Managing failed fixation: valgus osteotomy for femoral neck nonunion

Femoral neck non union is a relatively uncommon complication following intracapsular hip fracture in the young patient. Almost all patients with femoral neck non union are symptomatic for which they will require some form of revision surgery. This review discusses the role of valgus osteotomy in managing the younger patient with femoral neck non union.

Psychometric analysis of measuring functional outcomes in tibial plateau fractures using the Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA) and the Western Ontario McMaster Osteoarthritis (WOMAC) questionnaires

Patients participating in a modern prospective orthopaedic trauma database may be asked to complete many functional outcome measures, adding to the burden of study participation. This prospective study assessed the utility and responsiveness of the generic Short Form 36 (SF-36) and the disease specific Short Musculoskeletal Function Assessment (SMFA) and the Western Ontario McMaster Osteoarthritis (WOMAC) questionnaires in 55 patients treated operatively for tibial plateau fractures with the goal of determining if there was clear benefit of using multiple measures in a lower extremity peri-articular fracture population. There was very good correlation between all three scores at 6 and 12 months, indicating they are measuring similar factors. Responsiveness was assessed using the standard response mean (SRM), proportion of patients attaining the minimal clinically important difference (MCID) between 6 and 12 months, and floor and ceiling effects. The SRM for the SF-36 was statistically higher than the SRM for the SMFA or the WOMAC. Significantly more patients were found to have a MCID between 6 and 12 months post-surgery based on the SF-36 than the other two functional scores. There was no floor effect found on any of the 3 functional scores evaluated; however, a significant ceiling effect was noted with the WOMAC but not with the SF-36 or the SMFA. These results, along with the usefulness of the SF-36 for comparing disease burden across populations, favour the SF-36 as the instrument of choice in assessing functional outcome in patients with tibial plateau fractures.

Reamed nailing of Gustilo grade-IIIB tibial fractures

Reamed intramedullary nailing was carried out on 57 Gustilo grade-IIIB tibial fractures in 55 patients. After debridement, there was substantial bone loss in 28 fractures (49%). The mean time to union was 43 weeks (14 to 94). When there was no bone loss, the mean time to union was 32 weeks; it was 45 weeks if there was bone loss. Fractures complicated by infection took a mean of 53 weeks to heal. Revision nailing was necessary in 13 fractures (23%) and bone grafting in 15 (26%). In ten fractures (17.5%) infection developed, in four within six weeks of injury and in six more than four months later. Of these, nine were treated successfully, but one patient required an amputation because of osteomyelitis.

Our results indicate that reamed intramedullary nailing is a satisfactory treatment for Gustilo grade-III tibial fractures.

Reamed nailing of Gustilo grade-IIIB tibial fractures

Reamed intramedullary nailing was carried out on R57 Gustilo grade-IIIB tibial fractures in 55 patients. After debridement, there was substantial bone loss in 28 fractures (49%). The mean time to union was 43 weeks (14 to 94). When there was no bone loss, the mean time to union was 32 weeks; it was 45 weeks if there was bone loss. Fractures complicated by infection took a mean of 53 weeks to heal. Revision nailing was necessary in 13 fractures (23%) and bone grafting in 15 (26%). In ten fractures (17.5%) infection developed, in four within six weeks of injury and in six more than four months later. Of these, nine were treated successfully, but one patient required an amputation because of osteomyelitis. Our results indicate that reamed intramedullary nailing is a satisfactory treatment for Gustilo grade-III tibial fractures.

Reamed interlocking intramedullary nailing of open fractures of the tibia

One hundred twelve open tibial fractures were treated by reamed interlocking nailing in 108 patients. There were 31 (28%) Grade I fractures, 38 (34%) Grade II, 23 Grade IIIA (21%), and 20 (18%) Grade IIIB fractures. Early amputation was performed in 2 (10%) Grade IIIB fractures for severe crushing injuries. Compartment syndrome complicated 8 (7%) fractures. Mean time to union was 29 weeks for Grade I fractures, 32 weeks for Grade II, 34 weeks for Grade IIIA, and 39 weeks for Grade IIIB. Nonunion complicated 9 (8%) fractures: 1 (3%) Grade I fracture, 2 (5%) Grade II fractures, 3 (13%) Grade IIIA fractures, and 3 (17%) Grade IIIB fractures. Deep infection complicated 4 Grade II fractures (10%) and 2 (11%) Grade IIIB fractures. Reamed locking intramedullary nailing is a safe and effective technique for management of open tibial fractures.

Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study

One hundred and fifty-two patients who had 154 closed fractures of the shaft of the tibia were prospectively randomized to management with interlocking intramedullary nailing either with or without reaming. Thirteen patients who had been randomized to treatment without reaming were switched to the group that had reaming because of technical reasons; these patients were excluded from the analysis of the results. An additional five patients were lost to follow-up. Thus, seventy-two patients (seventy-three fractures) who had been managed with nailing with reaming and sixty-three patients (sixty-three fractures) who had been managed with nailing without reaming were available for follow-up at an average of twelve months (range, three to thirty-three months) postoperatively. The two groups were similar with regard to demographics and the configurations of the fractures. The average total duration of the procedures performed without reaming was eleven minutes shorter than that of the procedures done with reaming (p = 0.0013). The duration of fluoroscopy was not significantly different between the two groups (p = 0.35, Mann-Whitney test). The average estimated blood loss was identical for the two groups. Seventy fractures (96 per cent) that were treated with nailing with reaming and fifty-six (89 per cent) that were treated with nailing without reaming united without the need for an additional operation (p = 0.19). Because of the small sample size, the study has insufficient power (34.7 per cent) to detect this difference if it is real. There was only one deep infection, which developed after nailing without reaming. The nail fractured after one procedure with reaming. A screw fractured after two procedures with reaming and after ten without reaming (p = 0.012); multiple screws fractured after three procedures in the latter group. Malunion occurred after three nailing procedures with reaming and after two without reaming. Four malunions were of very proximal fractures and one was of a very distal fracture. Seventeen screws and twenty-four nails were removed after nailing with reaming, and twenty screws and nineteen nails were removed after nailing without reaming; neither of these prevalences was significantly different between the two groups (p = 0.27 and 0.89; chi-square test). We concluded that there are no major advantages to nailing without reaming as compared with nailing with reaming for the treatment of closed fractures of the shaft of the tibia. There was a higher prevalence of delayed union and breakage of screws after nailing without reaming.

Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study

Ninety-one patients who had ninety-four open fractures of the tibial shaft were randomized into two treatment groups. Fifty fractures (nine type-I, eighteen type-II, sixteen type-IIIA, and seven type-IIIB fractures, according to the classification of Gustilo et al.) were treated with nailing after reaming, and forty-four fractures (five type-I, sixteen type-II, nineteen type-IIIA, and four type-IIIB fractures) were treated with nailing without reaming. The average diameter of the nail was 11.5 millimeters (range, nine to fourteen millimeters) in the group treated with reaming and 9.2 millimeters (range, eight to ten millimeters) in the group treated without reaming. Follow-up information was adequate for forty-five patients (forty-seven fractures) who had been managed with reaming and forty patients (forty-one fractures) who had been managed without reaming. No clinically important differences were found between the two groups with regard to the technical aspects of the procedure or the rate of early postoperative complications. The average time to union was thirty weeks (range, thirteen to seventy-two weeks) in the group treated with reaming and twenty-nine weeks (range, thirteen to fifty weeks) in the group treated without reaming. Four (9 per cent) of the fractures treated with reaming and five (12 per cent) of the fractures treated without reaming did not unite (p = 0.73). There were two infections in the group treated with reaming and one in the group treated without reaming. Significantly more screws broke in the group treated without reaming (twelve; 29 per cent) than in the group treated with reaming (four; 9 per cent) (p = 0.014). There was no difference between the two groups with regard to the frequency of broken nails (two nails that had been inserted after reaming broke, compared with one that had been inserted without reaming). The functional outcome, in terms of pain in the knee, range of motion, return to work, and recreational activity, did not differ significantly between the groups. We concluded that the clinical and radiographic results of nailing after reaming are similar to those of nailing without reaming for fixation of open fractures of the tibial shaft, although more screws broke when reaming had not been done.

Range of motion and complications after postburn heterotopic bone excision about the elbow

OBJECTIVE

To review the results of surgical management of heterotopic ossification about the elbow in burned patients.

DESIGN

Retrospective analysis with long-term patient follow-up.

MATERIALS AND METHODS

Eleven patients with 16 elbows requiring surgery were admitted between January 1, 1982 and December 31, 1993. A posterior approach to the elbow with release of the encased ulnar nerve +/- anterior transposition and transolecranon osteotomy to access extensive bone formation in the olecranon fossa was employed. Eight patients (11 elbows) were available for long-term follow-up conducted at mean 50 +/- 13 months after surgery. Long-term follow-up consisted of measurement of range of elbow motion, as well as clinical assessment of ulnar nerve function.

MAIN RESULTS

For the 11 elbows examined postoperatively, the mean range of motion preoperatively in flexion-extension was 11 degrees +/- 5 degrees compared to 89 degrees +/- 12 degrees postoperatively (p < 0.001). Three patients with poor long-term results had ankylosis of the joint preoperatively. Of four patients with ulnar nerve paresis preoperatively, none had ulnar nerve dysfunction at follow-up. Of 16 elbows operated on, four (25%) had postoperative complications. Two suffered soft-tissue breakdown with hardware exposure requiring abdominal flap closure, one early failure of olecranon fixation, and one late infected hardware.

CONCLUSIONS

Surgery for both limited range of motion as well as ulnar nerve compression is effective in cases of heterotopic ossification about the elbows of burned patients. Early operative intervention is indicated in progressive disease, particularly ulnar nerve palsy, if soft-tissue quality is adequate. Complications with 25% of elbows suggest that use of olecranon osteotomy for joint access may warrant review.

Reamed nailing of open tibial fractures: does the antibiotic bead pouch reduce the deep infection rate?

