Percutaneous clamping of spiral and oblique fractures of the tibial shaft: a safe and effective reduction aid during intramedullary nailing.

The reduction of tibial shaft fractures during intramedullary nailing is important if limb alignment is to be restored and successful clinical outcomes are expected. We have used a percutaneously applied (or open) clamp or clamps to achieve and maintain reduction during nailing of all amendable tibial shaft fractures. In this article, we describe the technique and preliminary results comparing closed, simple spiral and oblique tibial shaft fractures (OTA 42-A1 and A2) managed with percutaneous clamp-assisted nailing (CAN) versus nailing using manual reduction (MRN) held by the surgical team. In the MRN group, there were an increased fracture gap (P = 0.04) and trends toward malalignment (P = 0.07) and healing time (P = 0.06) compared with the CAN group. There were also trends in clinical; no wound complications occurred in either group. We have found that percutaneous CAN of closed, simple spiral and oblique tibial shaft fractures seems safe and allows for early predictable union with reproducible alignment compared with nailing using MRN.

Operative treatment of acetabular fractures in an older population through a limited ilioinguinal approach.

OBJECTIVES: To compare treatment of acetabular fractures in elderly patients through a limited approach versus a standard ilioinguinal approach and assess changes in outcome and morbidity. DESIGN: Retrospective cohort comparison analysis. SETTING: Tertiary referral center. PATIENTS/PARTICIPANTS: Between January 1992 and January 2006, 143 patients 55 years of age or older were treated for acetabular fractures. Of these, 41 were treated through either a traditional or limited ilioinguinal approach. Patients with unilateral surgeries and a minimum follow-up of 2 years were included. INTERVENTION: Open reduction and internal fixation of acetabular fractures through a limited (lateral two windows) approach versus traditional three window ilioinguinal approach. OUTCOME MEASURES: Radiographic assessment of healing, reduction quality, progression to arthritis and total hip arthroplasty, operative time, length of stay, complications, SF-36, Musculoskeletal Functional Assessment, and the Short Musculoskeletal Functional Assessment. RESULTS: The two groups were equivalent in terms of preinjury comorbidities, mechanism of injury, type and severity of fracture pattern, time to surgery, length of hospitalization, and incidence of postoperative complications. The overall rate of secondary total hip arthroplasty was 26.8% and was equivalent between the two groups. Functional outcome scores were comparable. The use of the lateral two windows was associated with a significant reduction in both blood loss and operative time. CONCLUSIONS: The limited ilioinguinal approach to certain fracture patterns commonly seen in the elderly was associated with a decreased blood loss and surgical time. Moreover, there was no negative impact on outcomes in our cohort. The benefits of decreased blood loss and shorter operative time have a potential positive impact on management of these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of acetabular fractures in an older population.

OBJECTIVE: To identify factors predicting poor radiographic and functional outcome and delayed total hip arthroplasty in operatively managed acetabular fractures in patients 55 years of age and older. DESIGN: Retrospective chart and radiographic review of a prospectively maintained database. SETTING: Tertiary care hospital. PATIENTS: Ninety-three with a mean age of 67 years met all inclusion criteria and had follow up averaging 5 years. INTERVENTION: Open reduction and internal fixation and less commonly acute total hip arthroplasty for displaced acetabular fractures in an older cohort. MAIN OUTCOME MEASUREMENT: Three validated patient self-assessment measures were used: the Musculoskeletal Functional Assessment, the Short Musculoskeletal Functional Assessment, and the SF-36. RESULTS: The overall rate of hip replacement in our study was 30.95%. Poor fracture reduction (P < 0.02), development of avascular necrosis (P < 0.001), and previous contralateral hip arthroplasty (P = 0.02) were statistically associated with the need for secondary surgeries. Functional outcome scores in the current study compared favorably with functional outcome scores reported for acetabular fractures in younger populations and with age-matched "non-injured" norms published in recent literature. CONCLUSIONS: There was an acceptably low rate of major complications in 93 operatively managed fractures in this population. Nearly 70% of patients achieved functional outcomes similar to age- and injury-matched control subjects without the need for secondary surgeries. Thirty percent of patients required secondary total hip arthroplasty for posttraumatic arthritis. These patients achieved outcomes similar to patients in the other outcome groups and to injury- and age-matched norms.