESULTS: At 12 months, the rate of non-union was 11% for the study group versus 20% for the control group (P < 0.001). Significantly, better rate of fracture healing was noted in the study group than the control group at 3, 6 and 12 months (P < 0.001). CONCLUSION: Extracorporeal shockwave is effective on promoting fracture healing and decreasing the rate of non-union in acute high-energy fractures of the lower extremity.

Results of chronic osteomyelitis of the femur treated with hyperbaric oxygen: a preliminary report.

BACKGROUND: Although only a few studies have shown the effectiveness, hyperbaric oxygen (HBO) therapy has been used as an adjunct in the management of chronic osteomyelitis in many hospitals in Taiwan. This retrospective study investigated the clinical results of HBO therapy for chronic refractory osteomyelitis of the femur. METHODS: From December 1999 through May 2002, 13 patients with chronic refractory osteomyelitis of the femur were treated with adjunctive HBO. The most common infecting microorganism was Staphylococcus aureus. All cases were classified as type III or IV osteomyelitis according to the Cierny-Mader classification. Adequate surgical debridement and parenteral antibiotic treatment were performed. The average number of operations before HBO therapy was 4.6 times. HBO therapy at 2.5 atmospheres absolute for 120 minutes was administered for 5 days per week in all patients for an average of 50 days. The average number of HBO treatments was 32.2 times. The average follow-up period was 22 months, ranging from 12 to 42 months. RESULTS: Complete eradication of infection with no recurrence of infection was noted in 12 of the 13 patients. One patient failed to respond to the treatment. The success rate of the treatment regimen was 92%. There were no HBO therapy related complications. CONCLUSION: Hyperbaric oxygen therapy is an effective and safe adjunctive therapy for the management of chronic refractory osteomyelitis of the femur provided that patients had received adequate surgical debridement and appropriate antibiotic treatment.

Hyperbaric oxygen therapy in the treatment of chronic refractory osteomyelitis: a preliminary report.

BACKGROUND: Hyperbaric oxygen (HBO) has been proven to enhance bone and soft tissue healing in ischemic tissue in vitro and in vivo studies. Although only a few reports have been proven using controlled studies, this treatment modality remains encouraging for chronic refractory osteomyelitis. In this retrospective study, we reported the clinical results of HBO therapy for chronic refractory osteomyelitis. METHODS: From January through August 2000, 14 patients with chronic refractory osteomyelitis of the tibias treated with HBO were available for follow-up examination. According to the Cierny-Mader classification, all patients were classified as type III or IV osteomyelitis. Adequate debridement and parenteral antibiotic treatment in conjunction with HBO therapy at 2.5 atmospheres absolute for 120 minutes, and 5 days per week regimen was used in all patients. The patients were followed-up for an average of 15 months after completion of HBO therapy. RESULTS: The most common infecting microorganism was Staphylococcus aureus. Mixed infections were usually found in patients with open fractures. The average number of operations before HBO therapy was 5.4 including soft tissue reconstruction in 11 patients. The average number of HBO treatments was 33.6 times. There were no HBO related complications. No recurrence of infection was noted in 11 patients, which resulted in a success rate of 79%. CONCLUSIONS: Hyperbaric oxygen therapy is effective and safe for chronic refractory osteomyelitis provided that patients had received appropriate medical and surgical management.