Temporary partial intra-iliac balloon occlusion for the treatment of acetabulum fracture in a Jehovah's Witness: a case report.

Blunt trauma patients with acetabular fractures can lose as much as 2 L of blood after injury, and approximately 40% of these patients require blood transfusions. Fractures involving the anterior and posterior columns may require more than 1 surgery for adequate fracture fixation, increasing the potential for greater blood loss. Although blood transfusions may be medically necessary in these cases, Jehovah's Witnesses often refuse transfusion as a matter of religious conviction. The religious tenets of this faith preclude the use of blood transfusions and certain other blood products, based on an interpretation of Acts 15:29. To treat patients with these beliefs, various techniques have been developed to minimize blood loss as an alternative to transfusion. Temporary arterial balloon occlusion, also known as an "internal tourniquet," was first reported in 1954 for use in severe penetrating abdominal trauma. It was later used to control basilar artery bleeding and to limit blood loss in Jehovah's Witness patients undergoing revision total hip or knee arthroplasty. This case report documents the successful use of temporary balloon occlusion to minimize blood loss during an open reduction internal fixation of a both-column acetabulum fracture in a Jehovah's Witness patient. The method used for achieving this intra-iliac balloon occlusion is described in detail so that others also may implement this technique.

Biomechanical analysis of fixation for vertically unstable sacroiliac dislocations with iliosacral screws and symphyseal plating.

OBJECTIVES: To examine the effects of various iliosacral screw configurations with and without symphyseal plating on sacroiliac (SI) motion and hemipelvis stability in the vertically unstable pelvic model. DESIGN: Biomechanical, human cadaver. SETTING: Level 1 trauma center. INTERVENTION: Hemipelvis and SI motion were analyzed on a Materials Testing System before and after creation of a vertically unstable APC III pelvic injury. Posterior fixation constructs consisted of iliosacral screws: (1). one into S1, (2). two into S1, or (3). one into S1 and one into S2. Results were obtained for all posterior constructs with and without a two-hole symphyseal plate. MAIN OUTCOME MEASUREMENT: Hemipelvis and SI motion with axial loading. RESULTS: There was no statistically significant difference between one or two iliosacral screws when hemipelvis rotational or linear displacement was examined at the SI joint. The two-hole symphyseal plate significantly increased the stability of the fixation construct in resisting linear displacement in all three planes. Without the symphyseal plate, an abnormal loading response was seen at the SI joint, resulting in paradoxical posterior translation and sagittal plane rotation. The addition of the plate restored the normal response, and anterior rotation and translation were observed as in the intact state. CONCLUSIONS: Anterior symphyseal plating for the vertically unstable hemipelvis significantly increases the stability of the fixation construct and restores the normal response of the hemipelvis to axial loading. A significant benefit to supplementary iliosacral screws in addition to a properly placed S1 iliosacral screw was not shown.

Retrograde versus antegrade nailing of femoral shaft fractures.

