Outcomes After Proximal Medial Gastrocnemius Recession and Stretching vs Stretching as Treatment of Chronic Plantar Fasciitis at 6-Year Follow-up.

BACKGROUND: Evidence from prospective short-term studies suggest that proximal medial gastrocnemius recession is a safe and efficient procedure to treat chronic plantar fasciitis resistant to nonoperative treatment. The aim of this study was to evaluate the long-term clinical outcomes of proximal medial gastrocnemius recession and stretching compared to a stretching exercise protocol for patients with chronic plantar fasciitis and an isolated gastrocnemius contracture (IGC). METHODS: Forty patients with plantar fasciitis lasting more than 1 year were prospectively randomized to a home stretching exercise program only, or to proximal medial gastrocnemius recession in addition to the stretching program. Clinical and functional data in this study were obtained at baseline and 6-year follow-up. The main outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. Secondary outcomes were the visual analog scale (VAS) for pain, the Manchester Oxford Foot Questionnaire (MOxFQ), ankle dorsiflexion, and Achilles complex performance. RESULTS: Thirty-three of 40 patients completed the 6-year follow-up. Seven patients had crossed over from nonoperative treatment to operative treatment. At 6 years, the operative group demonstrated significantly better outcomes with AOFAS (88.9 vs 78.6, P = .012), for pain measured by VAS (2.5 vs 5.5, P < .001) and with the MOxFQ total score (24.4 vs 45.9, P = .05) (per protocol analysis excluding crossovers). No between-group differences were observed for ankle dorsiflexion or Achilles complex performance at 6 years. CONCLUSION: This study demonstrates that the improved function and reduced level of pain by proximal medial gastrocnemius recession and stretching is better compared to stretching alone after 6 years of follow-up for patients with chronic plantar fasciitis and a concomitant isolated gastrocnemius contracture. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Effect of Posterior Malleolar Fixation on Syndesmotic Stability.

BACKGROUND: Transsyndesmotic fixation with suture buttons (SBs), posterior malleolar fixation with screws, and anterior inferior tibiofibular ligament (AITFL) augmentation using suture tape (ST) have all been suggested as potential treatments in the setting of a posterior malleolar fracture (PMF). However, there is no consensus on the optimal treatment for PMFs. PURPOSE: To determine which combination of (1) transsyndesmotic SBs, (2) posterior malleolar screws, and (3) AITFL augmentation using ST best restored native tibiofibular and ankle joint kinematics after 25% and 50% PMF. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty cadaveric lower-leg specimens were divided into 2 groups (25% or 50% PMF) and underwent biomechanical testing using a 6 degrees of freedom robotic arm in 7 states: intact, syndesmosis injury with PMF, transsyndesmotic SBs, transsyndesmotic SBs + AITFL augmentation, transsyndesmotic SBs + AITFL augmentation + posterior malleolar screws, posterior malleolar screws + AITFL augmentation, and posterior malleolar screws. Four biomechanical tests were performed at neutral and 30° of plantarflexion: external rotation, internal rotation, posterior drawer, and lateral drawer. The position of the tibia, fibula, and talus were recorded using a 5-camera motion capture system. RESULTS: With external rotation, posterior malleolar screws with AITFL augmentation resulted in best stability of the fibula and ankle joint. With internal rotation, all repairs that included posterior malleolar screws stabilized the fibula and ankle joint. Posterior and lateral drawer resulted in only small differences between the intact and injured states. No differences were found in the efficacy of treatments between 25% and 50% PMFs. CONCLUSION: Posterior malleolar screws resulted in higher syndesmotic stability when compared with transsyndesmotic SBs. AITFL augmentation provided additional external rotational stability when combined with posterior malleolar screws. Transsyndesmotic SBs did not provide any additional stability and tended to translate the fibula medially. CLINICAL RELEVANCE: Posterior malleolar fixation with AITFL augmentation using ST may be the preferred surgical method when treating patients with acute ankle injury involving an unstable syndesmosis and a PMF ≥25%.

Arthroscopic Repair of Chronic Plantar Plate Tears of the First Metatarsophalangeal Joint: A New Surgical Technique With Patient Outcomes.

