Injury

Editorial Board

2012-06-01

The use of pelvic binders in the emergent management of potential pelvic trauma

T.J.S. Chesser, A.M. Cross, A.J. Ward — 2012-06-01

The prevalence of pelvic fracture in patients with blunt trauma is between 5% and 16%. A significant proportion of deaths from pelvic fracture are due to exsanguination and patients who are haemodynamically unstable on arrival to the Emergency Department have a much higher mortality rate than the stable patient. The sooner bleeding is controlled, the greater the chance of avoiding “the lethal triad” of hypothermia, coagulopathy and acidosis secondary to hypotension and hypoperfusion of tissues. In recent years, pelvic circumferential compression devices (PCCDs), or “pelvic binders”, have become widely adopted as part of resuscitation protocols worldwide and are now in established use by many trauma care providers. The pelvic binder has been promoted to maintain or restore mechanical stability to the pelvis and haemodynamic stability to the patient with a suspected pelvic ring injury prior to operative intervention or angiography. The reduction and stabilisation of the pelvic ring is believed to decrease fracture site bleeding while protecting any initial blood clot from disruption. In theory, a decrease in the pelvic volume may create a tamponade thus reducing venous bleeding. What is the clinical evidence to support the use of a pelvic binder and what are the problems, if any, with it's use? Are all pelvic fracture types suitable for treatment with a pelvic binder and how long can the binder safely be maintained?

The effect of ischemia reperfusion injury on skeletal muscle

Syed Gillani, Jue Cao, Takashi Suzuki, David J. Hak — 2012-06-01

Abstract: Ischemia reperfusion (IR) injury occurs when tissue is reperfused following a period of ischemia, and results from acute inflammation involving various mechanisms. IR injury can occur following a range of circumstances, ranging from a seemingly minor condition to major trauma. The intense inflammatory response has local as well as systemic effects because of the physiological, biochemical and immunological changes that occur during the ischemic and reperfusion periods. The sequellae of the cellular injury of IR may lead to the loss of organ or limb function, or even death. There are many factors which influence the outcome of these injuries, and it is important for clinicians to understand IR injury in order to minimize patient morbidity and mortality. In this paper, we review the pathophysiology, the effects of IR injury in skeletal muscle, and the associated clinical conditions; compartment syndrome, crush syndrome, and vascular injuries.

Preoperative predictors for mortality following hip fracture surgery: A systematic review and meta-analysis

Fangke Hu, Chengying Jiang, Jing Shen, Peifu Tang, Yan Wang — 2012-06-01

Abstract: Background: Hip fractures are always associated with a high postoperative mortality, the preoperative predictors for mortality have neither been well identified or summarised. This systematic review and meta-analysis was performed to identify the preoperative non-interventional predictors for mortality in hip fracture patients, especially focused on 1year mortality.Methods: Non-interventional studies were searched in Pubmed, Embase, Cochrane central database (all to February 26th, 2011). Only prospective studies and retrospective studies with prospective collected data were included. Qualities of included studies were assessed by a standardised scale previous reported for observational studies. The effects of individual studies were combined with the study quality score using a previous reported model of best-evidence synthesis. The hazard ratios of strong evidence predictors were combined only by high quality studies.Results: 75 included studies with 94 publications involving 64,316 patients were included and the available observations was a heterogeneous group. The overall inpatient or 1month mortality was 13.3%, 3–6months was 15.8%, 1year 24.5% and 2years 34.5%. There were strong evidence for 12 predictors, including advanced age, male gender, nursing home or facility residence, poor preoperative walking capacity, poor activities of daily living, higher ASA grading, poor mental state, multiple comorbidities, dementia or cognitive impairment, diabetes, cancer and cardiac disease. We also identified 7 moderate evidence and 12 limited evidence mortality predictors, and only the race was identified as the conflicting evidence predictor.Conclusion: Whilst there is no conclusive evidence of the preoperative predictors for mortality following hip fractures, special attention should be paid to the above 12 strong evidence predictors. Future researches were still needed to evaluate the effects of these predictors.

Evolving concepts of stability and intramedullary fixation of intertrochanteric fractures—A review

2012-06-01

Abstract: Intramedullary nailing is gradually emerging as the treatment of choice for pertrochanteric femoral fractures. Nevertheless, prospective randomised trials have failed to demonstrate the assumed superiority of cephalomedullary nails over the traditional treatment with the sliding hip screw. On the contrary, the gamma nail has been implicated in predisposing to secondary femoral fractures, although this seems to be rectified by newer techniques and nail designs. Sliding hip screw fixation remains the gold standard but can lead certain unstable pertrochanteric fracture subgroups to failure. Amongst these are transverse or reverse obliquity but also multifragmentary fractures, that suffer intra- or postoperative shattering of the lateral trochanteric wall. Nails seem to prevent failure by opposing the uncontrollable medialisation, and eventual failure, that occurs under these circumstances. The importance of the size of the proximal fracture fragment has not yet been elucidated. Nail fixation is, thus, mandatory in a small percentage of grossly unstable fractures, whose characteristics are still undergoing definition.

Knee chondral injuries: Clinical treatment strategies and experimental models

Javier Vaquero, Francisco Forriol — 2012-06-01

Abstract: Articular cartilage has a very limited capacity to repair and as such premature joint degeneration is often the end point of articular injuries. Patients with chondral injury have asymptomatic periods followed by others in which discomfort or pain is bearable. The repair of focal cartilage injuries requires a precise diagnosis, a completed knee evaluation to give the correct indication for surgery proportional to the damage and adapted to each patient. Many of the surgical techniques currently performed involve biotechnology. The future of cartilage repair should be based on an accurate diagnosis using new MRI techniques. Clinical studies would allow us to establish the correct indications and surgical techniques implanting biocompatible and biodegradable matrices with or without stem cells and growth factors. Arthroscopic techniques with the design of new instruments can facilitate repair of patella and tibial plateau lesions.

Occurrence of secondary fracture around intramedullary nails used for trochanteric hip fractures: A systematic review of 13,568 patients

Rory Norris, Dhritiman Bhattacharjee, Martyn J. Parker — 2012-06-01

Abstract: Introduction: A sliding hip screw (SHS) is currently the treatment of choice for trochanteric hip fractures, largely due to the low incidence of complications. An alternative treatment is the use of intramedullary proximal femoral nails. Unfortunately these implants have been associated with a risk of later fracture around the implant. The aim of this study was to see if any improvements have been made to the current intramedullary nails, to reduce the incidence of secondary fracture around the distal tip of the nail.Methods: We analysed data related to 13,568 patients from 89 studies, focusing on the incidence of post operative secondary femoral shaft fracture following the use of intramedullary nails in the fixation of trochanteric hip fractures.Results: The overall reported incidence of secondary fracture around the nail was 1.7%. The incidence of fracture has reduced in the 3rd generation Gamma nails when compared to the older Gamma nail (1.7% versus 2.6%, p value 0.03). However, the incidence of secondary fracture in the 3rd generation Gamma nails is still significantly higher than the other brands of short nail (1.7% versus 0.7%, p value 0.0005). Long nails had a slight tendency towards a lower risk of fracture although the difference was not statistically significant (1.1% versus 1.7%, p value 0.28). There was a significantly lower risk of fracture for those nails with a biaxial fixation as opposed to uniaxial fixation (0.6% versus 1.9%, p value <0.0001).Conclusion: Secondary fracture around a proximal femoral nail is one of the most significant of fracture healing complications, and this study suggests that continuing design changes to this method of fixation has reduced the risk of this complication occurring.