OBJECTIVES: To compare union rates and complications of retrograde intramedullary nailing of femoral shaft fractures with those of antegrade intramedullary nailing. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Two hundred eighty-three consecutive adult patients with 293 fractures of the femoral shaft who underwent stabilization with antegrade or retrograde inserted femoral nails were studied. There were 140 retrograde nails and 153 antegrade nails. Twelve fractures in twelve patients were excluded (three in patients who died early in the postoperative period, three in patients because of early amputation, four in patients who were paraplegic, and two in patients who fractured through abnormal bone owing to metastatic carcinoma), leaving 134 fractures treated with retrograde nails and 147 treated with antegrade nails. One hundred four femurs treated with retrograde nails (Group R) and ninety-four femurs treated with antegrade nails (Group A) had sufficient follow-up and served as the two study groups. The average clinical follow-up was twenty-three months (range 6 to 66 months) for Group R and twenty-three months (range 5 to 64 months) for Group A. Both groups were comparable with regard to age, gender, number of open fractures, degree of comminution, mode of interlocking (i.e., static or dynamic), and nail diameter (p > 0.05). INTERVENTION: Retrograde intramedullary nails were inserted through the intercondylar notch of the knee, and antegrade nails were inserted through the pirformis fossa using standard techniques. MAIN OUTCOME MEASURES: Union, delayed union, nonunion, malunion, and complication rates. RESULTS: After the index procedure there were no significant differences in healing or incidence of malunion between Group R and Group A (p > 0.05). Healing after the index procedure occurred in ninety-one (88 percent) of the femurs in Group R and in eighty-four (89 percent) of the femurs in Group A. In Group R, there were seven delayed unions (7 percent) and six nonunions (6 percent). In Group A, there were four delayed unions (4 percent) and six nonunions (6 percent). Healing ultimately occurred in 100 (96 percent) femurs from Group R and in ninety-three (99 percent) femurs from Group A. In Group R, there were eleven malunions (11 percent), and in Group A, there were twelve malunions (13 percent). When patients with ipsilateral knee injuries were excluded, the incidence of knee pain was significantly greater for Group R patients (36 percent) than for Group A patients (9 percent) (p < 0.001). When patients with ipsilateral hip injuries were excluded, the incidence of hip pain was significantly greater for Group A patients (10 percent) than for Group R patients (4 percent) (p < 0.05). CONCLUSIONS: Retrograde and antegrade nailing techniques provided similar results in union and malunion rates. There were more complications related to the knee after retrograde nailing and more complications related to the hip after antegrade nailing.

Angular malalignment after intramedullary nailing of femoral shaft fractures.

OBJECTIVES: To determine factors associated with angular malalignment of femoral shaft fractures treated with intramedullary nails and to determine differences in the incidence of angular malalignment based on fracture location, fracture comminution, and method of treatment (i.e., antegrade or retrograde). DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Three hundred sixty patients with 374 femoral shaft fractures were identified from a prospectively obtained orthopaedic trauma database. Complete sets of immediate postoperative anteroposterior and lateral radiographs were available for 355 (95 percent) of the 374 fractures. INTERVENTION: Patients were treated with antegrade (183 cases) or retrograde (174 cases) intramedullary femoral nailing. MAIN OUTCOME MEASURE: Goniometric measurements were made on all immediate postoperative radiographs to determine the coronal plane and sagittal plane angular alignments. A multiple linear regression statistical analysis was used to determine factors associated with increasing angular malalignment. The incidence of malalignment was determined using more than 5 degrees of deformity in any plane as the definition of malalignment. RESULTS: Proximal fracture location, distal fracture location, and unstable fracture pattern were associated with increasing fracture angulation (p < 0.001). Fracture location in the middle third, stable fracture pattern, method of treatment (i.e., antegrade or retrograde), and nail diameter were not associated with increasing fracture angulation (p > 0.05). The incidence of malalignment was 9 percent for the entire group of patients, 30 percent when the fracture was of the proximal third of the femoral shaft, 2 percent when the fracture was of the middle third, and 10 percent when the fracture was of the distal third. The incidence of malreduction was 7 percent for patients with stable fracture patterns and 12 percent for those with unstable fracture patterns. CONCLUSIONS: Patients with fractures of the proximal third of the femoral shaft treated with intramedullary nails are at highest risk for malalignment. Proximal fracture location, distal fracture location, and unstable fracture pattern are associated with increasing fracture angulation.

Bohler incision: an extensile anterolateral approach to the foot and ankle.

Incisions in the foot and ankle should allow efficient surgical approaches to the anatomic structures being addressed while preventing chronic neuritic symptoms, extensive scar contractures, soft tissue ischemia or necrosis, and chronic edema. The purpose of this report is to describe the Böhler incision, an extensile approach that provides the surgeon with easy access to the anterior surface of the distal tibia, the anterior talar dome, talar neck, talonavicular, subtalar, and calcaneocuboid joints by allowing direct visualization of these areas. The incision can be extended in both directions, if needed, or it can be used at either end, produces few complications, and closes with a cosmetically acceptable scar that does not produce pressure with shoe wear.

Treatment of complex tibial periarticular fractures using percutaneous techniques.

