Salvage of humeral nonunions with onlay bone plate allograft augmentation.

Eight women and one man were treated for 10 established diaphyseal humeral nonunions. Six patients sustained fractures in motor vehicle accidents and two patients sustained fractures in a fall. Two of the fractures were open. One patient with multiple myeloma originally was treated conservatively and received local radiation, followed by open reduction and internal plate fixation. The other patients previously were treated with fracture braces, intramedullary nails, dynamic compression plates, or a combination of these techniques. After removal of the surgical hardware and fibrous tissue at the nonunion site, stable fixation was accomplished using a cortical long bone plate allograft (femoral and tibial) or fibular shaft allograft and a dynamic compression plate. All humeral nonunions had united at an average of 2.9 months. Radiographic incorporation of the allograft cortical bone plate and fibular shaft into the host cortex occurred in all but one patient by 3 months. Graft to host junction healing was accomplished by incorporation of the cortical allograft plate into the host cortex, resulting in an increased diameter of the bone. Cortical allograft bone plates and fibular grafts provide structural and probably osteoinductive support to enhance healing of these nonunions.

Osteogenic protein-1 (bone morphogenetic protein-7) in the treatment of tibial nonunions.

BACKGROUND: The role of bone morphogenetic proteins (BMPs) in osseous repair has been demonstrated in numerous animal models. Recombinant human osteogenic protein-1 (rhOP-1 or BMP-7) has now been produced and was evaluated in a clinical trial conducted under a Food and Drug Administration approved Investigational Device Exemption to establish both the safety and efficacy of this BMP in the treatment of tibial nonunions. The study also compared the clinical and radiographic results with this osteogenic molecule and those achieved with fresh autogenous bone. MATERIALS AND METHODS: One hundred and twenty-two patients (with 124 tibial nonunions) were enrolled in a controlled, prospective, randomized, partially blinded, multi-center clinical trial between February, 1992, and August, 1996, and were followed at frequent intervals over 24 months. Each patient was treated by insertion of an intramedullary rod, accompanied by rhOP-1 in a type I collagen carrier or by fresh bone autograft. Assessment criteria included the severity of pain at the fracture site, the ability to walk with full weight-bearing, the need for surgical re-treatment of the nonunion during the course of this study, plain radiographic evaluation of healing, and physician satisfaction with the clinical course. In addition, adverse events were recorded, and sera were screened for antibodies to OP-1 and type-I collagen at each outpatient visit. RESULTS: At 9 months following the operative procedures (the primary end-point of this study), 81% of the OP-1-treated nonunions (n = 63) and 85% of those receiving autogenous bone (n = 61) were judged by clinical criteria to have been treated successfully (p = 0.524). By radiographic criteria, at this same time point, 75% of those in the OP-1-treated group and 84% of the autograft-treated patients had healed fractures (p = 0.218). These clinical results continued at similar levels of success throughout 2 years of observation, and there was no statistically significant difference in outcome between the two groups of patients at this point (p = 0.939). All patients experienced adverse events. Forty-four percent of patients in each treatment group had serious events, none of which were related to their bone grafts. More than 20% of patients treated with autografts had chronic donor site pain following the procedure. CONCLUSIONS: rhOP-1 (BMP-7), implanted with a type I collagen carrier, was a safe and effective treatment for tibial nonunions. This molecule provided clinical and radiographic results comparable with those achieved with bone autograft, without donor site morbidity.

Treatment of comminuted intraarticular distal femur fractures with limited internal and external tensioned wire fixation.

OBJECTIVE: Evaluate the treatment of C3 distal femur fractures with limited internal fixation and tensioned wire circular external fixation. DESIGN: Prospective cohort study, from June 1992 to July 1996. SETTING: Urban Level I trauma center. PATIENTS: Sixteen fractures in sixteen patients: nine male, seven female. Fractures: C3.1 one, C3.2 one, C3.3 fourteen. Twelve fractures were open: one GI, seven GII, two GIIIA, one GIIIB, and one GIIIC. INTERVENTION: Fractures were treated with limited open fixation of the condylar joint surface and tensioned wire circular external fixation of the metaphysis and shaft for axial alignment. Three fractures had acute autologous bone grafts. MAIN OUTCOME MEASUREMENTS: The patient's extremity function was evaluated by the authors by using the Sanders et al. Distal Femur Functional Evaluation. RESULTS: Sixteen of sixteen fractures healed. Two patients had delayed bone grafting for delayed union. Average frame time was twenty-five weeks. Average range of motion was 0 to 92 degrees. Five patients had less than 90 degrees of flexion. Five patients required a quadricepsplasty. Average follow-up was thirty-five months. One patient developed a pintract infection. One patient developed septic arthritis, and another developed osteomyelitis. The average Sanders et al. Function knee score was twenty-eight, with a maximum possible score of forty. CONCLUSIONS: C3 fractures of the distal femur are associated with severe soft tissue injuries and bone loss. Loss of function appears to be directly related to these factors. Treatment with limited internal fixation and tensioned wire external fixation has equivalent results to other methods but has a higher incidence of infection and complications. Joint motion is retarded by binding of the soft tissues with fixation wires and pins. The technique is recommended only for salvage of severely comminuted and open fractures of the distal femur with extensive soft tissue injury. Distal femur fractures with moderate comminution and soft tissue injury should be treated with alternate methods.