Background: Most plantar plate tears of the first metatarsophalangeal joint can be treated successfully by nonoperative means. Primary repair may be indicated to restore continuity of the plantar structures and joint stability. Inadequate or failed nonoperative treatment may cause persistent pain and disability and thereby represent a career-threatening injury to an athlete. The chronic plantar plate tears are difficult both to diagnose and to treat. When surgical treatment is indicated, traditionally a wide plantar or 2 parallel incisions are used. An arthroscopic approach allows for verification and visualization of the injury and, at the same time, repair of the injury. Purpose: To describe findings of plantar plate tears, present a new arthroscopic procedure for plantar plate tear repair, and present the outcomes after surgery. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective study on the first 10 patients treated with the arthroscopic technique. The patients underwent surgery between June 2017 and January 2021. Patient data, clinical symptoms and findings, and operative details were obtained from the patient records. Patients were contacted via email to complete patient-reported outcome measures (Manchester Oxford Foot Questionnaire [MOxFQ] and Numeric Rating Scale [NRS] for pain). Results: Four female and 6 male patients with a median age of 24 years (range, 12-44 years) were operated on at a median of 20 months (range, 2-38 months) after injury. Of the 10 patients, 8 had a hyperextension injury of the first metatarsophalangeal joint and 7 had a subtle valgus malalignment of the hallux; 8 patients were injured during sport activity. All patients reported plantar pain at pushoff. All but 1 patient returned to the same level of preinjury activity within 6 months. At a median of 29 months (range, 7-49 months) after surgery, the median MOxFQ score was 6 (range, 0-41) and the median NRS pain score was 0. Conclusion: Arthroscopic plantar plate repair of chronic plantar plate tears resulted in a high rate of return to activity/sport and excellent outcome scores.

Outcome after nonoperative treatment of stable Lisfranc injuries. A prospective cohort study.

BACKGROUND: The aim of this study was to evaluate the outcome after nondisplaced and stable Lisfranc injuries. METHODS: 26 patients with injuries to the Lisfranc joint complex detected on CT scans, but without displacement were tested to be stable using a fluoroscopic stress test. The patients were immobilized in a non-weightbearing short leg cast for 6 weeks. The final follow-up was 55 (IQR 53-60) months after injury. RESULTS: All the Lisfranc injuries were confirmed to be stable on follow-up weightbearing radiographs at a minimum of 3 months after injury. Median American Foot and Ankle Society (AOFAS) midfoot score at 1-year follow-up was 89 (IQR 84-97) and at final follow-up 100 (IQR 90-100); The AOFAS score continued to improve after 1-year (P=.005). The median visual analog scale (VAS) for pain was 0 (IQR 0-0) at the final follow-up. One patient had radiological signs of osteoarthritis at 1-year follow-up. CONCLUSION: Stable Lisfranc injuries treated nonoperatively had an excellent outcome in this study with a median follow-up of 55 months. The AOFAS score continued to improve after 1 year.

Unilateral, Volume-expanding Os Subcalcis: Patient History and Treatment: A Case Report.

Accessory bones of the foot are common, but the presence of accessory bones located at the plantar aspect of the calcaneus is rare. We present the case of a 72-year-old female that suffered with a volume expanding os subcalcis. Due to marked disability, the large os subcalcis was excised with a favorable outcome.

Chronic Syndesmotic Injury: Revision and Fixation With a Suture Button and a Quadricortical Screw.

Background. Chronic syndesmotic injury may cause long-term pain and reduced ankle function. Today, there is no consensus about the best surgical treatment of these injuries. We present the technique and results of revision and fixation with a suture button and a quadricortical screw. Methods. Eleven patients treated for chronic syndesmotic injury were included. The patients completed questionnaires regarding ankle function, and computed tomography scans were obtained to evaluate tibiofibular distance and osteoarthritis. Complications were registered. Results. At mean 45 months follow-up, the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 87 points. There were 5 complications, including 3 hardware-related pain. The tibiofibular distance was significantly reduced with surgery. Seven patients had progression of osteoarthritis. Conclusions. Even though the majority of the patients had progression of radiological signs of osteoarthritis, the functional outcome after revision and fixation with a suture button and a quadricortical screw in chronic syndesmotic ruptures is good and comparable to the results presented in other studies.Levels of Evidence: Level IV: Case series without control, technical note.