Open reduction and internal fixation typically is reserved for the treatment of patients with articular or periarticular tibia fractures, or other tibial injuries that are treated inadequately with intramedullary nailing. This approach can result in extensive dissection and tissue devitalization. By modifying the method of fixation, the plating of tibial fractures has been expanded using a percutaneous technique. Using this approach, the fracture is reduced indirectly and plates are placed through subcutaneous or submuscular tunnels through limited incisions. Between 1992 and 1998, 17 patients with tibial shaft fractures and associated severe soft tissue injury, were treated using a percutaneous plating technique. Followup was available in 14 patients. Six patients required bone grafting procedures for delayed union or nonunion, although four of these patients had significant bone loss related to their injury. There were no malunions. Three patients had superficial infections related to external fixator pin sites and one patient had osteomyelitis develop. Percutaneous plating of the tibia offers an alternative method for stabilizing complex fractures with severely compromised soft tissues, especially those injuries with periarticular extension. This technique is thought to cause no increase in the risk of infection or soft tissue damage and permits rapid mobilization of the limb and patient. When using this treatment for patients with significant bone loss, bone grafting should be considered.

Percutaneous fixation of proximal humeral fractures.

The purpose of the current study is to evaluate the technique of closed reduction and percutaneous pinning of proximal humeral fractures and to determine whether this technique provides enough stability to permit early active range of motion and subsequent fracture healing. Fractures were classified according to Neer et al and were included if the surgical or anatomic neck were angulated greater than 45 degrees, separation between fragments was greater than 1 cm, or the greater tuberosity was displaced more than 0.5 cm. There were 21 Type II, 16 Type III, and four Type IV fractures. Fractures were pinned using distally threaded Dynamic Hip Screw guide pins, 2-mm Kirschner wires, or 2.5-mm distally threaded Schantz pins. Patients were evaluated for union rates and motion. Assessment was made using the Modified American Shoulder and Elbow Surgeons Form. Thirty-six patients with 37 fractures were available for review with followup averaging 40 months (range, 12-68 months). All patients with Neer Type IV fractures did not respond to fixation and three had avascular necrosis develop, irrespective of the type of pin used. In the remaining 33 patients with Neer Type II and Type III fractures, a union rate of 94% was observed at an average of 2.6 months. All patients had good functional results. In the current series, there were no failures using Schantz pins. There was a 20% failure rate with Dynamic Hip Screw pins (2% if the patients with Type IV fractures were excluded) and a 100% failure rate with Kirschner wires. Stable fixation with early motion and subsequently good results can be obtained using percutaneous fixation in patients with Type II and Type III fractures; however, terminally threaded pins must be used and smooth Kirschner wires must be avoided. Percutaneous fixation cannot be recommended in patients with Type IV fractures.

Treatment of femoral shaft fracture using unreamed interlocked nails.

OBJECTIVE: To evaluate healing rates of femoral shaft fractures treated with interlocked nails inserted without reaming. STUDY DESIGN: Review of prospectively collected data. SETTING: Level I trauma center. METHODS: From the trauma registry, 159 patients with 164 femoral shaft fractures were identified who had been treated from March 1993 through December 1995 with femoral nails inserted without reaming in either an antergrade or retrograde manner. Fractures were classified according to the AO/OTA method. Patients were followed for a minimum of one year with clinical and radiographic examinations. RESULTS: One hundred twenty-one patients with 125 fractures were available for review. Average follow-up was 18.3 months (range 12 to 59 months). One hundred sixteen of the 125 fractures (93 percent) healed after the index procedure. Type A fractures healed at an average of 3.8 months (range 2 to 8 months), Type B fractures at 4.8 months (range 2 to 16 months), and Type C fractures at 6.2 months (range 3 to 12 months). There were no increases in complication rates or differences in ranges of knee and hip motion as compared with other published series. Overall, there was no difference in the length of time to union between antegrade or retrograde nailings, and the healing rates for the two methods showed only a small statistical difference. CONCLUSIONS: The use of femoral nails inserted in an unreamed manner in this series produced healing rates comparable with historic standards using reamed insertion. Smaller diameter nails inserted without reaming did not compromise fracture management and produced no increase in complication rates. The causes for delayed union or nonunion appear to be multifactorial, and secondary procedures should be considered if fractures have demonstrated little or no healing by three months.

