Angiographic embolization in the treatment of arterial pelvic hemorrhage: evaluation of prognostic mortality-related factors.

PURPOSE: The control of arterial bleeding associated with pelvic ring and acetabular fractures (PRAF) remains a challenge for emergency trauma care. The aim of the present study was to uncover early prognostic mortality-related factors in PRAF-related arterial bleedings treated with transcatheter angiographic embolization (TAE). METHODS: Forty-nine PRAF patients (46 pelvic ring and three acetabular fractures) with arterial pelvic bleeding controlled with TAE (within 24 h) were evaluated. RESULTS: All large arterial disruptions (n = 7) were seen in type C pelvic ring injuries. The 30-day mortality in large vessel (iliac artery) bleeding was higher (57 %) than in medium- or small-size artery bleeding (24 %). Overall 30-day mortality was 29 %. No statistically significant difference in the first laboratory values between the survivors and nonsurvivors was found. However, after excluding patients dying of head injuries (n = 5), a reasonable cut-off value was identified for the base excess (BE; lower than -10 mmol/l) obtained on admission. CONCLUSIONS: PRAF patients with exsanguinating bleeding from the large pelvic artery have the worst prognosis. Very low BE values (<-10.0 mmol/l) on admission for exsanguinating patients have a negative predictive value for survival, thus anticipating a poor outcome in bleeding controlled with TAE only and an increased risk of death. In critical cases, an aggressive bleeding control protocol prompts extraperitoneal pelvic packing prior to TAE. PRAF-related rupture of the external iliac artery is rare and indicates surgical techniques in controlling and restoring blood supply to the lower leg.

Hybrid external fixation in treatment of proximal tibial fractures: a good outcome in AO/ASIF type-C fractures.

INTRODUCTION: The treatment of proximal tibial fractures is often challenging, and internal fixation is occasionally associated with problems in wound healing due to frequently co-existing soft tissue injuries. External fixation of these fractures have yielded satisfactory results, but some studies have reported problems in the achievement and maintenance of fracture reduction. The purpose of the present study was to evaluate the performance of a hybrid external fixator in the treatment of different types of proximal tibial fractures. MATERIALS AND METHODS: Thirty-three proximal tibial fractures, of which 20 were high energetic, were treated with a hybrid external fixator (Tenxor Strker-Howmedica) in the acute phase. Fracture categorisation was done according to AO/ASIF, and the reduction was performed most often by closed means or through mini-open reduction (26/78.8%). The patients were followed up to an average of 12.7 months (range 10-22) and were evaluated with radiographs and clinical examinations. RESULTS: Five AO/ASIF type-C intraarticular fractures had a poor postoperative reduction, and were thus treated with internal fixation in a second operation. Of the remaining 28 patients, local and transient pin tract infection was observed in seven patients, and one had septic arthritis of the knee. All 13 C1 and five of six C2/C3 fractures united in mean time of 15.1 weeks, whereas three of nine type-A fractures failed to unite, albeit an adequate reduction, and needed a second operation (odds ratio 11.4, 95% CI 1.0-143, compared with type-C fractures). For the remaining six type-A fractures, the mean healing time was 24 weeks (mean difference 8.9, 95% CI 6-12 weeks compared with type-C fractures). Age over 48 and the presence of an open fracture, but not fracture type, gender, or the level of injury energy, correlated to a poor subjective outcome. CONCLUSIONS: The hybrid external fixation method we have used is safe, and type-C1 fractures are particularly suitable to be treated with this method. However, even C2/C3 fractures may be candidates for this method, but a meticulous fracture reduction should be performed. Type-A fractures are liable to healing problems when the fixator is used as a rigid complex.

Clinical and MRI evaluation of meniscal tears repaired with bioabsorbable arrows.

BACKGROUND AND AIMS: Excision of meniscal tissue has been shown to increase the risk of degenerative changes of the knee joint. Whenever possible, meniscus repair has become the procedure of choice for treatment of meniscal tears. MATERIALS AND METHODS: The present retrospective study evaluated the healing results of 77 meniscal ruptures treated with the an all-inside technique (Biofix meniscus arrow). The study group consisted of 73 patients with 77 longitudinal, vertical meniscal ruptures treated at Helsinki University Hospital between the beginning of January 1997 and the end of March 2001. The patients who had not received secondary surgery for failed repair during the follow-up period were examined clinically and with MRI. RESULTS: Fifty-one out of 77 meniscal ruptures (66%) healed clinically. In repairs performed in conjunction with ligament reconstruction the healing rate was higher (79%) than in the isolated tears (56%). The poorest results were seen in the very long vertical tears with luxation of the meniscus (38% healing rate). CONCLUSIONS: Bioabsorbable arrows offer a good alternative for treatment of meniscal ruptures, but the arrows alone do not seem to be sufficient to provide a reliable long-lasting result in the repair of very unstable meniscal ruptures.