Temporary Bridge Plating vs Primary Arthrodesis of the First Tarsometatarsal Joint in Lisfranc Injuries: Randomized Controlled Trial.

BACKGROUND: Unstable Lisfranc injuries are best treated with anatomic reduction and stable fixation. There are controversies regarding which type of stabilization is best. In the present study, we compared primary arthrodesis of the first tarsometatarsal (TMT) joint to temporary bridge plating in unstable Lisfranc injuries. METHODS: Forty-eight patients with Lisfranc injuries were included and followed for 2 years. Twenty-four patients were randomized to primary arthrodesis (PA) of the medial 3 TMT joints, whereas 24 patients were randomized to temporary bridge plate (BP) over the first TMT joint and primary arthrodesis of the second and third TMT joints. The main outcome parameter was the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scale and the secondary outcome parameters were the 36-Item Short Form Health Survey (SF-36) and visual analog scale for pain (VAS pain). Computed tomography (CT) scans pre- and postoperatively were obtained. Radiographs were obtained at follow-ups. Pedobarographic examination was performed at the 2-year follow-up. Twenty-two of 24 patients in the PA and 23/24 in the BP group completed the 2-year follow-up. RESULTS: The mean AOFAS midfoot score 2 years postoperatively was 89 (SD 9) in the PA group and 85 (SD 15) in the BP group (P = .32). There were no significant differences between the groups with regard to SF-36 or VAS pain scores. The alignment of the first metatarsal was better in the BP group than in the PA group measured by the anteroposterior Meary angle (P = .04). The PA group had a reduced peak pressure under the fifth metatarsal (P = .047). In the BP group, 11/24 patients had radiologic signs of osteoarthritis in the first TMT joint. CONCLUSION: Both treatment groups had good outcome scores. The first metatarsal was better aligned in the BP group; however, there was a high incidence of radiographic osteoarthritis in this group. LEVEL OF EVIDENCE: Therapeutic level I, prospective randomized controlled study.

Flexor hallucis longus tendon transfer for chronic Achilles tendon rupture. A retrospective study.

BACKGROUND: The transfer of Flexor Hallucis Longus Tendon (FHL) is an established method for the treatment of chronic Achilles tendon ruptures. An extensive examination of power, strength, endurance and complications related to this procedure is presented. METHODS: 21 patients treated with open FHL transfer for chronic Achilles tendon rupture were studied retrospectively. Medical records were reviewed. The patients were examined with a test battery for triceps surae strength, functional tests and PROMs. RESULTS: The median maximal concentric strength was equal,1300 vs 1336W, comparing affected with unaffected side. The endurance tests showed a larger difference, 219J vs. 2398J, respectively. The median AOFAS score was 87. 11 of 21 patients sustained one or more complications; the most common were infection, disturbed wound healing, and clawing of small toes. CONCLUSIONS: Patients achieve almost normal maximal strength after open FHL transfer, but endurance is notably lower. The complication rate was high.

Proximal Medial Gastrocnemius Recession and Stretching Versus Stretching as Treatment of Chronic Plantar Heel Pain.

BACKGROUND:: Plantar heel pain is a common disorder that can lead to substantial pain and disability. Gastrocnemius recession has been described as an operative treatment option, but there is a lack of prospective clinical and biomechanical outcome data. The aim of this study was to evaluate the clinical and biomechanical outcomes of gastrocnemius recession and stretching compared with a stretching exercise protocol for patients with plantar heel pain lasting more than 12 months. METHODS:: Forty patients with plantar heel pain lasting more than 1 year were randomized to a home stretching exercise program only or to surgery consisting of a proximal medial gastrocnemius recession in addition to stretching exercises. The main outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at 12 months. Secondary clinical outcomes were the Short Form-36 (SF-36) and visual analogue scale (VAS) pain scores. The biomechanical outcome parameters were ankle dorsiflexion, Achilles function evaluated by a test battery with 6 independent tests, and plantar pressure evaluated by pedobarography. All data were obtained at baseline and at 12-month follow-up. RESULTS:: The AOFAS score increased from 59.5 (42-76) to 88.0 (50-100; P < .001) for the operative group and from 52.5 (37-73) to 65.5 (31-88; P = .138) for the nonoperative group. The AOFAS, VAS pain, and SF-36 scores were significantly better in the operative compared with the nonoperative group at 12-month follow-up ( P < .05). Ankle dorsiflexion increased from 6 degrees (-3 to 15) to 10.5 degrees (0 to 23; P < .001). No between-group difference was observed for Achilles function at follow-up. The average forefoot plantar pressure for the operative group increased from 536 KPa (306-708) to 642 KPa (384-885) at follow-up ( P < .001). CONCLUSION:: Proximal medial gastrocnemius recession with a stretching program was a safe and efficient method of treating chronic plantar heel pain. LEVEL OF EVIDENCE:: Level 1, randomized clinical trial.

