Early experience with reduction of displaced disruption of the pelvic ring using a pelvic reduction frame.

We describe our early operative experience with a new pelvic reduction frame and the standard of reduction of fractures of the pelvic ring which we achieved in the first 35 consecutive patients, with 34 acute fractures and one nonunion. The pre-operative and immediate post-operative radiographs were measured, using two methods, to find the maximum radiological displacement of the fracture and the quality of the reduction according to the criteria of Tornetta and Matta. There were 19 vertical shear fractures and 16 compression injuries. The mean age of the patients was 33.5 years (10 to 59) and mean delay to surgery was 4.6 days (0 to 16) in the 34 acute injuries. The mean operative time in isolated procedures was 103.4 minutes (SD 6.5). All but one patient had iliosacral screws implanted, 18 had screws in the anterior column, six had plates at the symphysis pubis and 12 had anterior external fixators. The mean maximum horizontal or vertical displacement was improved from 30.8 mm (SD 2.7) to a mean of 7.1 mm (SD 0.7). The reduction was assessed as excellent in ten patients, good in 18, and fair in the remainder. There was no significant influence on the quality of the reduction caused by obesity (p = 0.34), the type of fracture (p = 0.41) or delay to surgery (p = 0.83). The frame was shown to be effective, allowing the surgeon to obtain a satisfactory reduction and fixation of acute displaced disruptions of the pelvic ring.

Preliminary results and complications following limited open reduction and percutaneous screw fixation of displaced fractures of the acetabulum.

Twenty-four patients underwent attempted closed or limited open reduction of displaced acetabular fractures. If reduction was successful, the fractures were stabilized with percutaneous screws. Group 1 was composed of elderly patients with complex fractures and radiographic findings that were felt to be predictive of post-traumatic arthritis. In these patients, percutaneous screw fixation was used to improve fracture anatomy, allow mobilization and total hip replacement later, if necessary. In group 1, anatomical reduction was not felt to be a necessity. Group 2 was composed of young patients with simple fracture types. For group 2, anatomical reduction was the goal. In 23/24 patients, closed or limited open reduction was successful. In group 1, maximum displacement averaged 10 mm preoperatively, 3 mm postoperatively. In group 2, maximum displacement averaged 7 mm preoperatively, 1 mm postoperatively. One elderly patient was lost to follow-up and one died, leaving 21 patients with an average follow-up of 12 months. All the fractures healed. One patient had a transient femoral nerve palsy, and two elderly patients had minor losses of reduction due to unprotected ambulation after surgery. Five of the elderly patients have gone on to total hip arthroplasty. The average Harris Hip scores in groups 1 and 2 were 85 and 96, respectively.

The "swashbuckler": a modified anterior approach for fractures of the distal femur.

A modified anterior approach to the distal femur is presented. The approach allows surgical exposure of the entire articular surface of the distal femur. The quadriceps muscle bellies are spared during the approach. The skin incision used will not interfere with subsequent total knee arthroplasty, if posttraumatic arthritis develops and arthroplasty is necessary.

Effect of recombinant human bone morphogenetic protein-2 on fracture healing in a goat tibial fracture model.