Quantifying and comparing torsional strains after olecranon plating

2012-06-01

Abstract: Purpose: Any torsion experienced at a fracture site will directly translate into shearing forces and has been regarded as detrimental to healing. The purpose of this study was to determine which plating system currently on the market controls torsional forces about comminuted olecranon fractures most effectively.Methods: Five olecranon plates (Acumed, Synthes-SS, Synthes-Ti, ITS/US Implants and Zimmer) were implanted to stabilise a simulated comminuted fracture pattern in 50 fresh-frozen, cadaveric elbows. All specimens were evaluated by dual energy X-ray absorptiometry (DXA) scan to determine bone density. Three-dimensional displacement analysis was conducted to assess fragment motion through physiologic cyclic arcs of motion. The specimens were cycled through progressive physiologic loads (0.18–5.6kg). Movements of the fragments were statistically compared amongst the different implants using one-way analysis of variance (ANOVA) and Tukey Honestly Significant Difference (HSD) post hoc comparisons with a critical significance level of α=0.05.Results: DXA bone mineral densities (BMDs) ranged from 0.465 to 0.927, with an average of 0.714. The Acumed, Synthes-SS, Synthes-Ti and Zimmer plates allowed <1° of torsion up to 1.6kg of load. The differences between these plates at this load were not statistically significant. The ITS/US Implants plate, however, allowed significantly more torsion above loads of 2.6kg (p=0.045) compared with all other plates. The ITS/US Implants plate allowed over 2° of torsion at 2.6kg (p=0.012), and nearly 3° at 3.6kg (p=0.045). The Zimmer plate consistently allowed more torsion than the Acumed plate or either of the Synthes plates, but the differences were not statistically significant.Conclusion: Regardless of which olecranon plate is used, the authors recommend limiting postoperative rehabilitation loads to below 1.6kg in an effort to minimise the detrimental effects of torsion on healing. If loads over 1.6kg are anticipated, the authors recommend the use of the Acumed plate or either of the Synthes plates.

A contoured locking plate for distal fibular fractures in osteoporotic bone: A biomechanical cadaver study

2012-06-01

Abstract: Objective: Fixation of ankle fractures in elderly patients is associated with reduced stability conditioned by osteoporotic bone. Therefore, fixation with implants providing improved biomechanical features could allow a more functional treatment, diminish implant failure and avoid consequences of immobilisation.Materials and methods: In the actual study, we evaluated a lateral conventional contoured plate with a locking contoured plate stabilising experimentally induced distal fibular fractures in human cadavers from elderly. Ankle fractures were induced by the supination-external rotation mechanism according to Lauge-Hansen. Stage II fractures (AO 44-B1) were fixed with the 2 contoured plates and a torque to failure test was performed. Bone mineral density (BMD) was measured by quantitative computed tomography to correlate the parameters of the biomechanical experiments with bone quality.Results: The locking plate showed a higher torque to failure, angle at failure, and maximal torque compared to the conventional plate. In contrast to the nonlocking system, fixation with the locking plate was independent of BMD.Conclusion: Fixation of distal fibular fractures in osteoporotic bone with the contoured locking plate may be advantageous as compared to the nonlocking contoured plate. The locking plate with improved biomechanical attributes may allow a more functional treatment, reduce complications and consequences of immobilisation.

Cross-cultural adaptation of the Dutch Short Musculoskeletal Function Assessment questionnaire (SMFA-NL): Internal consistency, validity, repeatability and responsiveness

2012-06-01

Abstract: The purpose of this study was to translate and culturally adapt the Dutch version of the Short Musculoskeletal Function Assessment questionnaire (SMFA-NL) and to investigate the internal consistency, validity, repeatability and responsiveness of the translated version.The original SMFA was first translated and culturally adapted from English into Dutch according to a standardised procedure and subsequently tested for clinimetric quality. The study population consisted of 162 patients treated for various musculoskeletal injuries or disorders at the departments of Orthopedics and Traumatology. All respondents filled in the SMFA-NL and the SF-36 and a region-specific questionnaire. To determine repeatability, 87 respondents filled in the SMFA-NL for a second time after a time interval of three to four weeks. To determine responsiveness, 29 respondents who were treated for their injury within three months before the first assessment filled in the SMFA-NL for a second time after two to three months. The following analyses were performed to evaluate clinimetric quality of the SMFA-NL: factor analysis and Cronbach's alpha (internal consistency), floor and ceiling effects, Spearman's Rho (construct validity), intraclass correlation coefficients and the Bland & Altman method (repeatability), and standardised response means (SRM) (responsiveness).Factor analysis demonstrated four subscales of the SMFA-NL. Both the newly identified subscales of the SMFA-NL and the conventional subscales of the SMFA showed good internal consistency. No floor and some ceiling effects were found. Construct validity was good, as high correlations were found between the subscales of the SMFA-NL and the respective subscales of the SF-36 and the region-specific questionnaires. Repeatability of the SMFA-NL subscales was high, with no systematic bias between first and second assessment. Responsiveness of the SMFA-NL was moderate, as small to moderate SRMs were found.We successfully translated and culturally adapted a Dutch version of the Short Musculoskeletal Function Assessment questionnaire (SFMA-NL). This study shows that the SMFA-NL is a valid, reliable and moderately responsive method for the assessment of functional status of patients who have a broad range of musculoskeletal disorders. Furthermore, it will allow for comparison between different patient groups as well as for cross-cultural comparisons.