Functional bracing for the treatment of fractures of the humeral diaphysis.

BACKGROUND: Nonoperatively treated fractures of the humeral diaphysis have a high rate of union with good functional results. However, there are clinical situations in which operative treatment is more appropriate, and, though interest in plate osteosynthesis has decreased, intramedullary nailing has gained popularity in recent years. We report the results of treating fractures of the humeral diaphysis with a prefabricated brace that permits full motion of all joints and progressive use of the injured extremity. METHODS: Between 1978 and 1990, 922 patients who had a fracture of the humeral diaphysis were treated with a prefabricated brace that permitted motion of adjacent joints. The injured extremities were initially stabilized in an above-the-elbow cast or a coaptation splint for an average of nine days (range, zero to thirty-five days) prior to the application of the prefabricated brace. Orthopaedic residents, supervised by teaching staff, provided follow-up care in a special outpatient clinic. Radiographs were made at each follow-up visit until the fracture healed. RESULTS: We were able to follow 620 (67 percent) of the 922 patients. Four hundred and sixty-five (75 percent) of the fractures were closed, and 155 (25 percent) were open. Nine patients (6 percent) who had an open fracture and seven (less than 2 percent) who had a closed fracture had a nonunion after bracing. In 87 percent of the 565 patients for whom anteroposterior radiographs were available, the fracture healed in less than 16 degrees of varus angulation, and in 81 percent of the 546 for whom lateral radiographs were available, it healed in less than 16 degrees of anterior angulation. At the time of brace removal, 98 percent of the patients had limitation of shoulder motion of 25 degrees or less. We were unable to follow most of the patients long-term, as they did not return to the clinic once the fracture had united and use of the brace had been discontinued. CONCLUSIONS: Functional bracing for the treatment of fractures of the humeral diaphysis is associated with a high rate of union, particularly when used for closed fractures. The residual angular deformities are usually functionally and aesthetically acceptable. The present study illustrates the difficulties encountered in carrying out long-term follow-up of indigent patients treated in charity hospitals that are affiliated with teaching institutions. These difficulties are also becoming common with patients insured under managed-care organizations and are frequent in our peripatetic population.

Infections in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixators.

OBJECTIVES: To observe the incidence and clinical presentation of infection in periarticular fractures of the tibia and femur treated with tensioned wire external fixators. DESIGN: Prospective cohort study. SETTING: Level One Trauma Center in urban community. Single surgeon. PATIENTS: One hundred thirty-five patients with 145 fractures: seventy tibial plateau, fifty-six pilon, and nineteen distal femur. Five-year treatment period, 1991 to 1995. MAIN OUTCOME MEASUREMENTS: The incidence of infection was evaluated. RESULTS: Nineteen of 145 fractures (13 percent) were complicated by infection. Infections presented as pin tract inflammation requiring intravenous antibiotics (seven), deep infection requiring debridement and removal (five), septic arthritis (three), deep fracture infection (three), and necrotizing fasciitis (one). CONCLUSIONS: Infection is a common complication of juxtaarticular fractures treated with tensioned wire fixators. Excellent pin care is required. Aggressive management of infections with intravenous antibiotics and debridement will resolve infections occurring in patients treated with tensioned wire fixators. Septic arthritis is associated with wires placed less than one centimeter from the subchondral bone. Deep infection is associated with insidious swelling and excessive proliferative callus. Wire infections increase with prolonged frame time.

Primary reamed intramedullary nailing of open femoral shaft fractures.