Lateral approach for fixation of the fractures of the distal tibia. Outcome of 20 patients. Technical note.

INTRODUCTION: The treatment of fractures of the distal third of the tibia remains still controversial. It is often difficult to get and retain good reduction by non-operative or nailing methods. Open reduction and plate fixation offers good reduction and retention of the achieved position. However, increased soft tissue damage and high complication rate has led to search less invasive surgical methods such as minimal invasive plating technique. MATERIAL AND METHODS: Lateral approach for the distal tibia allows to reduce and to plate both the fibula and the tibia using only one skin incision. We have used lateral approach for 20 consecutive tibia fracture patients and report clinical and radiological results after an average follow-up of 31 months. RESULTS: All fractures united, but two malunions were developed after good primary reduction. Seventeen patients achieved excellent or good subjective result while one had moderate and two poor results. Four superficial wound infections were noticed and they were treated conservatively. CONCLUSION: We conclude that lateral approach for the distal tibia is a demanding, but useful surgical method for treatment of the distal tibia fractures especially in cases where no medial comminution of the tibia is present and when the fibula has to be fixed, too.

Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation.

We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations. Our results suggest that the use of the proximal femoral nail may allow a faster post-operative restoration of walking ability, when compared with the dynamic hip screw.

Femoral shaft medialisation and neck-shaft angle in unstable pertrochanteric femoral fractures.

We analysed the time-dependent mean changes in the femoral neck length, neck-shaft angle and hip offset in a randomised study comprising 48 patients who were treated with the dynamic hip screw (DHS) or the proximal femoral nail (PFN) for an unstable intertrochanteric femoral fracture. As a consequence of fracture compression, the mean post-operative neck length was significantly shorter in patients treated with the DHS. During the first 6 weeks after the operation, a mean decrease of 4.6 degrees was observed in the neck-shaft angle, but there was not a significant difference between the treatment groups. The radiographic measures remained virtually unaffected during the interval from 6 weeks to 4 months in both groups. When the operated hip was compared to the opposite hip, patients who had received the DHS showed significantly greater medialisation of the femoral shaft at 4 months than those treated with the PFN. We thus recommend that unstable intertrochanteric fractures should be initially reduced in a slight valgus position in order to achieve an outcome after healing that is as normal as possible. As a result of differences in operative technique and implant stability, the PFN may be superior to the DHS in retaining the anatomical relations in the hip region in unstable intertrochanteric fractures.

Complications in the first 1,043 operations where self-reinforced poly-L-lactide implants were used solely for tissue fixation in orthopaedics and traumatology.

This is an analysis from one hospital of the first 1043 operations where pure self-reinforced poly-L-lactide (SR-PLLA) implants have been used alone. The operations were performed between 1988 and 1999 and included 407 orthopaedic patients and 636 trauma patients. There was a total of 107 complications. There were 21 infections but no sinus formation. Failure of fixation was seen in 46 patients. In 936 operations the healing was uneventful.

Causes of the clinical tissue response to polyglycolide and polylactide implants with an emphasis on the knee.

The causes of a clinical tissue response to self-reinforced polyglycolide (SR-PGA) and self-reinforced polylactide (SR-PLLA) implants were studied in the first 2500 polymeric fixations. The incidence was 8.0% in fixations with implants made of SR-PGA (n = 1879) and 0% in SR-PLLA fixations (n = 621). A small number of fixations per site seemed to increase the incidence of a tissue response. In diagnoses involving over 50 fixations, except for ankle fractures, the incidence was 4.2%. The site of fixation influenced the incidence; the lowest incidence was seen for radial head fracture fixation (1.1%). The aromatic dye which has not been used since 1988 in the SR-PGA implant increased the response. A large total implant volume and a large number of implants increased the incidence of a tissue response. In the knee (n = 131), the incidence of a clinical tissue response was 4.3%, with four fluid accumulations and one synovitis of the knee after fixation with SR-PGA implants.

Bioabsorbable fixation in orthopaedic surgery and traumatology.

