Unstable fractures of the tibia treated with a reamed intramedullary interlocking nail.

One hundred thirty-four acute unstable fractures of the tibia were treated with a reamed intramedullary nail with locking capabilities. There were 101 closed and 33 open fractures (20 Grade 1 fractures, 12 Grade 2 fractures, and 1 fracture from a gunshot wound). Patients were seen in followup for an average of 16 months after nailing. The time to fracture union averaged 28 weeks in closed fractures and 39 weeks in open fractures. Delayed union (> 6 months) developed in 14 fractures (8%): 11 closed (11%) and 3 open (9%) fractures. Eleven of the 14 delayed unions healed spontaneously, or after dynamization of statistically locked nails. Seven fractures (5%) were not healed by 9 months and were classified as nonunion (2 closed, 5 open). All fractures required major additional procedures to obtain union. Infection developed in 13 fractures (10%). In closed fractures, there were 2 superficial (2%) and 3 deep (3%) infections; in open fractures there was 1 superficial (3%) and 7 deep (21%) infections. The authors conclude that reamed intramedullary nails should be restricted to unstable, closed tibial shaft fractures. Its use in open fractures even on a delayed basis cannot be recommended because of unacceptably high infection rates.

The management of gunshot wounds to the femur.

This article is an overview of the management of femoral shaft fractures resulting from gunshot wounds. It deals with the initial patient evaluation, operative techniques of fracture stabilization and wound care, associated complications, and the postoperative rehabilitation of these complex fractures. The recommendations are based upon a large patient experience in an urban trauma center.

A prospective study of fractures of the femoral shaft treated with a static, intramedullary, interlocking nail comparing one versus two distal screws.

In a nonrandomized prospective study, 178 comminuted or length unstable femur fractures were treated with a statically locked, slotted, titanium alloy interlocking nail. Patients were divided into two groups based on the number of distal interlocking screws that were used. The patients were followed up for an average of 17 months to determine if the use of a single distal screw provided adequate fracture stability without loss of fracture fixation.

Hip joint arthrodesis utilizing anterior compression plate fixation.

Sixteen patients who had undergone hip arthrodesis utilizing an anteriorly placed compression plate were evaluated at an average of 4.5 years after surgery. The technique was designed to facilitate future conversion to a total hip arthroplasty by preserving the abductor musculature. Of the 11 patients who underwent primary fusions, 5 failed to unite (45%). Nonunion occurred in all five (100%) patients undergoing refusion for a failed surgical arthrodesis. The authors conclude that an anterior compression plate alone in patients with limited bone stock does not provide adequate fixation and predisposes the patient to failure of fixation and nonunion.

Nonunion of the tibia treated with a reamed intramedullary nail.

Forty-seven tibial nonunions were treated with a reamed intramedullary nail. Initially, there were 14 (30%) closed and 33 (70%) open tibial fractures. The initial fracture management consisted of casts in 12 (26%) patients, Ender or Lottes nails in nine (19%), and external fixation in 26 (55%). The time from injury to nailing averaged 31.5 weeks. All but one fracture was nailed using a closed technique (98%). Twenty-six patients were initially managed with external fixation. Duration of fixation averaged 11 weeks, and the time from fixator removal to nailing averaged 24 weeks. Patients were followed for an average of 18.7 months after nailing. Forty-two of the 47 (89%) nonunions united uneventfully. Infection developed in six (13%) patients, five of which occurred in previously open fractures treated with external fixation. After one or more procedures, these nonunions consolidated without apparent infection. Reamed intramedullary nailing is a safe and effective method of treatment for tibial nonunions of previously closed fractures and prior open fractures that have been treated with Ender or Lottes nails. Because of the risk of infection, we do not recommend its use after external fixation of open fractures.

Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications.

In a retrospective study, 58 patients with 60 tibial plafond fractures were treated by internal fixation and reviewed over an average follow-up period of 2.5 years. There were three Reudi Type I, 27 Reudi Type II, and 30 Reudi Type III fractures. Twelve fractures were open, and 60% of the fractures were the result of high-energy trauma. Results were evaluated based on a subjective and objective rating system. There were 15 good and excellent (25%), 15 fair (25%), and 30 poor results (50%). The deep infection rate in Reudi Types I and II fractures was 0%, and in Type III fractures it was 37%. The deep infection rate statistically correlated with the presence of a postoperative wound dehiscence or skin slough but not with the presence of an open fracture. Overall clinical rating correlated with the Reudi classification, quality of reduction, and the presence of a postoperative wound infection. The ankle fusion rate for Reudi Types I and II fractures was 10%, whereas that in Reudi Type III fractures was 26%. The results of this study show that operative treatment of complex intraarticular fractures of the distal tibia remain fraught with difficulty and that the complication rates and need for further reconstructive surgery remains high. If anatomic reduction without soft-tissue complications cannot be predicted preoperatively, consideration should be given to alternative types of treatment.