Forty-two patients with acute open femoral shaft fractures were assigned prospectively to primary immediate or delayed reamed intramedullary stabilization. There were 27 primary and 15 delayed intramedullary nailings performed (mean followup, 20 months). Twelve patients (29%) had Gustilo and Anderson Grade I injury; 16 (38%), Grade II; and 14 (33%), Grade III (including 3 Grade IIIC). Average time to union was 3.8 months. The infection and nonunion rate was 2.4%. Comparison of the 2 groups showed no significant differences in the incidence of infection, malunion, nonunion, or the time to union. The data suggest that primary reamed intramedullary nailing is an effective treatment alternative for the patient with multiple injuries, regardless of soft tissue injury, including Grade III wounds. Isolated open femoral shaft fractures with Grade I and Grade II soft tissue wounds may be stabilized safely primarily with no increased morbidity. Although results were promising, continued study is needed to delineate the optimum management of all Grade III injuries.

Mechanical failures of intramedullary tibial nails applied without reaming.

The clinical mechanical failures of small diameter intramedullary interlocking nails were evaluated to determine the relationship of failure modes to the type or location of tibial fractures. Methods were developed to duplicate failure modes in vitro in standardized tests to simulate the clinical situations. Where standard test methods were inadequate, new methods were developed to provide quantifiable, reliable methods of evaluating potential clinical performance. The modes and rates of mechanical failure in the clinical series were consistent among participating centers: (1) In diaphyseal fractures with secondary trauma, the intramedullary nail bent at the fracture site where the working length was unsupported; (2) failures that occurred several weeks after nailing were the result of fatigue fractures of the locking screws, usually at the distal end; and (3) nail and screw failures occurred most commonly in proximal and distal tibial fractures. The strength of the 8- and 9-mm sizes of Synthes and Russell-Taylor nails were comparable.

Diagnosis and management of infection after tibial intramedullary nailing.

A series of 20 patients with infection after intramedullary nailing of the tibia is discussed. The most common pathogen was Staphylococcus aureus, which was found in 14 patients (64%). Eleven nails were originally inserted without reaming, and 9 were reamed. Treatment protocols were based on the time of onset of infection (acute, subacute, and chronic) and the status of bone healing. In eight patients, the fractures (6) and nonunions (2) were healed at diagnosis of infection and were treated by debridement, nail removal, and antibiotics. Twelve patients had fractures (8) and nonunions (4) that were not healed. Four were treated with debridement, nail removal, and external fixation, and four with debridement and nail retention. The overall success rate for eradicating infection was 90%. Infection after unreamed nailing had fewer complications and a higher success rate for infection control than did reamed nailing. Risk factors identified in this study for infection are previous external fixation, severe open fracture, and substance abuse.

Assessment of soft tissue injury in open tibial shaft fractures by transcutaneous oximetry.

Transcutaneous oximetry was performed on 32 patients with 33 open tibial shaft fractures in an attempt to identify those patients at risk for the subsequent development of serious complications. Oxygen electrodes were placed on areas of intact skin, over viable compartments at the fracture site (wound) as well as on the anterior chest wall (control). Simultaneous wound and chest wall measurements were obtained after equilibration (30 minutes) on both room air and 100% oxygen. Values obtained were expressed as absolute values and as percentages of the wound measurement divided by the chest measurement. The study group consisted of 27 male and five female patients with an average age of 37 years (range, 17-63 years). There were 8 Grade I, 12 Grade II, and 13 Grade III fractures as described by Gustilo et al. Complications requiring medical or surgical intervention occurred in six patients: four deep infections, one deep vein thrombosis, and one superficial infection with severe bone and soft tissue loss requiring multiple procedures. Transcutaneous oximetry with patients breathing 100% oxygen was found to correlate with the development of complications in this study group. Five (42%) of 12 patients with transcutaneous oximetry values < or = 85 mm Hg and a wound-to-chest ratio < or = 25% developed a complication, whereas only one of 19 patients with either a fracture site value greater than 85 mm Hg or a wound to chest ratio greater than 25% developed a complication (p = 0.007).

[Treatment civilian gunshot fractures of the femur shaft]. / Behandlung ziviler Schussfrakturen des Femurschaftes.

35 consecutive cases of fractures of the femoral diaphysis due to gunshot wounds (GSW) treated at Jackson Memorial Hospital of the University of Miami between January 1988 and February 1990 were reviewed. There were 32 low velocity and 3 high energy transfer wounds. The treatment protocol for low velocity GSW consisted of 3 days i.v. antibiotics, balanced skeletal traction (for logistic reasons) and delayed closed intramedullary nailing. There was no formal debridement performed. 3 out of 32 patients declined any operative intervention. The remaining 29 patients were treated according to the above protocol. 12 patients could be followed until complete osseous consolidation. In this group the only complication consisted of one late infection. 17 patients were lost to follow-up before complete consolidation. Out of this group, 8 showed advanced fracture callus formation on the last radiograph available, whereas 9 patients were lost to follow-up almost immediately after discharge. Since GSW victims were generally uninjured and treatment of indigent patients in the Miami area is declined by all other hospitals, we assume that there were non major complications even in the group of patients lost to follow-up. We therefore conclude, that intramedullary nailing of low velocity gunshot fractures of the femoral diaphysis without formal debridement is the treatment of choice under civilian circumstances.