Validation of a New Device for Measuring Isolated Gastrocnemius Contracture and Evaluation of the Reliability of the Silfverskiöld Test.

BACKGROUND: Important aspects on the diagnostics of isolated gastrocnemius contractures (IGCs) have been poorly described. This study was designed to validate a new ankle range of motion (ROM) measuring device for diagnosing an IGC. In addition, we wanted to investigate the reliability of the clinical Silfverskiöld test. METHODS: Twelve health care personnel (24 feet) were examined by 4 testers on 3 different occasions for the reliability testing of the new ankle ROM measuring device. The same participants were examined using the Silfverskiöld test to examine the reliability of the clinical test. Eleven patients (15 feet) with IGC were examined before gastrocnemius recession, immediately after surgery, and 3 months after surgery to examine the validity and responsiveness of the ankle ROM device. RESULTS: An intraclass correlation coefficient (ICC) >0.85 was found for both inter- and intrarater reliability for the new ankle ROM device. The device confirmed an IGC in 13 of 15 feet before surgery and 3 of 13 feet at 3-month follow-up. At baseline, the measured ankle dorsiflexion was median 3 degrees with the knee in extension, which increased to 10 degrees ( P < .001) immediately after surgery and 12 degrees ( P = .003) at 3-month follow-up. ICC values of 0.230 to 0.791 were observed for the inter- and intrarater reliability testing of the clinical Silfverskiöld test. CONCLUSION: The new ankle ROM measuring device was reliable and responsive for detecting IGC. The Silfverskiöld test had poor inter- and intrarater reliability. Level of evidence Level II, prospective cohort study.

Endoscopic Transfer of Flexor Hallucis Longus Tendon for Chronic Achilles Tendon Rupture: Technical Aspects and Short-Time Experiences.

BACKGROUND: Chronic Achilles tendon ruptures can lead to reduced power of plantar flexion in the ankle with impaired gait ability. The open 1- or 2-incision technique for flexor hallucis longus transfer has proven good functional outcome but has the disadvantage of relatively extensive surgery performed at a vulnerable location. To reduce the risk of soft tissue problems, the flexor hallucis longus transfer can be performed endoscopically. MATERIAL AND METHOD: An endoscopic technique for flexor hallucis longus transfer is presented together with the experiences from the first six patients operated with this method. RESULTS: No wound healing problems or infections. Five of 6 patients managed single leg heel raise on the affected side 12 months after surgery. CONCLUSION: The functional results are promising. The soft tissue dissection is minor, and no patients had postoperative wound healing problems or infection. Endoscopic flexor hallucis longus transfer may be an operative procedure that can be considered also in patients with potential wound healing problems. LEVELS OF EVIDENCE: Level IV: Technical note/case series without controls.

Surgically treated talar fractures. A retrospective study of 50 patients.

BACKGROUND: Talar fractures are associated with a high incidence of avascular necrosis (AVN), osteoarthritis (OA) and malunion. The aim of this study was to evaluate the complications, the functional outcome, and the need for secondary surgery following surgically treated talar fractures. METHODS: Fifty patients with 52 talar fractures were included in the study. The health related quality of life was evaluated using visual analogue scale (VAS). The ankle function was scored using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. OA and AVN were evaluated on plain radiographs and computerized tomography (CT) scans. RESULTS: VAS score was 69±18 (mean±SD) and AOFAS ankle-hindfoot score was 73±17 (mean±SD). OA was seen in 98% and AVN in 65% of the talar bones. Secondary surgery had been performed in 38% of the feet. CONCLUSION: Long-term complications were commonly seen after talar fractures and had a significant impact on daily life activities and quality of life. The need for secondary surgery was high. Prolonged follow-up is necessary to detect long-term complications, and the patients should be offered a low threshold for recontact.