Bioabsorbable internal fixation devices were introduced clinically in the treatment of fractures and osteotomies of the extremities at the Department of Orthopaedics and Traumatology, Helsinki University, in 1984. Since November 5, 1984, a total of 3200 patients were managed using bone or ligament fixation devices made of self-reinforced (matrix and fibres of the same polymer) bioabsorbable alpha-hydroxy polyesters. The devices used included cylindrical rods, screws, tacks, plugs, arrows, and wires. The most common indication for the use of bioabsorbable implants was the displaced malleolar fracture of the ankle. Transphyseal fixation with small-diameter, mainly polyglycolide pins was used in children. The postoperative clinical course was uneventful in more than 90% of the patients. The complications included bacterial wound infection in 4% and failure of fixation in 4%. In one-fifth of the latter cases, however, re-operation was not necessary. The occurrence of non-infectious foreign-body reactions two to three months postoperatively has been observed in 2% of the patients operated in the last few years with polyglycolide implants but none of the patients managed with polylactide implants. This inflammatory tissue response often required aspiration with a needle but did not influence the functional or radiologic result of the treatment. Owing to the biodegradability of these internal fixation devices, implant removal procedures were avoided. This results in financial benefits and psychological advantages. Bioabsorbable implants can also be used in open fractures and infection operations.

Natural coral as bone-defect-filling material.

Natural coral (NC) has been studied experimentally and clinically as a bone substitute, but its resorption rate and possible replacement by bone still need to be defined in humans. In this study bicortical bone was harvested from the iliac crest of 10 patients. The defect was filled with a NC block, and changes were monitored by X-rays and quantitative CT scans for a mean of 2.1 years. A biopsy was taken at 1 year. The purpose of the study was to investigate the resorption rate and pattern of NC (Porites) implants and the replacement, if any, of the implant by new bone. The blocks underwent centripetal resorption, but all the blocks still could be detected by X-rays and CT scans at the end of the follow-up period. The density of the remaining block did not change. Seven of the 10 implants were smaller than 50% of their original size at the end of the study. Bone ingrowth could be observed only in two of seven biopsies. One implant had to be removed after 1.7 years due to infection. The study shows that resorption of natural coral proceeds centripetally and apparently more rapidly when accompanied by tissue ingrowth. None of the blocks resorbed completely, and the defect at the iliac crest had not been restored by the end of the study.

Failure of reduction with an external fixator in the management of injuries of the pelvic ring. Long-term evaluation of 110 patients.

We reviewed 110 patients with an unstable fracture of the pelvic ring who had been treated with a trapezoidal external fixator after a mean follow-up of 4.1 years. There were eight open-book (type B1, B3-1) injuries, 62 lateral compression (type B2, B3-2) and 40 rotationally and vertically unstable (type C1-C3) injuries. The rate of complications was high with loss of reduction in 57%, malunion in 58%, nonunion in 5%, infection at the pin site in 24%, loosening of the pins in 2%, injury to the lateral femoral cutaneous nerve in 2%, and pressure sores in 3%. The external fixator failed to give and maintain a proper reduction in six of the eight open-book injuries, in 20 of the 62 lateral compression injuries, and in 38 of the 40 type-C injuries. Poor functional results were usually associated with failure of reduction and an unsatisfactory radiological appearance. In type-C injuries more than 10 mm of residual vertical displacement of the injury to the posterior pelvic ring was significantly related to poor outcome. In 14 patients in this unsatisfactory group poor functional results were also affected by associated nerve injuries. In lateral compression injuries the degree of displacement of fractures of the pubic rami caused by internal rotation of the hemipelvis was an important prognostic factor. External fixation may be useful in the acute phase of resuscitation but it is of limited value in the definitive treatment of an unstable type-C injury and in type-B open-book injuries. It is usually unnecessary in minimally displaced lateral compression injuries.

Treatment of periprosthetic fractures in association with total hip arthroplasty--a retrospective comparison between revision stem and plate fixation.