Complex upper-extremity fractures.

Complex proximal humeral fractures are a challenge to the orthopaedic surgeon. Achieving fracture healing while avoiding loss of function is best accomplished by early rigid fixation or prosthetic replacement, depending on the fracture type and characteristics.

Diaphyseal fractures of the humerus. Treatment with prefabricated braces.

Using a prefabricated brace, we treated 233 patients who had a fracture of the humeral shaft. One hundred and seventy patients were available for follow-up, which ranged from five weeks to forty-eight months. In these patients (forty-three open and 127 closed fractures), the average time to union was 10.6 weeks; the average varus-valgus angulation, 5 degrees; the average anterior-posterior angulation, 3 degrees; and the average shortening, as measured radiographically, four millimeters. All but three of the patients had an excellent or a good functional result with a nearly full range of motion of the extremity. There were a minimum of complications, including three non-unions. Because of the low morbidity and high rate of success, we concluded that the treatment of choice for diaphyseal fractures of the humerus is the prefabricated brace.

Acute fracture of the proximal humerus superimposed on a chronic posterior dislocation of the humeral head.

We have reported the case of a 73-year-old woman with a posterior shoulder dislocation and comminuted fracture of the proximal humerus occurring during a seizure. Surgery disclosed an acute humeral fracture superimposed on a chronically dislocated humeral head. Endoprosthetic replacement yielded a satisfactory clinical result. We found no similar report in the literature.

Treatment of isolated ulnar shaft fractures with prefabricated functional fracture braces.

In a prospective study, from September 1980 to December 1984, 146 isolated ulnar shaft fractures were treated with prefabricated fracture braces. Clinical and roentgenographic follow-up data were available for 73 fractures. Functional results were rated excellent in 64 fractures (88%), good in seven (9%), and poor in two (3%). All fractures healed in an average time of 57 days. The mean angulation measured 6 degrees in the mediolateral plane and 4 degrees in the anteroposterior plane. The complication rate was 18%, relating mostly to residual angulation. Most isolated fractures of the distal one-half of the ulnar shaft can be treated successfully with prefabricated fracture braces.

An unusual fracture of the talus associated with a bimalleolar ankle fracture. A case report and review of the literature.

A 53-year-old man sustained a fall from 1.25 m, injuring his hindfoot and ankle. Roentgenographic examination demonstrated a displaced vertical fracture through the neck of the talus with dislocation at the subtalar and tibiotalar joints (Hawkins Group III) and an ipsilateral bimalleolar fracture. Prompt anatomic reduction of the talus and bimalleolar fracture with rigid internal fixation was performed. Roentgenograms three years postinjury confirmed solid union of all fractures. Avascular necrosis of the talus had not occurred. Minimally disabling post-traumatic arthritis as both the ankle and subtalar joints was the only sequela. Only four similar injuries seem to have been reported previously in the literature. Despite the generally high incidence of avascular necrosis in Hawkins Group III talar neck fractures, none of these four cases developed this complication. A possible explanation is that with the presence of ipsilateral bimalleolar fracture, there is preservation of the extraosseous vascular supply that accompanies the deltoid and talofibular ligamentous complexes.

Acute psoas abscess in a newborn infant.

A 1-month-old neonate was seen for an acute toxic illness, suggestive of septicemia. No obvious focus of infection was present. During attempted femoral venipuncture, purulent material, thought to originate from the right hip joint, was encountered. Because of this aspirate, as well as suggestive local signs, septic arthritis of the right hip was diagnosed. Arthrotomy failed to confirm the diagnosis, and on further surgical exploration a purulent psoas abscess was discovered. The patient made an uneventful recovery, and at follow-up 48 months later was asymptomatic with a normal clinical examination. This case illustrates the difficulty of differentiating acute psoas abscess from septic arthritis of the hip in the neonate.

Clinical experiences with a titanium alloy total hip prosthesis: a posterior approach.

Using a titanium alloy femoral prosthesis (STH Zimmer) and an ultra high molecular weight polyethylene acetabular cup with a posterior surgical approach to the hip joint, 237 consecutive total hip arthroplasties in 215 patients were performed between December 1975 and May 1977. The preliminary results and early postoperative complications suggest that this system can be considered an alternative to total hip arthroplasty using other materials and surgical approaches.