Hyphenated-history: the Kocher-Langenbeck surgical approach.

The language spoken by orthopaedic surgeons is filled with eponyms. In orthopaedics, perhaps more than any other medical specialty, we speak cryptically to one another using code words and other secret language. Certain hyphenated eponyms are of particular interest because they pique one's curiosity as to how these people came to be partners in orthopaedic history. In this paper, we offer some bits of orthopaedic hyphenated-history, outlining the pertinent work of Theodor Kocher and Bernhard von Langenbeck, as well as associated background information. These two surgeons are linked through a common hyphenated eponym in orthopaedic surgery: the Kocher-Langenbeck surgical approach, a well-known posterior approach to the proximal femur and acetabulum.

A staged protocol for soft tissue management in the treatment of complex pilon fractures.

OBJECTIVE: To determine whether open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol results in minimal surgical wound complications. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Between January 1991 and December 1996, 226 pilon fractures (AO types 43A-C) were treated, of which 108 were AO type 43C. Fifty-six fractures were included in a retrospective analysis of a treatment protocol. Injuries were divided into Group I, thirty-four closed fractures, and Group II, twenty-two open fractures (three Gustilo Type 1, six Type II, eight Type IIIA, and five Type IIIB). METHODS: The protocol consisted of immediate (within twenty-four hours) open reduction and internal fixation of the fibula when fractured, using a one-third tubular or 3.5-millimeter dynamic compression plate and application of an external fixator spanning the ankle joint. Patients with isolated injuries were discharged after initial stabilization and readmitted for the definitive reconstruction. Polytrauma patients remained hospitalized and were observed. Formal open reconstruction of the articular surface by plating was performed when soft tissue swelling had subsided. Complications were defined as wound problems requiring hospitalization. All affected limbs were then evaluated via chart and radiograph review, patient interviews, and physical examination until surgical wound healing was complete, for a minimum of twelve months. RESULTS: Group 1 (closed pilon): Follow-up was possible in twenty-nine out of thirty fractures (97 percent). Average time from external fixation to open reduction was 12.7 days. All wounds healed. None exhibited wound dehiscence or full-thickness tissue necrosis requiring secondary soft tissue coverage postoperatively. Seventeen percent (five out of twenty-nine patients) had partial-thickness skin necrosis. All were treated with local wound care and oral antibiotics and healed uneventfully. There was one late complication (3.4 percent), a chronic draining sinus secondary to osteomyelitis, which resolved after fracture healing and metal removal. Group II (open pilon): Follow-up was possible in seventeen patients with nineteen fractures (86 percent). Average time from external fixation to formal reconstruction was fourteen days (range 4 to 31 days). By definition, all Gustilo Type IIIB fractures required flap coverage for the injury. Two patients experienced partial-thickness wound necrosis. These were treated with local wound care and antibiotics. All surgical wounds healed. There were two complications (10.5 percent), both deep infections. One Type I open fracture developed wound dehiscence and osteomyelitis requiring multiple debridements, intravenous antibiotics, subsequent removal of hardware, and re-application of an external fixator to cure the infection. One Type IIIA open fracture of the distal tibia and calcaneus developed osteomyelitis and required a below-knee amputation. CONCLUSION: Based on our data, it appears that the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotation flaps, or free tissue transfers in our series. This technique appears to be effective in closed and open fractures alike.

Comparison of cloth gloves used in orthopaedic surgery: a clinical and experimental evaluation.