Locking plate fixation of humeral head fractures with a telescoping screw. A comparative biomechanical study versus a standard plate

2012-06-01

Abstract: Objectives: Locking plate fixation of humeral head fractures bares the risk of glenohumeral screw penetration. In order to circumvent this problem it is recommended to insert shorter locking screws having at least a 6mm distance to the humeral head cortex. This in turn may reduce fixation stability and may lead to early varus displacement. One second frequent failure mechanism is cranial displacement of the greater tubercle. The study evaluates the biomechanical properties of a locking plate employing an additional telescoping screw that may enhance resistance to varus displacement. Screw in screw fixation of the greater tubercle may reduce the rate of cranial displacement.Methods: In four paired fresh-frozen human cadaver humeri (age>70 years) a Neer IV/3 fracture was created with a 5mm osteotomy gap simulating metaphyseal comminution. Limbs were randomly assigned to receive plate fixation with an additional telescoping screw (Humerus Tele Screw: HTS) and on the contralateral limb Philos plate fixation before biomechanical evaluation (MTS-Bionix 858.2). Standard locking screws were placed in both groups 6mm below the radiological head circumference; the telescoping screw was placed in the subchondral layer. The greater tubercle was fixed with an additional screw in both techniques, in the HTS group the screw was anchored in the sleeve of the telescrew (screw in screw fixation).Findings: Fixation stability with a mean stiffness of 300.9±28.8N/mm in the HTS plate group proved to be significantly higher than in the Philos plate group (184.2±23.4N/mm; p=0.006). The HTS plate also resisted higher loads in terms of fixation failure with loss of reduction at 290±58.6N in comparison to 205±8.6N for the Philos plate (p=0.2). Displacement of the greater tubercle occurred in no case of the HTS plate group and in two out of four cases in the Philos plate group.Interpretation: The HTS plate provides high fixation stability in an in vitro humeral head fracture model and securely prevents displacement of the greater tubercle.

Development of an electronic emergency department-based geo-information injury surveillance system in Hong Kong

C.B. Chow, M. Leung, Adela Lai, Y.H. Chow, Joanne Chung, K.M. Tong, Albert Lit — 2012-06-01

Abstract: Objectives: To describe the experience in the development of an electronic emergency department (ED)-based injury surveillance (IS) system in Hong Kong using data-mining and geo-spatial information technology (IT) for a Safe Community setup.Methods: This paper described the phased development of an emergency department-based IS system based on World Health Organization (WHO) injury surveillance Guideline to support safety promotion and injury prevention in a Safe Community in Hong Kong starting 2002.Results: The initial ED data-based only collected data on name, sex, age, address, eight general categories of injury types (traffic, domestic, common assault, indecent assault, batter, industrial, self-harm and sports) and disposal from ED. Phase 1 – manual data collection on International Classification of External Causes of Injury pre-event data; Phase 2 – manual form was converted to electronic format using web-based data mining technology with built in data quality monitoring mechanism; Phase 3 – integration of injury surveillance-data with in-patient hospital information; and Phase 4 – geo-spatial information and body mapping were introduced to geo-code exact place of injury in an electronic map and site of injury on body map.Conclusion: It was feasible to develop a geo-spatial IS system at busy ED to collect valuable information for safety promotion and injury prevention at Safe Community setting. The keys for successful development and implementation involves engagement of all stakeholders at design and implementation of the system with injury prevention as ultimate goal, detail workflow planning at front end, support from the management, building on exiting system and appropriate utilisation of modern technology.

Computer navigation in the reduction and fixation of femoral shaft fractures: A randomized control study

2012-06-01

Abstract: Objectives: We investigated the accuracy of reduction of intramedullary nailed femoral shaft fractures in human cadavers, comparing conventional and computer navigation techniques.Methods: Twenty femoral shaft fractures were created in human cadavers, with segmental defects ranging from 9 to 53mm in length (Winquist 3–4, AO 32C2). All fractures were fixed with antegrade 9mm diameter femoral nails on a radiolucent operating table. Five fractures (“Fluoro” group) were fixed with conventional techniques and fifteen fractures (“Nav 1” and “Nav 2” groups) with computer navigation, using fluoroscopic images of the normal femur to correct for length and rotation. Postoperative CT scans compared femoral length and rotation with the normal leg.Results: Mean leg length discrepancy in the computer navigation groups was smaller, namely, 3.6mm for Nav 1 (95% CI: 1.072 to 6.128) and 4.2mm for Nav 2 (95% CI: 0.63 to 7.75) vs. 9.8mm for Fluoro (95% CI: 6.225 to 13.37) (p<0.023). Mean rotational discrepancies were 8.7° for Nav 1 (95% CI: 4.282 to 13.12) and 5.6° for Nav 2 (95% CI: −0.65 to 11.85) vs. 9.0° for Fluoro (95% CI: 2.752 to 15.25) (p=0.650).Conclusions: Computer navigation significantly improves the accuracy of femoral shaft fracture fixation with regard to leg length, but not rotational deformity.

Analysis of radiation exposure to the orthopaedic trauma patient during their inpatient hospitalisation

2012-06-01

Abstract: Purpose: There has been considerable concern regarding radiation exposure to both the patient and treating surgeon and the possible risk of resulting malignancy. We sought to analyse the total effective dose of radiation that a cohort of orthopaedic trauma patients are exposed to during their inpatient hospitalisation and determine risk factors for greater exposure levels.Methods: Following approval from the Institution Review Board, a search was conducted of a level I trauma centre database for radiation exposures to patients over a 1 year period. Patients were included if they had an ICD-9 code from 805 to 828, indicating a fracture involving the trunk (805–811) or extremities (812–828). We compared the total effective radiation dose in various injury patterns as well as those considered to be polytrauma patients to those who were not according to their injury severity score (ISS).Results: The records of 1357 trauma patients were available for review. The average patient age was 40.6 years and the mean ISS was 14.1. The average effective radiation dose for all patients during their hospitalisation was 31.6mSv. There was a statistically significant difference in radiation exposure between patients with an ISS greater than 16 (48.6mSv) versus those with an ISS equal to or less than 16 (23.5mSv), p<0.001. Patients with spine trauma can be expected to get more than 15mSv more radiation than non-spine patients, p<0.001. Extremity injuries received the least amount of radiation, spine only patients were next, then finally spine and extremity injury patients had the greatest exposures. Having a spine fracture, a pelvic fracture, a chest wall injury, or a long bone fracture were all risk factors for having more than 20mSv of effective dose exposure. Patients under the age of 18 years did receive less radiation than the remainder of the cohort, p<0.001.Conclusions: The average orthopaedic patient receives a total effective radiation dose of more than 30mSv, much greater than is considered acceptable as a recommended permissible annual dose by the International Commission on Radiological Protection (20mSv). These findings indicate that the average trauma patient (in particular those with polytrauma or fractures involving the spine, pelvis, chest wall, or long bones) is exposed to high levels of radiation during their inpatient hospitalisation. The treating physicians of such patients should take into consideration the large amounts of radiation their patients receive just during their initial hospitalisation, and be prudent with the ordering of imaging studies involving radiation exposure.