BACKGROUND AND AIMS: In periprosthetic fracture associated with hip arthroplasty, no consensus exists about the use of plate fixation or revision stem except for cases where the stem is loose in a young patient and a revision is made. The aim of the present retrospective study was to compare two commonly used alternatives for treatment of the fracture--revision arthroplasty and plate fixation. MATERIAL AND METHODS: Seventy-five fractures associated with total hip arthroplasty were treated with revision arthroplasty (N = 40) or compression plate fixation (N = 35). Twenty-one fractures were intraoperative and 54 were postoperative. In revision arthroplasty, cemented (N = 11) and porous-coated (N = 29) stems were sued. Autologous bone grafts were used in 15 revision arthroplasties and 20 plate fixations. The follow-up time was median 20 months (range 12-96 months). RESULTS: Bone grafting at the time of fracture treatment had no significant effect on fracture healing in the present setting. One patient in both groups was operated secondarily because of fracture instability. Five nonunions in the former and 9 nonunions in the latter group were treated by repeated revision and bone graft. In two revision arthroplasties and nine cases with plate fixation, a secondary bone grafting operation was performed for delayed union. In all, 20 secondary operations were needed after prosthesis stem revision and 27 secondary operations after plate fixation (p = 0.014). The need for reoperations was similar in fractures at different levels of the femur. Fracture healing was finally obtained in 39 revision arthroplasties and 34 cases with plate fixation during the follow-up period. CONCLUSIONS: Cases where the prosthesis stem is stable, where its removal would include great risks and, where the biomechanical conditions are optimal, are best treated with plate fixation. In cases where the stem is loose and where a choice is possible, stem revision is preferable to plate fixation.

Absorbable fixation of femoral head fractures. A prospective study of six cases.

BACKGROUND AND AIMS: Fracture of the femoral head associated with a traumatic dislocation of the hip is a rare but severe injury. The methods of the recommended treatment have varied from primary closed or open reduction without fixation to excision of fragments or internal fixation. In our department we have treated other kinds of intra-articular fractures successfully with totally absorbable polyglycolide and poly-L-lactide implants. The aim of this study was to investigate the value of totally absorbable rods and screws in the fixation of the femoral head fractures. MATERIAL AND METHODS: Six femoral head fractures associated with a posterior traumatic dislocation of the hip were treated by open reduction and internal fixation using self-reinforced absorbable polyglycolide (SR-PGA) or poly-L-lactide (SR-PLLA) rods and screws. The follow-up time was 38 months in average (range 6 weeks to 77 months). RESULTS: In three patients the end results were excellent and in one fair. One patient died six weeks after the accident from the consequences of the cerebral injury. In one 61-year-old patient an arthroplasty was performed one year after the primary osteosynthesis, because of avascular necrosis of the femoral head. CONCLUSIONS: Self-reinforced polyglycolide and polylactide implants can be used safely to fix femoral head fractures without the need of implant removal.

Redisplacement after ankle osteosynthesis with absorbable implants.

A total of 1202 fractures of the ankle were treated with absorbable implants made of polyglycolide/polylactide copolymer or self-reinforced polyglycolide and/or self-reinforced polylactide between November 5, 1984, and January 12, 1994. A redisplacement after fixation was diagnosed in 30 patients (2.5%). The redisplacement occurred in 8 of 934 (0.9%) simple ankle fractures and in 22 of 268 (8.2%) severer ankle fractures. A breakage or loosening of the absorbable implant was verified at reoperation in 8 cases and was suspected in another 9. A technical failure was the main reason in 13 cases. A reoperation was performed for 25 patients. The absorbable implants seem to provide a secure fixation in the majority of ankle fractures, but the use of these implants showed unsatisfactory results in unstable and comminuted fractures.

Bone mineral density in fractures treated with absorbable or metallic implants.

Absorbable fixation devices have been clinically used in the fracture treatment for over ten years. No studies have been published where bone mineral density has been measured after bone consolidation comparing absorbable and metallic fixation. In this study the bone mineral density was measured after operative ankle fracture treatment with absorbable self-reinforced polyglycolic acid (SR-PGA) screws (14 patients) or with absorbable self-reinforced polylactic acid (SR-PLLA) screws (eight patients) compared with metallic fixation (17 patients). The overall results were radiologically good in every group. A statistically significant difference in the bone mineral density (BMD) was found only in the distal tibial metaphysis between SR-PGA screw and metallic fixation. The BMD increased in the distal tibia after SR-PGA screw fixation by an average 18.3%. The average change of BMD in the distal tibia after SR-PLLA screw fixation decreased by 6.4% while after metallic fixation the average change of MBD decreased by 18.6%. Bone mineral density measurements in the present study may indicate osteogenetic capacity of polyglycolide implants in the bone after fracture or osteotomy fixation. On the other hand, metallic implants showed negative effects to the bone.

Fixation of osteotomies of the distal femur with absorbable, self-reinforced, poly-L-lactide plates. An experimental study on rabbits.

Osteotomies of the distal femur were fixed with two self-reinforced poly-L-lactic acid (SR-PLLA) plates and metallic screws placed through the plates on each side of the femur in 23 adult rabbits. They were followed-up after 3, 6, 12 and 24 weeks. After killing, radiological, histological, microradiographic and oxytetracycline fluorescence studies were performed. Except for one histologically confirmed fibrotic non-union at 24 weeks, the osteotomies healed, including one involving a rabbit which had suffered an ipsilateral femoral shaft fracture of unknown cause. No malformations were observed, and the macroscopically detected swelling was a normal postoperative reaction. This study showed that SR-PLLA plates implanted on both sides on the bone are suitable for the fixation of weight-bearing cancellous bone osteotomies in rabbits.