OBJECTIVES: (a) To compare the effectiveness of five cloth gloves for cut resistance and their ability to prevent inner latex glove perforation. (b) To evaluate the safety, efficacy, and comfort of the outer gloves when reused. SETTING: Tertiary care level I trauma hospital and biomechanics laboratory. METHODS: Laboratory evaluation consisting of assessing cut resistance and fabric deterioration and clinical assessment of all cloth gloves worn as a liner between two latex gloves. RESULTS: Laboratory testing demonstrated significant differences in cut resistance, with gloves divided into three groups: most resistant (Centurion, which required over 3,000 slices or 1,300 chops to failure), resistant (MedArmor, failing at eighty-five slices or 121 chops; Paraderm, failing at thirty-eight slices or ninety-four chops; and Repel, failing at forty-six slices or seventy-five chops), and least resistant (Protek, failing at two slices and less than two chops). Clinically, 3 percent of all the inner latex gloves demonstrated a perforation, with no violation of the skin in any of the five types of cloth gloves used. Only the Protek and MedArmor cloth gloves were positively ranked for comfort. CONCLUSION: All gloves provided equal protection with respect to inner latex glove perforation during all of the orthopaedic procedures, with comfort being the most important variable. Gloves should be selected based on comfort, because it appears that all gloves provide equal protection during surgery regardless of the material woven into the fabric.

Radiation exposure to the orthopaedic surgical team during fluoroscopy: "how far away is far enough?".

OBJECTIVES: To correlate the amount of radiation exposure to members of the orthopaedic surgical team based on their relative positions during a simulated fluoroscopically assisted orthopaedic procedure. DESIGN: Experimental study using commercially available fluoroscopic units and dosimetry badges designed to measure "eye" (ocular lens), "shallow" (hands/skin), and "deep" (whole-body) radiation exposure. SETTING: Standard hospital operating room at a level one trauma center. PARTICIPANTS: Dosimetry badge clusters at specified distances from a fluoroscopic x-ray beam. Represented positions were direct beam contact, surgeon (12 in/30.5 cm), first assistant (24 in/70 cm), scrub nurse (36 in/91.4 cm), and anesthesiologist (60 in/152.4 cm). INTERVENTION: Dosimetry badges were systematically exposed by a protocol intended to maximize radiation scatter. A maximum time for continuous fluoroscope use was set at ten minutes. MAIN OUTCOME MEASUREMENTS: Radiation exposure readings from dosimetry badges processed by a commercially available dosimetry service. RESULTS: Maximum readings are reported. Direct beam contact resulted in approximately 4000 mrem/minute (40 mSv/min) of radiation exposure. Deep exposure for the surgeon and first assistant was 20 mrem/min (0.2 mSv/min) and 6 mrem/min (0.06 mSv/min), respectively. Superficial exposure was 29 mrem/min (0.29 mSv/min) for the surgeon and 10 mrem/min (0.1 mSv/min) for the first assistant. Eye exposure was 10 mrem/min (0.1 mSv/min) for the surgeon and 6 mrem/min (0.06 mSv/min) for the first assistant. At the scrub nurse position, no deep or eye exposure was detected. One positive badge for shallow exposure was noted at the scrub nurse position, reflecting a 2 mrem/min (0.02 mSv/min) exposure rate. After ten minutes of continuous exposure, badges assigned to the anesthesiologist position never registered any positive readings. CONCLUSIONS: These results indicate that unprotected individuals working twenty-four inches (70 cm) or less from a fluoroscopic beam receive significant amounts of radiation, whereas those working thirty-six inches (91.4 cm) or greater from the beam receive an extremely low amount of radiation.

Ipsilateral fractures of the talus and calcaneus.

Nine ipsilateral fractures of the talus and calcaneus were treated at Tampa General Hospital between 1991 and 1994 and entered into the trauma registry of this level 1 trauma center. During this same period, a total of 78 talar fractures and 334 calcaneal fractures were entered into the registry. The patients who sustained this rare combined injury were studied retrospectively to characterize the fractures that occurred, examine the treatments instituted, and determine outcomes. Four patients had severe intra-articular damage of the subtalar joint surfaces and underwent either primary or delayed arthrodesis. This subgroup of patients was followed for an average of 39 months (range, 25-45 months), and all had excellent or good outcome as assessed by the Maryland Foot Score. Three patients had nondisplaced or avulsion-type fractures of both bones, which were treated with immobilization. These all healed well. One patient had a Hawkins type 2 talus fracture with an extra-articular avulsion fracture of the Achilles tendon. This patient did well with open reduction and internal fixation of both fractures. The final patient had a crushed lower extremity in association with her hindfoot injury, which resulted in primary below-knee amputation. In general, we believe each individual fracture in this combined injury can be addressed with standard treatment regimens.