The incidence of fractures in children under the age of 24 months – In relation to non-accidental injury

2012-06-01

Abstract: Introduction: Fractures in children are the second most common presentation of child abuse. In younger children, especially in those less than 18 months, fractures should be considered suspicious of a non-accidental injury (NAI). Risk factors associated for abuse are: age younger than 12 months, non-ambulatory status, delayed presentation, unknown or inconsistent history of mechanism of injury, and presence of any other injuries. Our objective was to identify the incidence of fractures in children below the age of 24 months who presented to our institution's Emergency Department (ED), and identify which cases should arouse suspicion around possible NAI.Methods: A 2 year retrospective analysis was carried out of our ED and hospital notes from 2007 to 2008, of all children under the age of 24 months who presented with a fracture of any description to the ED. The study looked at the patients age (months) and gender, the site and type of fracture, whether the patient was hospitalised or discharged from the ED, if any concern was reported or a child protection referral was made, and also the area of the city the child was from.Results: In 2007–2008 there was an incidence of 53 fractures per 10,000 children less than 2 years. The proportion increased with age with femur and skull fractures found in the youngest age category being associated with a referral to the child protection services. An unclear history regarding mechanism of injury was also noted in a high proportion of referrals. In 34% of patients the time interval was not recorded, a crucial risk factor in NAI.Conclusion: Age is a strong determinant when accessing NAI and a non-ambulant child presenting with a femur or skull fracture should be regarded highly suspicious of NAI. The time interval between the injury and presentation to the ED must be recorded in all notes when assessing a child for NAI.

Rest easy? Is bed rest really necessary after surgical repair of an ankle fracture?

2012-06-01

Abstract: Introduction: Bed rest with elevation of the affected limb is commonly prescribed postoperatively following ankle fracture fixation although there is no evidence that this is necessary.Aim: The aim of this prospective, randomised study was to investigate the effects of early mobilisation following surgical fixation of an ankle fracture on wound healing and length of stay (LOS).Method: A total of 104 patients underwent primary internal fixation of an ankle fracture at The Alfred hospital, Melbourne between July 2008 and January 2010.Intervention: The strategy included either early mobilisation group (first day post surgery) or control group (bed rest with elevation until day 2 post surgery).Outcome measures: Data collected included demographic, injury type and surgical procedure. Outcome data included inpatient LOS, wound condition at 10–14 days, opioid use and re-admission rate.Results: Groups were comparable at baseline. Wound breakdown rate was 2.9% (3 patients in the control group). Median LOS of the early mobilisation group was 55h compared with 71h in the control group (p<0.0001). Opioid use for the control group was an average of 90mg morphine equivalent in the first 24h post surgery compared with 67mg morphine equivalent for the early mobilisation group (p=0.32).Conclusion: This study indicates that early mobilisation following surgical fixation of an ankle fracture results in a shorter hospital stay without evidence of an increased risk of re-admission or wound complication.

Early soft tissue coverage and negative pressure wound therapy optimises patient outcomes in lower limb trauma

David Shi Hao Liu, Foti Sofiadellis, Mark Ashton, Kirstie MacGill, Angela Webb — 2012-06-01

Abstract: Background: The timing of soft tissue reconstruction for severe open lower limb trauma is critical to its successful outcome, particularly in the setting of exposed metalware and pre-existing wound infection. The use of negative pressure wound therapy (NPWT) may allow a delay in soft tissue coverage without adverse effects. This study evaluated the impact of delayed free-flap reconstruction, prolonged metalware exposure, pre-flap wound infection, and the efficacy of NPWT on the success of soft tissue coverage after open lower limb injury.Methods: Retrospective review of all free-flap reconstructions for lower limb trauma undertaken at a tertiary trauma centre between June 2002 and July 2009.Results: 103 patients underwent 105 free-flap reconstructions. Compared with patients who were reconstructed within 3 days of injury, the cohort with delayed reconstruction beyond 7 days had significantly increased rates of pre-flap wound infection, flap re-operation, deep metal infection and osteomyelitis. Pre-flap wound infection independently predicted adverse surgical outcomes. In the setting of exposed metalware, free-flap transfer beyond one day significantly increased the flap failure rate. These patients required more surgical procedures and a longer hospital stay. The use of NPWT significantly lowered the rate of flap re-operations and venous thrombosis, but did not allow a delay in reconstruction beyond 7 days from injury without a concomitant rise in skeletal and flap complications.Conclusions: Following open lower limb trauma, soft tissue coverage within 3 days of injury and immediately following fracture fixation with exposed metalware minimises pre-flap wound infection and optimises surgical outcomes. NPWT provides effective temporary wound coverage, but does not allow a delay in definitive free-flap reconstruction.

Injury to the infrapatellar branch of the saphenous nerve, a possible cause for anterior knee pain after tibial nailing?

M.S. Leliveld, M.H.J. Verhofstad — 2012-06-01

Abstract: The purpose of this study was to determine the long-term incidence of infrapatellar nerve damage after tibial nailing and its relation to anterior knee pain. We retrospectively evaluated 71 patients in whom 72 isolated tibial shaft fractures were treated with an intramedullary nail. The mean follow-up time was 84 months. Twenty-seven patients (38%) complained of chronic anterior knee pain. Infrapatellar nerve damage was found in 43 patients (60%). Of the 27 patients with knee pain, 21 (78%) had sensory deficits in the distribution area of the infrapatellar nerve, compared to 22 of the 45 patients (49%) without knee pain (p=0.025). Patient and fracture characteristics showed no significant differences between the two groups. At time of follow-up a total of 33 nails were removed of which twelve were taken out because of knee pain. The pain persisted in seven of these twelve patients (58%).The incidence of iatrogenic damage to the infrapatellar nerve after tibial nailing is high and lasting. Injury to this nerve appears to be associated with anterior knee pain after tibial nailing.

The ICI classification for calcaneal injuries: A validation study

Herman Frima, Rienk Eshuis, Paul Mulder, Luke Leenen — 2012-06-01

Abstract: Introduction: The integral classification of injuries (ICI), by Zwipp et al. has been developed as a classification system for injuries of the bones, joints, cartilage and ligaments of the foot. It follows the principles of the comprehensive classification of fractures by Müller et al. The ICI was developed for ‘everyday use’ and scientific purposes. Our aim was to perform a validation study for this classification system applied to the calcaneal injuries.Methods: A panel of five experienced trauma and orthopaedic surgeons evaluated the ICI score in 20 calcaneal injuries. After 2months, a second classification was performed in a different order. Inter- and intra-observer variability were evaluated by kappa statistics.Results: Panel members were not able to evaluate capsule and ligamental injuries based on X-ray and computed tomography (CT) films. Two injuries were excluded for logistical reasons. The inter-observer agreement based on 18 injuries of bone and joints was slight; kappa 0.14 (90% confidence interval (CI): 0.05–0.22). The intra-observer agreement was fair; kappa 0.31 (90% CI: 0.22–0.41). Overall, the panel rated the system as very complicated and not practical.Conclusion: The ICI is a complicated classification system with slight to fair inter- and intra-observer variabilities. It might not be a practical classification system for calcaneal injuries in ‘everyday use’ or scientific purposes.