Bone morphogenetic proteins (BMPs) are considered to have important regulatory roles in skeletal embryogenesis and bone healing. Recombinant human BMPs (rhBMPs) have been shown to heal critical size defects and promote spinal fusion. We studied the effects of rhBMP-2 in an absorbable collagen sponge (ACS) on bone healing in a large animal tibial fracture model. Bilateral closed tibial fractures were created in 16 skeletally mature goats and reduced and stabilized using external fixation. In each animal, one tibia received the study device (0.86 mg of rhBMP-2/ACS or buffer/ACS), and the contralateral fracture served as control. The device was implanted as a folded onlay or wrapped circumferentially around the fracture. Six weeks following fracture, the animals were sacrificed and the tibiae harvested for torsional testing and histomorphologic evaluation. Radiographs indicated increased callus at 3 weeks in the rhBMP-2/ACS treated tibiae. At 6 weeks, the rhBMP-2/ACS wrapped fractures had superior radiographic healing scores compared with buffer groups and controls. The rhBMP-2/ACS produced a significant increase in torsional toughness (p = 0.02), and trends of increased torsional strength and stiffness (p = 0.09) compared with fracture controls. The device placed in a wrapped fashion around the fracture produced significantly tougher callus (p = 0.02) compared with the onlay application. Total callus new bone volume was significantly increased (p = 0.02) in the rhBMP-2/ACS fractures compared with buffer groups and controls regardless of the method of device application. The rhBMP-2/ACS did not alter the timing of onset of periosteal/endosteal callus formation compared with controls. Neither the mineral apposition rates nor bone formation rates were affected by rhBMP-2/ACS treatment. The increased callus volume associated with rhBMP-2 treatment produced only moderate increases in strength and stiffness.

Treatment of femur fracture with associated head injury.

OBJECTIVES: The aim of this study was to determine (a) whether delay in femur fracture stabilization beyond twenty-four hours in patients with head injury increased the risk of pulmonary complications and (b) whether immediate (up to twenty-four hours) femur fracture stabilization increased the risk of central nervous system (CNS) complications. DESIGN: Retrospective analysis. MATERIALS AND METHODS: Thirty-two patients with femur fracture and head injury were identified. Fourteen underwent immediate stabilization of their fractures, and eighteen underwent delayed (four-teen patients) or no (four patients) stabilization of their fractures. RESULTS: In the immediate stabilization group, five patients had severe head injuries [Glasgow Coma Score (GCS) < or = 8] and nine had mild head injuries (GCS > 8). In the mild head injury group, no patient had a pulmonary complication and one had a CNS complication. In the severely head-injured group, one patient had a pulmonary complication and no patient had a CNS complication. In the delayed stabilization group, six patients had mild head injuries (GCS > 8) and twelve had severe head injuries (GCS < or = 8). In the mildly head injured group, one patient had a pulmonary complication, two patients had CNS complications, and one patient died. In the severely head injured group, nine patients had pulmonary complications, three patients had CNS complications, and one patient died. Logistic regression identified delay in femur stabilization as the strongest predictor of pulmonary complication (p = 0.0042), followed by severity of chest Abbreviated Injury Score (AIS; p = 0.0057) and head AIS (p = 0.0133). Delaying fracture stabilization made pulmonary complications forty-five times more likely. Each point increase in the chest AIS and head/neck AIS increased the risk of pulmonary complication by 300 percent and 500 percent, respectively. A statistically significant predictor of CNS complications could not be identified by using logistic regression. CONCLUSION: Delay in stabilization of femur fracture in head-injured patients appears to increase the risk of pulmonary complications. However, due to selection bias in this patient sample, this question cannot be definitively answered. Early fracture stabilization did not increase the prevalence of CNS complications.

Percutaneous fixation of the columns of the acetabulum: a new technique.

A technique for percutaneous placement of cannulated screws in the acetabulum is presented. Surgical technique is described, and fluoroscopic imaging techniques used to guide screw placement are also illustrated. The technique was used to limit soft tissue dissection in three patients. Results and examples are presented.

Treatment of femur fracture with associated vascular injury.

OBJECTIVE: The aim of this study was to determine (1) if internal fixation was associated with a high amputation rate in patients with femur fracture and vascular injury; and (2) if patients who underwent internal fixation before vascular repair had a higher amputation rate. DESIGN: This is a retrospective analysis. MATERIALS AND METHODS: Twenty-six patients requiring femoral stabilization with injury to the superficial femoral artery, popliteal artery, or common femoral vein were studied. The Injury Severity Score and the Mangled Extremity Severity Score were calculated for each. Nineteen patients underwent internal fixation. Ten patients had internal fixation before vascular repair. RESULTS: Sixteen of 19 patients treated with internal fixation had limb salvage. Nine of 10 patients who had internal fixation before vascular repair had limb salvage. Poor outcomes (gangrene, amputation, or death) were associated with a Mangled Extremity Severity Score > or = 6 (p = 0.005). CONCLUSIONS: In these patients, poor outcome is associated with severe leg injury, (with a Mangled Extremity Severity Score of > or = 6). Internal fixation can be safely used, and skeletal stabilization can be safely performed before vascular repair. If ischemic time is prolonged, vascular shunts should be used until skeletal stabilization is completed.