Ipsilateral fractures of the femur and tibia: treatment with retrograde femoral nailing and unreamed tibial nailing.

Between 1989 and 1995 a total of 47 patients with 50 fractures of the ipsilateral femoral and tibial shafts without significant articular involvement were treated at Tampa General Hospital. Within this group were 24 patients with 26 fractures who were treated with intramedullary fixation of both bones using a technique of retrograde insertion of a femoral nail and unreamed insertion of an interlocking tibial nail. Information concerning the injuries, treatments, and much of the follow-up was gleaned from a trauma registry. Five of the femoral fractures (19%) and 14 of the tibial fractures (54%) were open. Associated injuries were present in 18 of the 24 patients (75%) with injuries of the pelvis, other extremities, and head being most prevalent. The average Injury Severity Score was 14 (range 9-32). The femoral nails were placed either through the medial femoral condyle (n = 14) or the intercondylar notch of the distal femur (n = 12). Twenty patients with 22 extremities had sufficient follow-up at an average of 20 months (range 4-60) postinjury to be included in the review. One patient had died, and three were completely lost to follow-up. Both fractures in 14 extremities had healed or were healing uneventfully at final review. Seven of the tibiae and three of the femora had complications after initial hospitalization. Two patients developed problems in both bones. Three patients had electrical stimulation of a tibia fracture, one of which underwent simultaneous nail dynamization. A total of 18 additional operative procedures were necessary after the primary treatment in six problematic extremities. Thirteen additional operative procedures were required in five complicated tibiae (one nail dynamization, six debridement procedures, five bone grafts, and one muscle flap) after the initial hospitalization. Five additional operative procedures were required in the three complicated femora (two nail dynamizations, one bone graft, and two exchange nailing procedures). Functional results were good or excellent in 13 of the 20 patients (65%) and 15 of the 22 extremities (68%) available at final review. No significant knee problem related to the femoral nailing technique was identified. This method of treatment can be performed using a standard radiolucent table and a single medial parapatellar incision. It is expedient and allows other procedures to be performed simultaneously in this group of severely injured patients.

Injuries of the shoulder girdle.

Shoulder girdle injuries occur infrequently, but can lead to high rates of morbidity and mortality if these high energy injuries are underdiagnosed or mistreated. Most injuries can be treated conservatively, but a high index of suspicion and aggressive physical and radiographic evaluations should be used to evaluate patients with polytrauma. This article discusses these injuries, their associated pathoanatomy, and current management.

Intraoperative somatosensory evoked potential monitoring during acute pelvic fracture surgery.

Independent clinical neurological evaluation and intraoperative somatosensory evoked potential (SSEP) monitoring was performed on 30 vertically unstable hemipelvis fractures in 28 patients undergoing acute open reduction and internal fixation. Preoperative ipsilateral neurologic injury of the sciatic/lumbosacral plexus was noted in 15 of 30 fractures (50%). Significant unilateral SSEP changes occurred during manipulative reduction of two displaced sacroiliac joints and one sacral fracture. Because of the expeditious response of the surgical team, with release of traction/retraction, SSEP returned to baseline and no patient sustained an iatrogenic nerve injury or worsening of their preoperatie neurologic status. The incidence of postinjury lumbosacral plexopathy in unstable pelvic fractures is high (50%) when careful preoperative evaluation including SSEP is performed. The use of intraoperative SSEP monitoring is feasible in acute posterior pelvic fracture surgery and can help identify potential intraoperative iatrogenic lumbosacral neurological compromise.

The treatment of open tibial shaft fractures using an interlocked intramedullary nail without reaming.