An in vivo rodent model of contraction-induced injury in the quadriceps muscle

Stephen J.P. Pratt, Michael W. Lawlor, Sameer B. Shah, Richard M. Lovering — 2012-06-01

Abstract: Most animal studies of muscle contractile function utilise the anterior or posterior crural muscle (dorsiflexors and plantarflexors, respectively). An advantage to using these muscles is that the common fibular and tibial nerves are readily accessible, while the small size of the crural muscles is a disadvantage. Working with small muscles not only makes some in vivo imaging and the muscle testing techniques more challenging, but also provides limited amounts of tissue to study. The purpose of this study was to describe a new animal muscle injury model in the quadriceps that results in a significant and reproducible loss of force. The thigh of Sprague Dawley rats (N=5) and C57BL/10 mice (N=5) was immobilised and the ankle was attached to a custom-made lever arm. The femoral nerve was stimulated using subcutaneous electrodes and injury was induced using 50 lengthening (“eccentric”) contractions through a 70° arc of knee motion. This protocol produces a significant and reproducible injury, with comparable susceptibility to injury in the rats and mice. This novel model shows that the quadriceps muscle provides a means to study whole muscle contractility, injury, and recovery in vivo. In addition to the usual benefits of an in vivo model, the larger size of the quadriceps facilitates in vivo imaging and provides a significant increase in the amount of tissue available for histology and biochemistry studies. A controlled muscle injury in the quadriceps also allows one to study a muscle, with mixed fibre types, which is extremely relevant to gait in humans and quadruped models.

Transplantation of oligodendrocyte precursor cells improves myelination and promotes functional recovery after spinal cord injury

Bo Wu, Lei Sun, Peijia Li, Min Tian, Yongzhong Luo, Xianjun Ren — 2012-06-01

Abstract: Loss of oligodendrocytes and demyelination further impair neural function after spinal cord injury (SCI). Replacement of lost oligodendrocytes and improvement of myelination have a therapeutic significance in treatment of SCI. Here, we transplanted oligodendrocyte precursor cells (OPCs) to improve myelination in a rat model of contusive SCI. The labelled OPCs were transplanted to injured cord 7 days after injury. As a result, the implanted cells still survived in vivo 8 weeks after transplantation. They proliferated, integrated and differentiated in the injured cord. In the OPCs-treated rats, enhanced myelination in the lesioned area was observed and substantial improvement of motor function and nerve conduction was also recorded. Thus, this study provides strong evidence to support that transplantation of OPCs could improve myelination of injured cord and enhance functional recovery after contusive SCI.

Biomechanical analysis of a novel femoral neck locking plate for treatment of vertical shear Pauwel's type C femoral neck fractures

2012-06-01

Abstract: Background: The purpose of this study is to determine the biomechanical stability of a novel prototype femoral neck locking plate (FNLP) for treatment of Pauwels type C femoral neck fractures compared with other current fixation methods.Methods: Forty femur sawbones were divided into groups and a vertical femoral neck fracture was made. Each group was repaired with one of the following: (CS) three parallel cancellous screws; (XCS) two cancellous lag screws into the head and one transverse lag screw into the calcar; and (FNLP) a novel FNLP with two 5.7mm locking, one lag screw into the calcar and two screws into the shaft; and (AMBI) a two-hole, 135° AMBI plate with a derotation screw. All groups were tested for change in axial stiffness over 20000 cycles, and rotational stiffness was measured before and after cyclic testing. A maximum load to failure test was also conducted. Results were compared with one-way analysis of variance (ANOVA) and Fisher protected least significant difference (PLSD).Results: Results for axial stiffness show that AMBI, CS, XCS and FNLP are 2779.0, 2207.2, 3029.9 and 3210.7N-mmm−1, respectively. Rotational rigidity results are 4.5, 4.1, 17.1 and 18.7N-mmm−1. The average cyclic displacements were 0.75, 0.88, 0.80 and 0.65mm, respectively. Destructive failure loads for AMBI, CS, XCS and FNLP were 2.3, 1.7, 1.6 and 1.9kN, respectively.Conclusions: The results of this experiment show statistically significant increases in axial stiffness for the FNLP compared with three traditional fixation methods. The FNLP demonstrates increased mechanical stiffness and combines the desirable features of current fixation methods.

Cemented Thompson hemiarthroplasty versus cemented Exeter Trauma Stem (ETS) hemiarthroplasty for intracapsular hip fractures: A randomised trial of 200 patients

Martyn J. Parker — 2012-06-01

Abstract: Numerous different designs of hemiarthroplasty are available but few have been compared within the context of a randomised controlled trial. Two-hundred patients presenting with a displaced intracapsular fracture of the hip were randomised to receive either a cemented Thompson hemiarthroplasty or a cemented smooth tapered stem hemiarthroplasty (Exeter Trauma Stem). All operations were undertaken or directly supervised by one surgeon using the same operative approach. Patients were followed up for 1 year from injury by a research nurse blinded to the treatment used. The smooth tapered stem was felt to present less operative difficulties compared to the Thompson prosthesis. There were no other statistically significant differences in outcomes between the two prostheses.

Preoperative plasma B-type natriuretic peptide (BNP) identifies abnormal transthoracic echocardiography in elderly patients with traumatic hip fracture

2012-06-01

Abstract: Introduction: This prospective study was designed to evaluate whether preoperative plasma brain natriuretic peptide (BNP) could identify significant preoperative cardiovascular disease in elderly hip-fractured patients.Patients and methods: Preoperative plasma BNP measurement and rest transthoracic echocardiography (TTE) were performed within 24h after admission in consecutive hip-fractured patients aged ≥65 years. The major echocardiographic abnormality (MEA) group included patients with at least one TTE abnormality, defined as systolic pulmonary artery pressure (PAPs) ≥50mmHg, left ventricular (LV) systolic dysfunction, increased LV filling pressure (LVFP) or severe valvular disease. The control group included the remaining patients.Results: Seventy-five patients (mean±SD (range) age=85±5 (69–97) years) were included during a 6-month period. Twenty-four (32%) patients constituted the MEA group (17 elevated PAPs, three LV systolic dysfunctions, 10 increased LVFP, one severe aortic stenosis and one severe mitral regurgitation). Median (interquartile) preoperative BNP value was significantly greater in MEA than in the control group (527 (361) vs. 119 (154) pgml−1; p<0.0001). A preoperative plasma BNP cut-off value at 285pgml−1 predicted well MEA with an area under the receiver operating characteristic (ROC) curve equal to 0.895 (p<0.0001) and with a hazard ratio (HR) (confidence interval, CI) of 23.8 (3.7–142.9) (p=0.0008) on multivariate analysis. The presence of MEA or BNP≥285pgml−1 was associated with high mortality.Discussion: The incidence of echocardiographic signs of elevated PAPs or elevated LVFP in elderly hip-fractured patients was high. A preoperative BNP value ≥285pgml−1 can discriminate between elderly hip-fractured patients with or without MEA.