Excision of posterolateral talar dome lesions through a medial transmalleolar approach.

Posterolateral osteochondral fractures of the talus are rare. Although arthroscopy is becoming an increasingly important method of evaluating and treating lesions of the ankle, these techniques may not always be feasible, especially for posterolateral lesions. Classic treatment of displaced or symptomatic chronic lesions is excision, usually with a distal fibular osteotomy and turndown procedure. Subsequent removal of the syndesmosis screw is required. The surgical dissection of the distal fibula is extensive and devascularizing. An alternate technique for debriding posterolateral talar dome lesions through a medial transmalleolar approach is described. Exposure of the lateral talar dome is sufficient to allow debridement and curettage of the lesion. Anatomic rigid fixation of the medial malleolus allows for rapid healing of the osteotomy site and immediate ankle rehabilitation. For those ankle lesions that are not accessible to arthroscopy or an anterolateral arthrotomy, this approach is preferable to the distal fibular osteotomy and turndown.

Treatment of unstable tibial diaphyseal fractures with minimal internal and external fixation.

We prospectively studied 20 patients whose selected unstable tibial diaphyseal fractures were treated with the combined techniques of minimal internal fixation and external fixation. Five fractures were closed and 15 were open (six Grades I and II, nine Grade III). Seventeen were due to high-energy injuries. The minimum followup was 2 years. All fractures healed, one with malalignment. Time to union averaged 12 weeks in closed fractures and 19 weeks in open fractures. All high-energy fractures underwent bone grafting. The external fixation was removed by dynamization. Thirteen complications occurred in nine patients, all with open fractures. Three of 120 pins became infected (2.5%). Early bone grafting and dynamization of the external fixation prevented the malunions and nonunions reported previously with this technique.

Heterotopic ossification as a complication of acetabular fracture. Prophylaxis with low-dose irradiation.

In a retrospective review of thirty-seven patients who had operative treatment for thirty-eight complex acetabular fractures, postoperative low-dose irradiation was administered to seventeen patients (eighteen fractures) to suppress heterotopic ossification. All of the patients had been operated on through either an extended iliofemoral incision or a modified extended iliofemoral incision. The prophylactic radiation was administered using a low-dose protocol; most of the patients received 1,000 rads in 200-rad increments, starting on the third post-operative day. The incidence of heterotopic ossification in the eighteen irradiated limbs was much lower than in the twenty patients who comprised the control group (50 per cent compared with 90 per cent). Only two of the irradiated limbs had Class-3 heterotopic ossification as described by Brooker et al., and no patient had Class-4 (ankylosis of the hip). Of the twenty control-group patients, ten had severe heterotopic ossification: Class 3 in seven and Class 4 in three. The difference in the incidence of severe (Class-3 or 4) heterotopic ossification between the two groups of patients was significant (p less than 0.01).

A modified extensile exposure for the treatment of complex or malunited acetabular fractures.