Between January 1989 and September 1991, 117 consecutive open tibial shaft fractures were treated at our institution. Of these, 64 (55%) met the inclusion criteria and were prospectively treated according to protocol using unreamed interlocking intramedullary nails as definitive fixation. Wounds were classified according to the method of Gustilo et al., and included 10 type I, 16 type II, and 38 type III (17 type IIIA, 21 type IIIB) wounds. Contraindications to intramedullary nailing included (a) fractures involving the proximal or distal one fifth of the tibia, (b) patients with open physes, and (c) an associated vascular injury (type IIIC). Proximal locking was routinely performed, whereas distal locking was used as needed for axial and/or rotational stability. Soft-tissue coverage was obtained after adequate debridement within 7 days: 26 of 64 fractures (41%) required a soft-tissue procedure (17 split-thickness skin grafts, eight free-tissue transfers, one rotational muscle flap). Patients were encouraged to bear full weight in a short leg cast or Sarmiento brace as soon as other injuries or pain permitted. Average follow-up time was 24.8 months (range 12-44) and was possible in 46 fractures (71.875%; nine of 10 type I, 12 of 16 type II, 10 of 17 type IIIA, and 15 of 21 type IIIB). Mean time to healing was as follows: type I, 4.8 months; type II, 4.7 months; type IIIA, 8.28 months; and type IIIB, 9.30 months. Twenty fractures exhibited a delay in healing (> 6 months). This included two of 12 type II (16%), six of 10 type IIIA (60%), and 12 of 15 type IIIB fractures (80%).(ABSTRACT TRUNCATED AT 250 WORDS)

The reliability of detecting screw penetration of the acetabulum by intraoperative auscultation.

Open reduction and internal fixation of the acetabulum frequently requires placement of screws in a blind fashion that risks penetrating the joint surface. While in the operative suite, direct visualization of the joint surface may not be possible, and fluoroscopy can be difficult to interpret. Auscultation of the hip with motion in a quiet room has been suggested as a useful adjunct to detecting screw penetration. Carrying that concept further, we auscultate the hip using a sterile esophageal stethoscope at the operating table and have found this to be a highly reliable method of detecting intraarticular screw placement. To test the reliability and reproducibility of this technique, an experiment was performed using inexperienced volunteers. In part I, two adult mongrel dogs were prepared. A screw was placed violating the hip joint in one dog, and in the other dog a screw was placed near but not penetrating the joint. Screw placement was verified under direct vision. Seventy-seven volunteers who did not know which hip was penetrated then auscultated both hips in random order and recorded their impressions after each hip was heard. After hearing both hips, 74 of 77 were able to identify the screw in the hip joint correctly; 69 were able to recognize the extraarticular screw correctly. In part II, both hips of a human cadaver were exposed and dislocated. In one hip, a screw was placed that tangentially violated the joint, and in the same area of the contralateral hip a screw was placed that did not penetrate the joint surface.(ABSTRACT TRUNCATED AT 250 WORDS)

The treatment of open and/or unstable tibial fractures with an unreamed double-locked tibial nail.

A multicenter, prospective study was conducted to assess the efficacy of an unreamed, double-locked tibial nail for the acute management of open and/or unstable tibial fractures. Seventy-seven acute unstable and/or open tibial fractures in 74 patients were treated from December 1986 to February 1989. Forty fractures were closed and 37 were open; 25% occurred in polytraumatized patients and 39% of the patients had additional fractures. All closed tibial fractures healed at an average of 14.2 weeks; 94.6% of the open tibial fractures healed at an average of 20.1 weeks. There were no infections in the closed tibial fracture group. There were 4 infections among the 37 patients (11%) in the open tibial fracture group, 2 superficial and 2 deep. There were 7 problems intraoperatively (8.4%) with fin deployment: 2 fins bent during nail insertion, 4 fins penetrated the cortex, while 1 set of fins only partially deployed. Difficulty was encountered with proximal screw insertion in one third of the cases. Considering the high energy of these injuries, the treatment of open and/or unstable tibial fractures with an unreamed, double-locked tibial nail can offer the surgeon a high rate of union (97%) with minimal complications. The low infection rate found in this series indicates that this nail may be of particular benefit in the treatment of closed and select open tibial fractures.