Do stable multiply injured patients with bilateral femur fractures have higher complication rates? An investigation by the EPOFF study group.

BACKGROUND: Polytrauma patients with bilateral femur shaft fractures are known to have a higher rate of complications when compared with those who have sustained unilateral fractures. The current study tests the hypothesis that the high incidence of posttraumatic complications in patients who do not have a severe head or chest injury is caused by accompanying injuries rather than by the additional femur fracture. METHODS: Inclusion criteria New Injury Severity Score > 16 points; AIS score value of the chest ≤3 points and no severe head injury. Two study groups: a unilateral group (USF group) (n = 146) and a bilateral femur shaft fracture group (BSF group) (n = 19). Endpoints monitored were length of stay in the intensive care unit, duration on a ventilator, and several postsurgical complications (e.g., SEPSIS, acute lung injury). Statistics Fisher's exact test for binary variables, and independent t-tests and regression analyses for continuous indicators of injury severity and clinical outcomes. RESULTS: Patients with bilateral femur fractures had a significantly higher incidence of hemothorax. Moreover, they received blood transfusions more often upon admission, and exhibited a longer ICU stay (p = 0.008). However, this patient group did not exhibit a significantly higher incidence of postsurgical complications (p = 0.1) than those with unilateral fractures. After adjusting for injury severity, no difference in the length of the ICU stay was observed. Bilateral fracture patients who were in an uncertain condition preoperatively had a longer length of stay in the ICU postoperatively (p = 0.002). CONCLUSIONS: In the absence of major head or chest injuries, patients with multiple injuries and bilateral femur shaft fractures have a similar complication rate to polytrauma patients with unilateral fractures. Moreover, an uncertain condition preoperatively was associated with an increased stay in the intensive care unit. The results support the idea that associated injuries rather than the additional femur fracture are responsible for complications during the clinical stay.

Coagulation, fibrinolysis and cytokine responses to intramedullary nailing of the femur: an experimental study in pigs comparing traditional reaming and reaming with a one-step reamer-irrigator-aspirator system.

INTRODUCTION: Operations in trauma patients represent a second insult and the extent of the surgical procedures influences the magnitude of the inflammatory response. Our hypothesis was that a reamer-irrigator-aspirator (RIA) system would cause a lesser inflammatory response than traditional reaming (TR). MATERIALS AND METHODS: Coagulation, fibrinolysis and cytokine responses were studied in Norwegian landrace pigs during and after intramedullary nailing (IMN) with two different reaming systems using ELISA and chromogenic peptide substrate assays. The TR (n=8) and the RIA (n=7) reaming systems were compared to a control group (n=7). The animals were followed for 72 h. Arterial, mixed venous and femoral vein blood were withdrawn simultaneously peroperatively and until 2 h after the nail was inserted for demonstration of local, pulmonary and systemic activation of the cascade systems. At 6 h, 24 h, 48 h and 72 h postoperatively arterial blood samples were withdrawn. RESULTS: Significantly procedure-related increased levels were found for thrombin-antithrombin (TAT) and tissue plasminogen activator (t-PA) in the TR group and TAT in the RIA group. The local and the pulmonary activation of coagulation and fibrinolysis were more pronounced in the TR than in the RIA group, the difference reached significance for plasminogen activator inhibitor-1 (PAI-1) (arterial blood). The cytokine response, mainly represented by IL-6 increase, was more pronounced in the TR than the RIA group, and was significant for IL-6 in femoral vein blood. The arterial levels of IL-6 exceeded the mixed venous levels indicating an additional pulmonary activation of IL-6. Two animals in the TR group, who died of pulmonary embolism (PE) prior to planned study end point, had a more pronounced response compared to the rest of the TR group. CONCLUSION: A procedure-related coagulation and fibrinolytic response was demonstrated in both reaming groups, with more pronounced response in the TR than in the RIA group. Elevated levels of cytokines were demonstrated related to reaming and nailing, with significantly higher IL-6 levels in the TR than in the RIA group.