External skeletal fixation and rectus abdominis free-tissue transfer in the management of severe open fractures of the tibia.

The management of severe open fractures of the tibia remains one of the more challenging problems facing the orthopedic surgeon. Patients who sustain high-energy injuries with loss of soft tissue in conjunction with displaced comminuted fractures face high rates of delayed union, nonunion, infection, and in some instances, amputation. This article discusses materials, methods, and surgical techniques.

Meniscal injury associated with femoral shaft fractures. An arthroscopic evaluation of incidence.

We studied 47 patients with closed, displaced, diaphyseal fractures of the femur caused by blunt trauma, to determine the incidence of associated knee injuries, particularly of the meniscus. After femoral nailing, all patients had an examination under anaesthesia and an arthroscopy. There were 12 medial meniscal injuries (5 tears) and 13 injuries of the lateral meniscus (8 tears). Ten of the 13 tears were in the posterior third of the meniscus, and two patients had tears of both menisci. Synovitis was common at the meniscal attachments. Complex and radial tears were more common than peripheral or bucket-handle tears. Examination under anaesthesia revealed ligamentous laxity in 23 patients (49%), but meniscal injuries had a similar incidence in knees with and without ligament injury. Femoral shaft fractures are often associated with injuries to the ipsilateral knee, and a high index of suspicion is necessary to identify these lesions.

Olecranon fractures. A clinical and radiographic comparison of tension band wiring and plate fixation.

Forty-one adult patients with displaced olecranon fractures were treated with open reduction internal fixation in a prospective, randomized study comparing tension band wiring (TBW) and plate fixation (PF). Plate fixation required longer operative time, but did not lead to an increased complication rate. Range of elbow motion at six months did not differ significantly between the two groups. Symptomatic metal prominence was frequently observed after TBW (42%), although true Kirschner wire (K-wire) migration was seen in only one patient. Postoperative loss of reduction, leading to a significant articular step-off or gap, was more frequent after TBW (53%) than after PF (5%). Tension band wiring resulted in 37% good clinical and 47% good roentgenographic results, as compared with PF, which resulted in 63% good clinical and 86% good roentgenographic results. Plate fixation should be carefully considered when planning open reduction and internal fixation of displaced olecranon fractures.

Compression plating for non-union after failed external fixation of open tibial fractures.

Fifty non-unions of the tibia that were present in forty-nine patients after external fixation and immobilization in a cast for a high-energy fracture were subsequently treated by compression plating. Initially, there were forty-six open fractures and four closed fractures with a compartment syndrome. Twenty-two non-unions (44 per cent) had early soft-tissue reconstruction (thirteen rotational and nine free flaps). The duration of external fixation averaged ten weeks, and the mean time from injury to plating was eight months. None of the non-unions were infected at the time of plating. The average preoperative deformity in the sagittal (anterior-posterior) plane was 8 degrees and in the frontal (medial-lateral) plane, 9 degrees; after plate fixation, the residual angulation averaged 3 and 2 degrees. Autogenous bone graft was used in thirty-nine of the fifty non-unions. The patients were followed for an average of twenty-four months. Forty-six (92 per cent) of the non-unions united, in an average of seven months, without further intervention. In four patients (8 per cent), the plate broke, necessitating re-plating in three and external fixation in one (the latter patient had an infected non-union). A deep infection developed in three patients (6 per cent). Ultimately, forty-eight non-unions (96 per cent) healed without evidence of infection. Plate osteosynthesis is an effective method of treatment for patients who have had an open fracture of the tibia that has failed to unite after external fixation and immobilization in a cast.

Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing.

Ninety-five subtrochanteric femoral fractures were treated with an interlocking nail. There were 69 closed and 26 open fractures. This injury was the result of high-energy trauma in 77% of the cases. The average time to healing was 25 weeks. There were three delayed unions, one nonunion, and six malunions. Essentially all nonpathologic, subtrochanteric femur fractures can be stabilized by interlocking nailing, regardless of the fracture pattern or degree of comminution. Favorable mechanical characteristics of interlocking nails have eliminated the requirement of surgically reconstituting the medial femoral cortex. Closed interlocking nailing is the preferred treatment for subtrochanteric fractures of the femur resulting from trauma.

Type II floating knee: ipsilateral femoral and tibial fractures with intraarticular extension into the knee joint.