Osteolytic changes after polyglycolide pin fixation in chevron osteotomy.

Absorbable polyglycolide pins were used for fixation of 94 chevron osteotomies in 70 patients at the Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, between 1986 and 1992. Postoperative osteolytic changes around the degrading pin occurred in 21 of 94 (22%) metatarsal heads. In 17 of 21 metatarsal heads, polydioxanone-coated polyglycolide pins were used. This type of pin has not been used since 1988. At follow-up, 16 of 21 osteolytic changes resolved completely and four partially resolved. In the remaining one, the osteolytic area remained visible after 6 years. Cystic changes in the metatarsal head, not attributable to the location of the absorbable implants, occurred in seven (7.4%) metatarsal heads and avascular necrosis of the entire metatarsal head in one (1.1%). Foreign body reaction occurred in six (6.3%) metatarsal heads and wound infection in three (3.2%) metatarsal heads. No association was observed between osteolytic changes and foreign body reaction or infection. Osteolysis in patients receiving polyglycolide implants only require observation, because associated symptoms with the radiographic findings are transient.

Totally absorbable fixation in the treatment of fractures of the distal femoral epiphyses. A prospective clinical study.

Nine adolescent patients with a femoral fracture involving the physeal plate were treated by using self-reinforced absorbable polyglycolide (SR-PGA) and poly-L-lactide (SR-PLLA) screws with a follow-up for an average of 2 years and 2 months. During the follow-up all but one of the femurs became skeletally mature. In two of nine patients a clinically significant growth disturbance occurred. The average length difference of the femurs was -5 mm (ranging from +8 mm(-)-41 mm). One valgus deformity was noted. In four patients a lengthening and in four patients a shortening of the operated femur were registered at the end of follow-up. Open reduction and fixation with absorbable screws seem to be suitable for the fixation of distal femoral fractures in adolescents.

Intraosseous plating with absorbable self-reinforced poly-L-lactide plates in the fixation of distal femoral osteotomies on rabbits.

Osteotomies of distal femur were fixed by intraosseous self-reinforced poly-L-lactic acid (SR-PLLA) plates in 29 adult rabbits. The follow-up times were from 3 to 24 weeks. After sacrifice, radiological, histological, microradiographic, and oxytetracycline fluorescence studies were performed. Although radiographically no redisplacements were found, in 12 weeks two fixations were broken and a fibrotic nonunion was observed in one case. At 24 weeks full bone consolidation was seen in all except one osteotomy. No foreign-body reactions were observed. The present article is the first report on successful application of absorbable plates for intraosseous fixation of weight-bearing bone osteotomies. The present investigation demonstrated that the SR-PLLA plates were suitable for the fixation of cancellous bone osteotomies in rabbits.

Absorbable devices in the fixation of fractures.

Totally absorbable internal fracture fixation devices were introduced clinically in the treatment of fractures and osteotomies of the extremities at our department in 1984. A total of 2,500 patients were managed using bone or ligament fixation devices made of self-reinforced (matrix and fibers of same polymer) absorbable alpha-hydroxy polyesters between November 5, 1984, and January 12, 1994. The devices used included cylindrical rods or pins, screws, tacks, plugs, and wires. The most common indication for the use of absorbable implants was displaced malleolar fracture of the ankle. Transphyseal fixation with small-diameter polyglycolide pins was used in children. The postoperative clinical course was uneventful in over 90% of the patients. The complications included bacterial wound infection in 3.6% and failure of fixation in 3.7%. In one-fifth of these cases, however, reoperation was not necessary. The occurrence of noninfectious foreign-body reactions 2 to 3 months postoperatively has been observed in 2.3% of the patients operated in the last years with polyglcolide implants but in none of the patients with polylactide implants. This inflammatory tissue response often required aspiration with a needle or small incision but did not influence the ultimate functional or radiologic result of treatment. Owing to the biodegradability of these internal fixation devices, over 1,000 implant removal procedures were avoided during the 9-year period under review, allowing medical personnel at these facilities to focus on other procedures. Avoidance of removal procedures results in financial benefits and psychological advantages. The benefits of absorbable implants for war surgery are the same as for civilian life. Absorbable implants can also be used in open fractures and infection operations.