Posterolateral transfibular approach to tibial plateau fractures: technique, results, and rationale.

We describe a posterolateral transfibular neck approach to the proximal tibia. This approach was developed as an alternative to the anterolateral approach to the tibial plateau for the treatment of two fracture subtypes: depressed and split depressed fractures in which the comminution and depression are located in the posterior half of the lateral tibial condyle. These fractures have proved particularly difficult to reduce and adequately internally fix through an anterior or anterolateral approach. The approach described in this article exposes the posterolateral aspect of the tibial plateau between the posterior margin of the iliotibial band and the posterior cruciate ligament. The approach allows lateral buttressing of the lateral tibial plateau and may be combined with a simultaneous posteromedial and/or anteromedial approach to the tibial plateau. Critically, the proximal tibial soft tissue envelope and its blood supply are preserved. To date, we have used this approach either alone or in combination with a posteromedial approach for the successful reduction of tibial plateau fractures in eight patients. No complications related to this approach were documented, including no symptoms related to the common peroneal nerve, and all fractures and fibular neck osteotomies healed uneventfully.

The subcristal pelvic external fixator: technique, results, and rationale.

We report a new technique for pelvic external fixation that we have developed as an alternative to the anterosuperior (Slätis) and the anteroinferior (supra-acetabular) type pelvic external fixator configurations. The method principally differs from the other techniques by virtue of the subcristal positioning of the pins and offers advantages in terms of easier pin placement, less skin irritation, less pin tract infection and loosening, and less interference with hip flexion, while allowing dressing, sitting, and walking. Between 1992 and 2006, we successfully used subcristal pelvic external fixators as the definitive fixation device for 20 patients with pelvic ring disruptions. The only complications encountered were superficial pin tract infections in 4 patients (20%) who were successfully treated with wound care and antibiotics.

Differentially loaded radiostereometric analysis to monitor fracture stiffness: a feasibility study.

Inability to accurately and objectively assess the mechanical properties of healing fractures in vivo hampers clinical fracture management and research. We describe a method to monitor fracture stiffness during healing in a clinical research setting by detecting changes in fracture displacement using radiostereometric analysis and simultaneously measuring applied axial loads. A method was developed for load application, positioning of the patient, and radiographic setup to establish the technique of differentially loaded radiostereometric analysis (DLRSA). A DLRSA examination consists of radiostereometric analysis radiographs taken without load (preload), under different increments of load, and without load (postload). Six patients with distal femur fractures had DLRSA examinations at 6, 12, 18, and 26 weeks postoperatively. The DLRSA method was feasible in a clinical setting. The method provides objective and quantifiable data for internally fixed fractures and may be used in clinical research as a tool to monitor the in vivo stiffness of healing femoral fractures managed with nonrigid internal fixation.

Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice.

BACKGROUND: Hemorrhage-related mortality (HRM) associated with pelvic fractures continues to challenge trauma care. This study describes the management and outcome of hemodynamically unstable patients with a pelvic fracture, with emphasis on primary intervention for hemorrhage control and HRM. METHODS: Blunt trauma patients [Injury Severity Score (ISS) >or=16] with a major pelvic fracture (Abbreviated Injury Score, pelvis >or=3) and hemodynamic instability [admission systolic blood pressure (SBP) or=6 units of packed red blood cells (PRBCs)/24 hours) were included into a 48-month (ending in December 2003) multicenter retrospective study of 11 major trauma centers. Data are presented as the mean +/- SD. RESULTS: A total of 217 patients (mean age 41 +/- 19 years, 71% male, ISS 42 +/- 16) were studied. The admission SBP was 96 +/- 37 mmHg and the Glascow Coma Scale (GCS) 11 +/- 5. Patients received 4 +/- 2 liters of fluids including 4 +/- 4 units of PRBCs in the emergency room (ER). In total, 69 (32%) patients died, among whom the HRM was 19%; 29% of the deaths were due to pelvic bleeding. Altogether, 120 of the 217 (55%) patients underwent focused abdominal sonography for trauma (FAST) or diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL); 60 of the 217 (28%) patients were found to have pelvic binding in the ER. In all, 53 of 109 (49%) patients had no bleeding noted at laparotomy, 26 of 106 (25%) had no abdominal findings, and 15 of 53 (28%) had had no prior abdominal investigation (FAST/DPL/computed tomography). Angiography was positive in 48 of 58 (83%) patients. The HRM was highest in patients with laparotomy as the primary intervention (29%) followed by the angiography group (18%), the combined laparotomy/pelvic fixation group (16%), and the pelvic fixation-only group (10%). CONCLUSION: HRM associated with major pelvic trauma is unacceptably high especially in the laparotomy group. Hence, nontherapeutic laparotomy must be avoided, concentrating instead on arresting pelvic hemorrhage. Standards of care must be implemented and abided by.

Design and evaluation of International Video Teleconference (iVTC) for orthopedic trauma education.

This poster describes the design and evaluation of an International Video Teleconference (iVTC) system for orthopedic trauma case studies. Three medical facilities in the United States and one in Australia participated in monthly sessions where past and ongoing military and civilian cases were discussed. Participant feedback indicated that iVTC fully met their expectations as an educational tool and that remote participation did not adversely impact their ability to engage in discussion.

Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients.

BACKGROUND: The treatment of open fractures of the tibial shaft is often complicated by delayed union and nonunion. The objective of this study was to evaluate the safety and efficacy of the use of recombinant human bone morphogenetic protein-2 (rhBMP-2; dibotermin alfa) to accelerate healing of open tibial shaft fractures and to reduce the need for secondary intervention. METHODS: In a prospective, randomized, controlled, single-blind study, 450 patients with an open tibial fracture were randomized to receive either the standard of care (intramedullary nail fixation and routine soft-tissue management [the control group]), the standard of care and an implant containing 0.75 mg/mL of rhBMP-2 (total dose of 6 mg), or the standard of care and an implant containing 1.50 mg/mL of rhBMP-2 (total dose of 12 mg). The rhBMP-2 implant (rhBMP-2 applied to an absorbable collagen sponge) was placed over the fracture at the time of definitive wound closure. Randomization was stratified by the severity of the open wound. The primary outcome measure was the proportion of patients requiring secondary intervention because of delayed union or nonunion within twelve months postoperatively. RESULTS: Four hundred and twenty-one (94%) of the patients were available for the twelve-month follow-up. The 1.50-mg/mL rhBMP-2 group had a 44% reduction in the risk of failure (i.e., secondary intervention because of delayed union; relative risk = 0.56; 95% confidence interval = 0.40 to 0.78; pairwise p = 0.0005), significantly fewer invasive interventions (e.g., bone-grafting and nail exchange; p = 0.0264), and significantly faster fracture-healing (p = 0.0022) than did the control patients. Significantly more patients treated with 1.50 mg/mL of rhBMP-2 had healing of the fracture at the postoperative visits from ten weeks through twelve months (p = 0.0008). Compared with the control patients, those treated with 1.50 mg/mL of rhBMP-2 also had significantly fewer hardware failures (p = 0.0174), fewer infections (in association with Gustilo-Anderson type-III injuries; p = 0.0219), and faster wound-healing (83% compared with 65% had wound-healing at six weeks; p =0.0010). CONCLUSIONS: The rhBMP-2 implant was safe and, when 1.50 mg/mL was used, significantly superior to the standard of care in reducing the frequency of secondary interventions and the overall invasiveness of the procedures, accelerating fracture and wound-healing, and reducing the infection rate in patients with an open fracture of the tibia.