Fixation of Vancouver B1 peri-prosthetic fractures by broad metal plates without the application of strut allografts.

The use of allograft struts and cerclage wire, possibly augmented by plate fixation, for the treatment of Vancouver type-B1 peri-prosthetic fractures around a total hip replacement has been strongly advocated. We examined our results using plate fixation without allograft struts and compared them with the results of the use of struts alone or when combined with plate fixation. Of 20 consecutive patients with type-B1 fractures treated by open reduction and plate fixation, 19 were available for follow-up. The fractures healed in 18 patients with a mean time to weight-bearing of ten weeks (4 to 19). There were no cases of infection or malunion. Nonunion occurred in one patient and required a second plate fixation to achieve union. Safe, cost-effective treatment of Vancouver type-B1 fractures can be performed by plate fixation without the addition of cortical struts. This procedure may allow earlier weight-bearing than allograft strut fixation alone.

Femoral canal reaming in the polytrauma patient with chest injury. A clinical perspective.

It has been well documented that early fracture stabilization reduces morbidity and mortality in the patient who is multiply injured. However, controversy has developed recently concerning the timing and type of stabilization for the patient with multiple injuries who has sustained a femoral fracture and an associated severe chest injury. Reports from Europe have indicated an increased mortality rate and adult respiratory distress syndrome rate in the patient treated with reamed femoral rodding. A retrospective review of patients with multiple injuries with Injury Severity Scores of 18 points or greater who also had severe chest trauma was done at the Erie County Medical Center, Buffalo, NY. Three groups of patients were developed and studied: The patients in Group 1 had femoral fractures that were treated with early stabilization with a reamed rod; the patients in Group 2 had femoral fractures stabilized with plate fixation; and in Group 3, there were no femoral fractures. The Injury Severity Score for each group was nearly the same; however, the intensive care unit time was more than doubled in Group 2 and Group 3. There was a 33% adult respiratory distress syndrome rate in Group 2, a 27% rate in Group 3, and a 0% rate in Group 1. The mortality rate was highest for the group of patients without femoral fractures (Group 3), 10.9%. These clinical data seem to associate the chest injury with the increased adult respiratory distress syndrome and mortality rate, not the method of treatment for the femoral fracture.

Rotational remodeling of malrotated femoral fractures: a model in the rabbit.

It is estimated that 20-40% of femoral fractures in children heal in malrotation, yet few patients later complain. To determine if malrotation corrects spontaneously, midshaft osteotomies were made in femurs of 16 rabbits aged 8 weeks and the distal fragments were internally rotated 45 degrees, where they were held with external fixators. The animals were killed between week 0 and week 17. Version of the femoral necks was determined by computed tomography scan (CT). The version altered rapidly toward normal from weeks 0 to 4 and then remained stable, with an average rotational remodeling of 55%.

John Caffey Award paper. Avascular necrosis: early MR imaging and histologic findings in a canine model.

To examine the early MR and histologic changes of avascular necrosis, we surgically devascularized the distal femur of adult beagle dogs and performed short TR/short TE MR imaging and histologic examinations. MR showed increasing areas of low signal, and histologic examination showed changes of fat necrosis, inflammatory infiltrate, and fibrocytic and bony repair. These processes were divided into four stages. Stage 1 is seen in the first days after surgery and consists of homogeneous high signal on MR and only subtle histologic changes of early fat necrosis. Stage 2, seen by 7 days after surgery, shows linear low-signal areas within the high-signal marrow on MR and fat necrosis and an inflammatory infiltrate on histologic sections. Stage 3, seen by 16 days after surgery, shows patchy low signal occupying more of the marrow on MR with a fibrocytic infiltrate on histologic sections. Stage 4, seen by 23 days after surgery, shows a more homogeneous low and intermediate signal on MR and histologic findings of more organized fibrocytes and the onset of new bone formation. Using this model, we have proved that MR imaging can show marrow changes as soon as 1 week after the onset of avascular necrosis. Whereas MR imaging showed a progression of increasing areas of low signal, the histologic findings seen during this time were diverse, including inflammatory infiltration (a previously unreported finding), fat necrosis, and fibrocytic and osseous repair.

Definitive control of mortality from severe pelvic fracture.

Within a group of 271 patients with pelvic fracture, 69 patients met criteria for severe hemorrhage. Sixty consecutive patients were treated by a combined multispecialty musculoskeletal trauma service using a protocol designed to control bleeding, rapidly diagnose and control associated injuries, as well as to prepare the patient for open reduction of the pelvic fracture, if appropriate. The pneumatic antishock garment, external fixation, and angiography were selectively used to control bleeding. Abdominal injuries were diagnosed using clinical examination and diagnostic peritoneal lavage. When lavage aspirate was grossly bloody, patients had no negative explorations. Microscopically positive lavages were associated with a 50% false-negative rate. Using the protocol, the mortality rate was 5%. Overall mortality rate was 10%. The combination of a trauma team approach and a specifically designed protocol reduces the number of deaths from pelvic fracture.

Redirection of central venous pressure catheters using a flow directed technique.

The malposition of the tip of a central venous catheter occurs in 5 to 30 per cent of the attempts. Repositioning of the catheter tip can be successfully and safely performed in 87.5 per cent of the patients using a Fogarty balloon catheter and flow directed techniques to float the CVP catheter to the ideal location in the superior vena cava. Since the first attempt is almost uniformly successful (in six of seven patients), the flow directed technique is both cost effective and clinically efficient.

Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state.

Fifty-six blunt multiple trauma patients (HTI-ISS 22-57) were studied for the effects of immediate versus delayed internal fixation of a femur or acetabular fracture on the pulmonary failure septic state. The pulmonary failure septic state may be defined as an alveolar arterial oxygen tension difference greater than 100, plus fever and leukocytosis. These patients were divided into four groups. Group I (N = 20) had immediate internal fixation, postoperative ventilatory support, and was sitting up at 30 hours. Group II (N = 20) had 10 days of femur traction and postoperative ventilatory support. Group III (N = 9) was immediately extubated after surgery and had 30 days of femur traction. Group IV (N = 7) had special circumstances that should increase the duration of the pulmonary failure septic state. These four groups of patients were statistically identical by 20 different criteria on admission except that Group I had more recognized chest injuries than Group II (12 vs. 9). Group I required 3.4 +/- 2.6 days of ventilator support and 7.5 +/- 3.8 intensive care unit (ICU) days; they had 12 +/- 8.8 elevated white counts, 3.8 +/- 4 febrile days, 0.05 positive blood cultures per patient, four fracture complications out of 93 fractures, 59 injections of narcotics, and 23 +/- 8.6 acute care days. Ten days of femur traction doubled the duration of the pulmonary failure septic state relative to Group I at a statistically significant level for nine out of 10 criteria, while increasing the number of positive blood cultures by a factor of 10, the number of fracture complications by a factor of 3.5, and the use of injectable narcotics by a factor of 2. Thirty days of femur traction increased the duration of the pulmonary failure septic state relative to Group I by a factor of 3 to 5 for all criteria at a statistically significant level, while increasing fracture complications by a factor of 17, positive blood cultures by a factor of 74, and the use of narcotics by a factor of 2. Group IV, which had four out of seven immediate internal fixations, behaved similarly to Group II. Femoral shaft traction should be avoided in the blunt multiple trauma patients because it greatly increases the cost of care and the risk of multiple systems organ failure.(ABSTRACT TRUNCATED AT 400 WORDS)