Reverse oblique intertrochanteric femoral fractures treated with the intramedullary hip screw (IMHS)

Daud Tai Shan Chou, Andrew M. Taylor, Chris Boulton, Chris G. Moran — 2012-06-01

Summary: Aims: Recent studies have recommended the use of cephalo-medullary devices for the treatment of reverse oblique intertrochanteric femoral fractures (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen, OTA/AO 31-A3). Both the proximal femoral nail (PFN) and the gamma nail (GN) have shown good outcome results but the results of treatment with the intramedullary hip screw (IMHS) have not been reported in the literature. Our aim was to review the outcomes of these unstable fractures treated with the IMHS implant at our institute.Methods: Between 1999 and 2008, 6724 consecutive hip fractures were treated at our institute. There were 115 reverse oblique intertrochanteric fractures and 63 of these were treated with the IMHS. We retrospectively reviewed clinical and radiological records for these fractures treated with the IMHS. Follow-up duration ranged from 1 to 6 years.Results: Amongst the 63 patients treated with the IMHS, 57 (90.5%) fractures were reduced satisfactorily with one poorly positioned hip screw and one breach of the anterior femoral cortex. The mean operative time was 115min, 22 patients required a blood transfusion and 20 had postoperative medical complications. The major orthopaedic complications included two cases of malrotation, three nonunions and one traumatic periprosthetic fracture with a total failure rate of 7.9%. There were four cases of distal locking bolts breaking or backing out. The 30-day mortality was 6.5%.Conclusion: The clinical and radiological outcomes achieved with the IMHS compare favourably to the results achieved with other cephalo-medullary devices. We consider the long IMHS a good implant for the treatment of these unstable fractures.

Sequential therapy of vacuum sealing drainage and free-flap transplantation for children with extensive soft-tissue defects below the knee in the extremities

2012-06-01

Abstract: Purpose: The aim of the study is to evaluate the surgical technique and clinical significance of the sequential therapy of vacuum sealing drainage (VSD) and free-flap transplantation for children with extensive soft-tissue defects below the knee in the extremities.Methods: Twenty-two children (aged from 3 to 10 years) received sequential therapy of VSD and free-flap transplantation. All cases suffered from extensive area soft-tissue defects and exposure or partial defects of bones, tendons and other deep tissues. The wound sizes varied from 10cm×6cm to 30cm×22cm. Amongst 22 cases, 12 cases had fresh wounds and the remaining 10 children had necrotising infection. After complete debridement, the wounds were covered by VSD. External fixation or Kirschner-wire fixation should be performed for the cases complicated by unsteady fractures. After the removal of negative pressure VSD devices, free-flap transplantations were performed in 8 cases after debridement, and 14 cases received combined therapy of free-flap transplantation and skin grafting depending upon the severity of soft-tissue and deep-tissue defects. The flap survival and wound healing were followed up postoperatively.Results: After VSD treatment, the infection of deep-tissue exposure was effectively prevented, and granulation tissues surrounding the exposed areas of tendons and bones grew well. All patients who received free-flap transplantation at the second stage survived without the occurrence of vascular crisis, infection or sinus formation. During follow-up ranging from 6 to 24 months, all the patients were satisfied with the morphological appearance and functional recovery of the affected limbs.Conclusion: Sequential therapy of VSD and free-flap transplantation can serve as a reliable option for children with extensive soft-tissue defects below the knee in the extremities and exposed deep tissues, after complete debridement, which significantly shortens remedy period, enhances success rate for surgery and achieves maximal restoration of limb function.

Discharge destination following lower limb fracture: Development of a prediction model to assist with decision making

2012-06-01

Abstract: Background: Accurate prediction of the likelihood of discharge to inpatient rehabilitation following lower limb fracture made on admission to hospital may assist patient discharge planning and decrease the burden on the hospital system caused by delays in decision making.Aims: To develop a prognostic model for discharge to inpatient rehabilitation.Method: Isolated lower extremity fracture cases (excluding fractured neck of femur), captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), were extracted for analysis. A training data set was created for model development and validation data set for evaluation. A multivariable logistic regression model was developed based on patient and injury characteristics. Models were assessed using measures of discrimination (C-statistic) and calibration (Hosmer–Lemeshow (H–L) statistic).Results: A total of 1429 patients met the inclusion criteria and were randomly split into training and test data sets. Increasing age, more proximal fracture type, compensation or private fund source for the admission, metropolitan location of residence, not working prior to injury and having a self-reported pre-injury disability were included in the final prediction model. The C-statistic for the model was 0.92 (95% confidence interval (CI) 0.88, 0.95) with an H–L statistic of χ2=11.62, p=0.17. For the test data set, the C-statistic was 0.86 (95% CI 0.83, 0.90) with an H–L statistic of χ2=37.98, p<0.001.Conclusion: A model to predict discharge to inpatient rehabilitation following lower limb fracture was developed with excellent discrimination although the calibration was reduced in the test data set. This model requires prospective testing but could form an integral part of decision making in regards to discharge disposition to facilitate timely and accurate referral to rehabilitation and optimise resource allocation.

Objective sound wave amplitude measurement generated by a tuning fork. An analysis of its use as a diagnostic tool in suspected femoral neck fractures

Z. Jawad, A. Odumala, M. Jones — 2012-06-01

Abstract: Introduction: Hip injuries are becoming a more common problem as the elderly population increases and their management represents a significant proportion of health care costs. Diagnosis of a fracture based on clinical assessment and plain films is not always conclusive and further investigations for such occult fractures, such as magnetic resonance imaging (MRI), are sometimes required which are expensive and may be difficult to access. Disruption to the conduction of a sound wave travelling through a fractured bone is a concept that has been used to diagnose fractures.Patients and methods: In our study we used a tuning fork with frequency of 128Hz to objectively measure the reduction in sound amplitude in fractured and non-fractured hips. We looked at the feasibility of using this test as a diagnostic tool for neck of femur fractures.Results: A total of 20 patients was included in the study, using MRI scan as the standard for comparison of diagnostic findings. Informed consent was obtained from the patients. There was a significant difference in the amplitude reduction of the sound waves when comparing normal to fractured hips. This was 0.9 in normal hips, compared to 0.31 and 0.18 in intra-capsular and extra-capsular fractures, respectively. Our test was 80% accurate at diagnosing neck of femur fractures.Conclusion: In conclusion this test may be used as a diagnostic test or screening tool in the assessment of occult hip fractures.