Eighty-one open tibial fractures were treated by reamed intramedullary nailing. There were 38 type II, 23 type IIIa and 20 type IIIb injuries. At the end of the nailing procedure the first 26 fractures (15 type II, five type IIIa, and six type IIIb) had antibiotic prophylaxis and delayed closure of the open wound. The subsequent 55 fractures (23 type II, 18 type IIIa, and 14 type IIIb) had identical management but in addition had an antibiotic bead pouch inserted into the open wound following debridement. Three amputations were performed: one (3.8%) in the group treated without a bead pouch and two (3.6%) in the bead pouch group in patients with grade IIIb fractures and severe crushing injuries. Of the remainder, there were four deep infections (16%) in the 25 fractures treated prior to the use of the bead pouch and two (4%) deep infections in the 53 fractures following introduction of the bead pouch. Addition of the bead pouch to the wound management protocol was associated with a worthwhile reduction of deep infection.

Fixation of intertrochanteric hip fractures: gamma nail versus dynamic hip screw. A randomized, prospective study

OBJECTIVE

To compare the efficacy of the gamma nail (GN) to the dynamic hip screw (DHS) in the management of intertrochanteric hip fractures.

DESIGN

Randomized, prospective clinical trial with a mean follow-up of 52 weeks (range from 11 to 82 weeks).

SETTING

A university teaching hospital.

PATIENTS

One hundred and one patients with 102 fractures: 49 fractures were treated with the DHS and 53 fractures were treated with the GN.

INTERVENTIONS

Fracture fixation with the DHS or the GN.

MAIN OUTCOME MEASURES

Comparison of duration of operation, blood loss, early and late complications, functional outcome and duration of hospital stay.

RESULTS

There was no significant difference between the two groups with respect to intraoperative blood loss, days in hospital, time to union and eventual functional outcome. The length of the procedure and fluoroscopy time were longer for the GN group.

CONCLUSIONS

Both the GN and the DHS can be used effectively for the treatment of intertrochanteric fractures. In this study the DHS was associated with a lower risk of local complications and should still be considered to be the implant of choice for patients with intertrochanteric fractures.

Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomized study of compression alone versus no prophylaxis

A prospective, randomized clinical trial in 304 orthopaedic trauma patients with hip and pelvic fractures was conducted to investigated the effectiveness of pneumatic sequential leg compression devices (PSLCDs) for the prevention of thromboembolic disease. The control group received no specific form of prophylaxis. Patients were followed by venous Doppler, duplex can, and ventilation perfusion lung scans. The study end-point was documented pulmonary embolism and/or deep vein thrombosis. The incidence of a venous thromboembolic event in the control group was 11% and in the experimental group 4%. This difference was statistically significant (p = 0.02). These patients were also stratified into hip and pelvic fracture groups. In the hip fracture patients, the control group had a thromboembolic event incidence of 12% and the experimental group 4%. This difference was also statistically significant (p = 0.03). In the pelvic fracture group there was a thromboembolic incidence of 11% in the controls, demonstrating this patient population to be at significant risk. In this group, the PSLCDs were not statistically shown to be effective. Pneumatic leg compression devices are effective in reducing the incidence of thromboembolic events in patients with hip fractures.

Intramedullary nailing of the femoral shaft: a prospective, randomized study

We conducted a prospective, randomized study on 84 consecutive patients with 88 acute, traumatic femoral shaft fractures using 32 Grosse-Kempf nails, 29 Russell-Taylor nails, and 27 Synthes nails. Although total operative times and proximal and distal locking times were similar for the three groups, the procedure was faster with the Grosse-Kempf nail. Three proximal fractures could not be locked with the Synthes nail. At first follow-up, we found no significant difference in terms of pain, limp, range of motion, or time to union; however, we removed fewer Synthes nails to resolve patient complaints of pain. Three delayed unions were attributed to fracture distraction. We conclude that all three nails are suitable for the treatment of almost all femoral shaft fractures. A careful analysis of intraoperative technique and instrumentation indicates that all three nails can be used safely and easily once experience is gained. Clinical outcome is similar regardless of the nail chosen.

External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol

Between 1983 and 1989, forty-one open fractures of the tibial shaft were treated with débridement and provisional external fixation, followed by delayed soft-tissue closure and subsequent intramedullary nailing with reaming. The average duration of external fixation was seventeen days (range, six to fifty-two days). The average time between removal of the fixator and intramedullary nailing was nine days (range, zero to twenty-four days). Of thirty-nine patients who had adequate follow-up, two (5 per cent) subsequently had a deep infection. Both infections healed, with retention of the nail and without chronic osteomyelitis. There were two nonunions and one delayed union. Satisfactory alignment was achieved in thirty-seven patients (95 per cent). This sequential protocol for treatment, which involved a short period of external fixation and thus minimized colonization of the pin tracks, yielded excellent results and a low rate of infection.

Arthroscopic anatomy of the shoulder

Arthroscopic anatomy of the shoulder was evaluated using cadaver dissections. The anatomical areas of clinical importance were documented both photographically and with illustrations. It is hoped this anatomical study will prove to be an aid to arthroscopists during their early experiences with shoulder arthroscopy.