Thirty-four patients with ipsilateral fractures of the femur and tibia with intraarticular extension into the knee of at least one fracture were reviewed at an average follow-up of 38 months. Joint involvement was present in 22 (65%) femoral fractures and 23 (68%) tibial fractures. In 11 (32%) patients, both fractures were intraarticular. In 71% of the patients, there were major associated injuries. Open fractures were common, occurring in 21 (62%) extremities. Associated vascular injuries were seen in seven (21%) cases. Ninety percent of the fractures were surgically stabilized. The average time to healing was 39 and 37.5 weeks for the femur and tibia, respectively. The average flexion of the knee was 96 degrees (5-140 degrees) with flexion contractures occurring in five (15%) knees. Results were graded according to criteria established by Karlström and Olerud. Only eight (24%) patients had good or excellent results. Complications were frequent, with deep infections occurring in 11 (32%) extremities, leading to above-knee amputations in three (9%) patients. This subgroup of floating knee injuries appears to be associated with a higher degree of systemic trauma, a higher percentage of open injuries, and a much graver prognosis.

Ipsilateral fractures of the femoral neck and shaft.

Thirty-three patients with ipsilateral intracapsular femoral neck and shaft fractures were treated with antegrade reamed intramedullary (IM) nails and cancellous screw fixation of the femoral neck. The shaft fractures were fixed prior to definitive neck stabilization. A "reversed" nail construct was used in 13 patients, a conventional interlocked nail was used in 6, and a reconstruction nail was used in the remaining 14. Thirty-one (94%) of the femoral shaft fractures healed primarily. In two patients, the shaft fracture failed to unite and was bone grafted and plated, respectively; the fractures subsequently healed. However, only 27 (82%) of the femoral neck fractures healed after initial fixation. In six patients (18%), a symptomatic varus nonunion developed, requiring a valgus osteotomy. Five of the six femoral neck non-unions and all of the osteotomy sites united; however, two of these patients later developed osteonecrosis of their femoral heads. Closed reamed antegrade IM nailing with supplemental screw fixation of ipsilateral femoral neck and shaft fractures did not produce uniformly successful results because of high rates of varus nonunion of the femoral neck fracture.

Interlocking nailing for the treatment of femoral fractures due to gunshot wounds.

Fifty-six patients who had a fracture of the femur due to a low-velocity gunshot injury were treated with interlocking nailing with the Grosse-Kempf nail. Patients who had an isolated fracture were treated by intravenous administration of antibiotics followed by delayed interlocking nailing. Ninety-three per cent of the fractures had Grade-III or IV comminution. At an average duration of follow-up of sixteen months (range, twelve to twenty-nine months), the results of closed interlocking nailing were excellent. All of the fractures united an average of twenty-three weeks (range, fourteen to forty weeks) after the nailing. There were no apparent infections in the entire series. There were two delayed unions and seven malunions. Five patients had a serious associated vascular injury; four of these five had interlocking nailing immediately after vascular repair. The fractures united without any residual vascular insufficiency.

Subtrochanteric femur fractures: a comparison of the Zickel nail, 95 degrees blade plate, and interlocking nail.

Seventy-nine nonconsecutive patients with subtrochanteric femur fractures were divided into three groups based on the method of fracture fixation. Group I consisted of 21 patients treated with a Zickel nail, Group II comprised 25 patients treated with a 95 degrees blade plate, and Group III included 33 patients treated with an interlocking nail. All patients in Group I and Group II had open reduction and internal fixation of their fractures. Ninety-four percent of the patients in Group III were treated by closed intramedullary nailing. The average operating times for Groups I, II, and III were 212, 272, and 181 min, respectively, while blood loss averaged 900, 1,500, and 600 ml for each group, respectively. Group I had one infection, ten malunions, and one nonunion. Group II had one infection, six malunions, and two nonunions. Group III had no infections, two malunions, and one nonunion. We conclude that closed interlocking nailing is the treatment of choice for acute nonpathologic subtrochanteric femur fractures in adults. There is decreased blood loss, reduced operating time, and fewer complications than with either the Zickel nail or the 95 degrees blade plate regardless of the fracture pattern or the degree of fracture comminution.

Type III fractures of the tibial tubercle in adolescents.

Fifteen patients with Type III avulsion fractures of the tibial tubercle treated surgically were reviewed at an average of 9.6 years after injury. Six patients had a history of Osgood-Schlatter disease, and two patients had Type I osteogenesis imperfecta. Associated injuries to the meniscus were found and repaired in three patients. Two of these patients had also avulsed the origin of the tibialis anterior muscle, leading to a compartment syndrome in one. All but one fracture healed. There was one refracture. Five patients developed bursitis over prominent screw heads, which required screw removal. All but two patients were asymptomatic and participated in sports. A full range of knee motion without instability was present in all patients. Thigh and calf circumferences were equal to the opposite side. Radiographs showed normal knee joints in all but one asymptomatic patient, who showed signs of an early arthrosis. No patient developed angular or recurvatum deformities. However, a leg-length discrepancy of 1.0-1.8 cm was noted in four patients (two overgrowth, two undergrowth).