Intravasation of bone marrow content. Can its magnitude and effects be modulated by low pressure reaming in a porcine model?

INTRODUCTION: Intramedullary orthopaedic procedures may increase the intramedullary pressure (IMP) and thereby cause intravasation of bone marrow contents. In recent studies by the authors the reamer-irrigator-aspirator (RIA) has been demonstrated to reduce IMP and coagulation-, fibrinolysis- and cytokine responses, but did not prove any significant difference in cardiopulmonary function parameters or numbers of emboli when compared to a traditional reaming (TR) system. The correlations between IMP increase, regardless type of reamer, and inflammatory- and coagulation responses, pulmonary embolization, and cardiopulmonary alterations have, however, not previously been analyzed in this material. Our hypothesis was that a lower IMP would result in reduced occurrence of pulmonary embolization, reduced inflammatory-and coagulation responses, as well as reduced cardiopulmonary alterations. MATERIALS AND METHODS: Twenty-eight young Norwegian landrace pigs were exposed to femoral intramedullary reaming, with either the TR (n = 10) or the RIA (n = 10) system, or used as controls (n = 8). IMP was recorded during reaming and nailing. Serial blood samples for demonstration of coagulation-, fibrinolysis-, and cytokine activation were withdrawn peroperatively and until 72 hours post nail insertion. Circulatory and pulmonary effects were monitored peroperatively and until two hours postoperatively. The animals were sacrificed 72 hours post nail insertion and lung tissue biopsies were harvested and examined for lung emboli. RESULTS AND CONCLUSIONS: A strong correlation between increased IMP and increased coagulation-and cytokine responses was found. The number of emboli was not significantly correlated to IMP, but was strongly correlated to changes in the coagulation- and cytokine responses. No clinical relevant correlations were observed between increased IMP or numbers of lung emboli and changes in hemodynamic- or pulmonary function parameters. A correlation between coagulation activation and cytokine activation was observed. This study confirms the connection between increased IMP, increased coagulation activation and the magnitude of pulmonary emboli in a model evaluating the effects of intramedullary reaming of intact pig femora. In this model, the lowering of IMP during reaming, as obtained with RIA, reduced the magnitude of and the effects of bone marrow extravasation.

Cardiopulmonary response to reamed intramedullary nailing of the femur comparing traditional reaming with a one-step reamer-irrigator-aspirator reaming system: an experimental study in pigs.

BACKGROUND: Intramedullary reaming and nailing increases intramedullary pressure. This may cause intravasation of bone marrow contents, leading to bone marrow embolization and altered cardiopulmonary function. Possible beneficial effects of attenuation of the intramedullary pressure increase by the use of a reamer-irrigator-aspirator (RIA) system were studied with the hypothesis that the RIA technique would cause lower numbers of pulmonary embolisms (PEs) and lesser cardiopulmonary affection than traditional reaming (TR). MATERIAL AND METHODS: Intramedullary reaming and nailing was performed in intact femora of young Norwegian landrace pigs using either a standard intramedullary nailing technique (n = 8) or a RIA technique (n = 7). The hemodynamic and pulmonary effects were investigated during the reaming and nailing procedure and for 2 hours postoperatively. The animals were killed after 72 hours, and the lung/carcass weight ratio and the numbers of PEs were investigated. RESULTS AND CONCLUSION: The pattern of the procedure-related hemodynamic and pulmonary effects did not differ significantly between the RIA and the TR groups. The RIA group had lower numbers (ns) of embolisms per square centimeter lung area than the TR group. After reaming with the TR device, two animals died of PEs, the first postoperative day. The patients with femoral shaft fracture and additional cardiopulmonary injury or preexisting reduced cardiopulmonary function, however, need special attention, and the use of RIA may, in these cases, represent a better operative alternative with a lesser operative burden.

Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients).