A modification of the extended iliofemoral incision of Letournel and Judet facilitates the operative exposure of T-type, complex transverse, and both-column acetabular fractures and malunions. The modification includes the utilization of a T-shaped skin incision with large flaps, and osteotomies of the iliac crest, greater trochanter, and anterior superior iliac spine. The iliotibial band is transected and the abductor muscle mass is rotated posteriorly, hinged on the superior gluteal neurovascular bundle. Twenty patients had open reduction and internal fixation of a complex acetabular fracture using this surgical approach. Excellent surgical exposure allowed good or excellent reduction of the acetabulum in all patients. No flap necrosis developed, and all fractures healed. One non-union of a trochanteric osteotomy needed revision. This approach provides increased exposure of the posterior column and visualization of the entire surface of the joint and it allows fixation of the fracture from both sides of the iliac wing. The T-shaped skin incision allows utilization of a standard posterior approach with conversion to the extensile exposure if necessary. Options for late reconstruction are not compromised. Lagscrew fixation of the osteotomies allows aggressive rehabilitation of the joint.

A technique for removing a fractured interlocking tibial nail.

The reported incidence of implant failure following reamed intramedullary tibial fixation is low. When necessary, retrieval of failed tibial nail segments is best performed in a closed fashion in order to avoid the delayed healing and increased risk of infection that may result from exposure of the tibial fracture site. A method to facilitate closed removal of the distal segment of a failed tibial nail is described.

Preoperative angiographic assessment of the superior gluteal artery in acetabular fractures requiring extensile surgical exposures.

Extensile exposures used for complex acetabular fracture reconstructive surgery often create abductor muscle flaps pedicled on the superior gluteal artery. Preoperative arteriograms were performed in eight patients who required extended iliofemoral or modified extended iliofemoral surgical approaches to assess the integrity of the superior gluteal artery. All of the patients had complex acetabular fractures, with significant displacement of the fracture into the sciatic notch. Abnormalities of the superior gluteal artery were found in three patients. One patient demonstrated a complete laceration of the superior gluteal artery, one patient a complete arterial occlusion, and one patient had a compressive entrapment of the artery at the fracture site. Preoperative angiographic evaluation of the superior gluteal artery is suggested for patients with acetabular fractures that are displaced into the sciatic notch and who will require an extensile surgical exposure creating an abductor muscle flap supplied by the superior gluteal artery.

Bacterial meningitis following Pantopaque myelography. A case report and literature review.

A case of acute bacterial meningitis following Pantopaque myelography is reported, and the literature reviewed pertaining to this uncommon but potentially fatal complication. A positive Gram's stain is most helpful in differentiating bacterial from chemical meningitis. Treatment of the meningitis before and after determination of its cause is described. Preventive steps include removal of Pantopaque from the subarachnoid space immediately at the conclusion of fluoroscopy, and observance of strict sterile technique during myelography, including use of face masks.

Surgical stabilization of thoracic and lumbar spine fractures: a retrospective study in a military population.

Twenty-two patients underwent surgical stabilization of thoracic and lumbar spine fractures. Twenty patients were operated on within 4 weeks of the injury and two patients more than 1 year following injury. Harrington rods were used in 21 and Dwyer instrumentation in one. The presenting neurological deficits were: four complete, five incomplete, and 13 intact. Clinical failure was noted in four patients, two of whom underwent posterior instrumentation more than 1 year following the initial injury. The most important contributing factor to failure was use of instrumentation in deviation from standard practice. The aim of operative treatment to maintain fracture reduction, decompress neural elements, promote fracture healing, and shorten hospitalization was achieved.

The use of epidural morphine to decrease postoperative pain in patients undergoing lumbar laminectomy.

In a double-blind study of fifty patients that was done to test the ability of epidural morphine to decrease the discomfort after lumbar laminectomy, we found that during the first postoperative day the patient's pain was lessened appreciably but that the total dose of morphine received postoperatively was not diminished. We used a three-milligram dose of epidural morphine, and there were no problems with respiratory depression. The addition of epinephrine to the morphine solution had no beneficial effect.

Complex dislocation of first metatarsophalangeal joint.

Dislocation of the first metatarsophalangeal joint is rare. Closed reduction is often impossible due to soft tissue interposition. A case is presented and the literature is reviewed with emphasis on normal and pathologic anatomy. Treatment recommendation is open reduction performed as soon as possible following injury if the dislocation cannot be reduced by closed methods.