OBJECTIVES: The timing of definitive fixation for major fractures in patients with multiple injuries is controversial. To address this gap, we randomized patients with blunt multiple injuries to either initial definitive stabilization of the femur shaft with an intramedullary nail or an external fixateur with later conversion to an intermedullary nail and documented the postoperative clinical condition. METHODS: Multiply injured patients with femoral shaft fractures were randomized to either initial (<24 hours) intramedullary femoral nailing or external fixation and later conversion to an intramedullary nail. Inclusion: New Injury Severity Score >16 points, or 3 fractures and Abbreviated Injury Scale score > or =2 points and another injury (Abbreviated Injury Scale score > or =2 points), and age 18 to 65 years. Exclusion: patients in unstable or critical condition. Patients were graded as stable or borderline (increased risk of systemic complications). OUTCOMES: : Incidence of acute lung injuries. RESULTS: Ten European Centers, 165 patients, mean age 32.7 +/- 11.7 years. Group intramedullary nailing, n = 94; group external fixation, n = 71. Preoperatively, 121 patients were stable and 44 patients were in borderline condition. After adjusting for differences in initial injury severity between the 2 treatment groups, the odds of developing acute lung injury were 6.69 times greater in borderline patients who underwent intramedullary nailing in comparison with those who underwent external fixation, P < 0.05. CONCLUSION: Intramedullary stabilization of the femur fracture can affect the outcome in patients with multiple injuries. In stable patients, primary femoral nailing is associated with shorter ventilation time. In borderline patients, it is associated with a higher incidence of lung dysfunctions when compared with those who underwent external fixation and later conversion to intermedullary nail. Therefore, the preoperative condition should be when deciding on the type of initial fixation to perform in patients with multiple blunt injuries.

Bone marrow fat in the circulation: clinical entities and pathophysiological mechanisms.

Fat embolism (FE) and fat embolism syndrome (FES) are controversial topics, particularly regarding their clinical relevance and their independency as a clinical syndrome. FE describes the presence of fat globules within the microcirculation. FES on the other hand, is a clinical syndrome characterized by the presence of FE with the manifestation of an identifiable clinical pattern of signs and symptoms. Both experimental and clinical studies have demonstrated the occurrence and the possible harmful effects of FE. For instance, FE involving the lungs can result in adult respiratory distress syndrome (ARDS). The effects of FE are certainly mechanical, leading to capillary congestion, but are also highly likely to be of a proinflammatory and prothrombotic nature. The demarcation of FES against ARDS is mainly demonstrated by the single organ involvement of ARDS, exclusively influencing the lungs, whereas FES has a multiorgan effect with pulmonary, skin and, neurological manifestations. This article is a review of the pathophysiological mechanisms of FE and the clinical occurrence and influence of FE and FES.

The influence of a one-step reamer-irrigator-aspirator technique on the intramedullary pressure in the pig femur.

BACKGROUND: Increased intramedullary pressure in the femoral cavity causes intravasation of bone marrow content to the circulation which may lead to occlusion of pulmonary vessels and cardiorespiratory dysfunction. A one-step reamer-irrigator-aspirator (RIA) technique has been developed to reduce the intramedullary pressure (IMP) during the reaming procedure. This study was design to compare IMP with a standard reaming technique with IMP during reaming with the RIA system with a hypothesis that the RIA system would involve lower pressures. MATERIAL AND METHOD: In a randomised study in 19 Norwegian landrace pigs reamed intramedullary nailing was performed with two different reamer devices. Nine animals were operated with a traditional reamer and 10 animals with RIA. One animal in the RIA group was excluded due to a perioperative femoral fracture, and three animals in the traditional group were excluded due to a perforation of the distal medial femoral cortex. The intramedullary pressure was registrated with a transducer-tipped pressure monitoring catheter during reaming. RESULTS: There was a significantly higher intramedullary pressure (P<0.05) during reaming in the traditional reamer group (mean 188+/-38 mmHg) than in the RIA group (mean 33+/-8 mmHg). Intramedullary pressures recorded before surgery, at the opening of the femoral cavity with an awl, by insertion of a guide wire, at insertion of the intramedullary nail, and 10 min after nail insertion showed no significant differences between the groups. CONCLUSION: The use of a one-step reamer-irrigator-aspirator technique in the pig femur induced less intramedullary pressure increase than the use of a traditional reamer.