Tightrope fixation of ankle syndesmosis injuries: Clinical outcome, complications and technique modification

Gohar A. Naqvi, Aseer Shafqat, Nasir Awan — 2012-06-01

Abstract: Background: Ankle syndesmotic injuries are complex and require anatomic reduction and fixation. Tightrope fixation is a relatively new technique and we present the largest series of syndesmosis fixation using Arthrex Tightrope™ (Naples, FL, USA).Materials and methods: Forty-nine patients with ankle diastasis, treated with Arthrex tightrope™, were reviewed retrospectively, using American Orthopaedic Foot and Ankle Society (AOFAS) and Foot and Ankle Disability Index (FADI) scores and radiographic parameters for syndesmosis integrity. The operative technique was slightly modified by the senior author in 31 cases to avoid soft-tissue complications requiring removal of the implant. The aim of this study was to assess the rate of hardware removal after tightrope fixation and the effect of the author's modification to avoid soft-tissue complications.Results: The mean age of patients was 37.7 years. Eighteen were performed with standard technique whilst 31 with the modified technique. The mean radiological follow-up was 6 months. Final data were collected using a confidential questionnaire and FADI score at an average of 24 (12–38) months postoperatively. The average time to full weight bearing was 7.7 weeks and to return to normal activities was 11.2 weeks. Postoperative radiographic measurements demonstrated satisfactory reduction of syndesmosis. The Mean AOFAS score was 85.57(95% confidence interval (CI) 77.96–93.18) and the mean FADI score was 81.20 (95% CI 73.86–88.53). There were three cases of hardware removal in the standard technique group as compared to none in the group with the modified technique.Conclusion: Arthrex Tightrope™ provides an effective method of syndesmosis stabilisation, which obviates the need for routine removal of implant and facilitates dynamic stabilisation. The results of this study are satisfactory and comparable to previously reported studies. We emphasise that surgeons must be aware of the potential risk of soft-tissue complications and recommend our modified technique. Further long-term prospective studies should be carried out to resolve this issue.

A national survey of acute hospitals in England on their current practice in the use of femoral nerve blocks when splinting femoral fractures

N. Pennington, R.J. Gadd, N. Green, P.R. Loughenbury — 2012-06-01

Abstract: Introduction: Missed compartment syndrome can have devastating long-term impact on a patient's function. Femoral fracture has been reported in 52–58% of acute thigh compartment syndromes in the existing literature. Time to diagnosis of compartment syndrome is cited as a key determinant of outcome. Use of femoral nerve blocks in splinting of femoral fractures may mask signs of early compartment syndrome. We present the attitudes of emergency department and orthopaedic staff in NHS trusts in England with regard to this issue.Methods and materials: Survey of all 171 acute hospitals in the United Kingdom accepting trauma admissions. On-call middle grade doctors in emergency and orthopaedic department completed a telephone survey into departmental protocol and their experience of femoral nerve blocks for lower limb fractures.Results: Middle grades from all 171 trusts completed the survey (100% response rate). 54 emergency departments (30.8%) had a protocol for the use of femoral nerve blocks. Middle grades in the ED reported using a nerve block routinely in 95 hospitals (54%) with 63 using a long-acting and 32 a short-acting agent. Of those that did not 70% (n=53) felt they were unnecessary, 21% (n=16) were not confident in the technique and 9% (n=7) had worries over compartment syndrome. 68% would be worried about compartment syndrome in high-energy injuries. Orthopaedic departmental protocols for nerve block use were reported in 16 trusts (9%). 45 orthopaedic middle grades (26%) indicated that they would use them routinely with 17 using long-acting and 28 using short-acting agents. 59.5% (n=75) of orthopaedic middle grades felt nerve blocks were unnecessary, whilst 22% (n=28) had worries about compartment syndrome and 18% (n=23) were not confident with the technique. 77% orthopaedic middle grades would be more worried about compartment syndrome in high energy injuries.Conclusion: Femoral nerve block is an under-utilised, effective mode of analgesia following femoral fractures. There is a low risk of associated compartment syndrome, but clinicians should be especially vigilant in high-energy injuries. We recommend that all acute trusts receiving trauma should have a protocol for the use of femoral nerve blocks agreed by the emergency and orthopaedic departments.

Accuracy of in situ neck-shaft angle and shortening measurements of the anatomically reduced, varus malreduced and shortened proximal femur: Can we believe what we see on the postoperative films?

2012-06-01

Abstract: Objectives: Measuring the neck-shaft angle (NSA) and amount of shortening of the femoral neck on the anterior to posterior (AP) X-ray is important when treating proximal femur fractures. To compensate for proximal femoral external rotation, the X-rays need to be taken with the leg internally rotated, an act that cannot always be performed or verified. This study aims to define the utility of in situ AP X-ray in NSA and shortening measurements.Methods: Computed tomography (CT) scans of 50 patients undergoing abdominal CT scans were assessed for the in situ rotation of the femoral neck relative to the AP beam. Three proximal femur fracture Sawbones models were made and AP X-rays of the models were taken with changing proximal femur rotation. NSA and shortening were measured on all X-rays.Results: In situ femoral neck rotation averaged 25.4±10.6° of external rotation (range, 0.9–51.8°, 80% of measurements less than 35°). NSA measurements varied less than 5° with less than 35° of rotation in all models, and were always greater than the true value. Femoral neck vertical length (VL) measurement was independent of proximal femur rotation whereas the horizontal length component was found to be highly dependent on the same.Conclusions: NSA measured on AP X-ray will be accurate to within 5° in 80% of patients with the hip left in situ and in 100% of the patients if the hip is internally rotated 15°. Measurement of significant varus or loss of VL of the femoral neck can be considered accurate regardless of leg rotation at the time of X-rays being taken.

Where do locking screws purchase in the humeral head?

2012-06-01

Abstract: Introduction: One of the limiting factors in finding the best osteosynthesis approach in proximal humerus fractures is the current lack of information on the properties of the cancellous bone regions engaged by the implants fixing the epiphysis. The aim of this study is to assess the densitometric and mechanical characteristics of these regions when using a proximal humerus locking plate (PHLP).Materials and methods: Nineteen PHLPs were mounted on cadaveric humeri using only their three most distal screws. Subsequently, the plates were removed and the bones were scanned using high-resolution peripheral quantitative computed tomography. Bone mineral density (BMD) was determined in the intact proximal epiphysis and in the exact locations where the six proximal screws would have been positioned concluding the instrumentation. Each plate was then repositioned on its bone and a minimally destructive local torque measurement was performed in the same six locations. A statistical analysis was performed to detect significant differences in the investigated parameters between screw positions, and to test the ability of local torque values to discriminate the bone mineral density of the entire humeral head (BMDTOT).Results: Novel data about the cancellous bone engaged by the screws of a PHLP are provided. Different epiphyseal locations showed statistically significant different properties. A local torque measurement was a good predictor of the BMDTOT.Conclusion: Position and direction of the epiphyseal screws on a locking implant are determinant to engage bone regions with significantly better bone quality. A breakaway torque measurement in a given screw position can distinguish between humeral heads with different densitometric properties.

Radiological evaluation of intertrochanteric fracture fixation by the proximal femoral nail

2012-06-01

Abstract: Background: Successful treatment of intertrochanteric femoral fractures was reportedly influenced by the position of the fixation devices, by reduction quality and by fracture type.Methods: The records of 227 patients with intertrochanteric fractures treated by intramedullary hip screws were analysed retrospectively. The angle and distance from the femur head apex were transformed into Cartesian coordinates. Comparisons were performed between patients with no mechanical failure (207 patients, 90.7%), with cutouts (15 patients, 6.6%) and with secondary loss of reduction (5 patients, 2.2%).Results: The standard tip apex distance (TAD) measurement above 25mm did not predict failure (p=0.62). Mechanical failure rates increased from 4.8% to 34.4% when the centre of lag screw was not in the second quarter of the head–neck interface line (the so-called “safe zone”) (p=0.001). Lag screw insertion lower or higher than 11mm of the head apex line were associated with failure rates of 5.5% and 18.6%, respectively (p=0.004). Multivariate logistic regression showed that lag screw insertion not within the “safe-zone” was associated an Odds Ratio of 13.4 (95% CI 2.24–81) for mechanical failure (p=0.004).Conclusions: The TAD scale focuses on length measurement and lacks the vector properties of multidirectional measurements. Vector analysis revealed that the caudal-cranial correct lag screw position is the most important factor in preventing mechanical failure.

Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures

2012-06-01

Abstract: Introduction: Bicondylar tibial plateau fractures can be treated with locked plating applied from the lateral side with or without additional application of a medial plate (dual plating). Recent studies demonstrate that these injuries can be sub-grouped based upon their morphology by computed tomography (CT). The purpose of this study is to evaluate the relationship between fracture pattern, method of fixation and loss of reduction in bicondylar tibial plateau fractures.Patients and methods: Preoperative CT scans and postoperative plain films were evaluated on a consecutive series of bicondylar tibial plateau fractures. Fracture patterns were classified by CT. Angular alignment was measured immediately postoperatively and again at clinical and radiographic union to assess loss of reduction.Results: A total of 140 patients were studied. Sixty-six (47%) had a single large medial fragment with the articular surface intact, 19 (14%) had a medial articular fracture line with a mainly sagittal component and 55 (39%) had a coronal fracture through the medial articular surface. A total of 129 patients had been treated with lateral locked plating alone whilst 11 patients (all with a coronal fracture of the medial condyle) underwent dual plating.There was little loss of reduction (median subsidence 0.5°) when lateral locked plating was employed alone in patients with a single medial fracture fragment or with a sagittal medial fracture line. When lateral locked plating was used in the presence of a medial coronal fracture line, there was a significantly higher rate of subsidence (median 2.0°) compared to those with no medial fracture line (p=0.002). Patients with coronal fracture lines treated with dual plating had significantly less loss of reduction that those treated with lateral locked plating (p=0.01).Conclusions: Most patients with bicondylar tibial plateau fractures do well when treated with lateral locked plating. However, those with a medial coronal fracture line tend to have a higher rate of subsidence and loss of reduction when lateral locked plating is employed alone. These fractures may be better treated with dual plating if the soft tissues allow.Level of evidence: Level III (retrospective comparative study).

Intramedullary nailing versus submuscular plating in adolescent femoral fracture

2012-06-01

Abstract: Background: Femoral fractures in adolescents usually need operative treatment, but the optimal method is unclear. The purpose of this study is to compare intramedullary nailing (IN) and submuscular plating (SP) in adolescent femoral fractures.Materials and methods: We performed the prospective, comparison study of IN and SP in adolescent femoral shaft fractures at a mean age of 13.9 years (11–17.4). Twenty-two cases of IN and 23 cases of SP were followed for a minimum of 1 year. We compared radiological and clinical results, surgical parameters, and complications of two techniques.Results: Bony union was achieved in all cases except one case of IN. Time to union was similar in both groups. None showed mal-union over 10° or limb length discrepancy over 1cm. None of SP group and 2 in IN group experienced re-operation; one patient had deep infection with nonunion. The other patient sustained mal-rotation. Both patients healed after revision procedure. All patients showed excellent or satisfactory results of Flynn's criteria. The time to full-weight bearing was shorter in IN (IN: 57.3 days, SP: 89.2 days, p<0.05). In surgical parameters, operative time seemed shorter in IN (IN: 94.7min, SP: 104min, p=0.095), and fluoroscopy time was shorter in IN (IN: 58s, SP: 109s, p<0.05) than SP group.Conclusion: Although both IN and SP yield good results and minimal complication in adolescent femoral fractures, IN may be advantageous in less need of fluoroscopy, technical easiness in reduction and early weight bearing.

Proximal femoral nail antirotation versus hemiarthroplasty: A study for the treatment of intertrochanteric fractures

Peifu Tang, Fangke Hu, Jing Shen, Licheng Zhang, Lihai Zhang — 2012-06-01

Abstract: Intertrochanteric fractures in elderly patients are always associated with poor prognosis in the functional outcome as a result of the complications and mortality. A retrospective study was performed in our institution, 303 consecutive patients were followed up with mean age of 81.7 years. 147 were treated with PFNA, and 156 were underwent hemiarthroplasty. The average follow-up period was 39.9 months. The mortality at 1 month, 1 year, 3 years and the total was 6.6%, 18.6%, 27.6% and 30.3%, respectively. There were no significant differences between the groups in terms of demographic data. There were statistical significances in the operative statistics, especially the anaesthesia, operation lasting time, blood loss, blood transfusion and the drainage. There was no significant difference in Harris Hip Score between PFNA and hemiarthroplasty group, but the detail items were quite different. Significant difference was found in the excellent-to-fine rate (PFNA 90.2% and hemiarthroplasty 79.6%). Complications occurred in 34 patients, although incidences of complications were higher in hemiarthroplasty group (14.1% vs. PFNA 8.96%), no statistical difference was found. For elderly patients with intertrochanteric fractures, PFNA was superior to hemiarthroplasty according to the operative statistics, but there were no significant differences in functional outcome.

Subsidence of collarless uncemented femoral stems in total hips replacements performed for trauma

Alanna K. Pentlow, James S. Heal — 2012-06-01

Abstract: Introduction: Collarless, uncemented, femoral stems give excellent results in elective hip replacements but few studies look at outcomes in trauma patients. The presence of osteoporosis and subsequent widened femoral canal may compromise the mechanical stability of uncemented femoral stems resulting in early subsidence. The aim of this study was to assess whether early subsidence occurred when collarless uncemented stems were used to treat trauma patients.Materials and methods: Post-operative radiographs of 46 patients, mean age 71, who underwent an uncemented, collarless, total hip replacement for trauma, were reviewed. The difference in distance from the calcar to the prosthesis tip between the immediate post operative radiograph and the subsequent follow-up radiograph was calculated and adjusted for magnification. The same procedure was performed on 36 age-matched patients, who underwent elective hip replacements for osteoarthritis. Hospital notes were reviewed to assess for complications and DEXA scans reviewed for trauma patients where available.Results: The mean femoral stem subsidence was significantly greater in the fracture cohort than in elective patients (p=0.001) with mean subsidence of 4.27mm (range 0.02–22.05mm) and 1.57mm (range 0–5.5mm), respectively. In the fracture cohort there were 4 revisions within 6 months of surgery, 1 for infection and 3 for femoral stem subsidence leading to dislocation. There were no revisions in the elective cohort.Discussion and conclusions: This study showed that collarless uncemented stems subsided significantly more when performed for fractures and had a high early revision rate. We recommend that uncemented collarless should not be used in trauma patients requiring total hip replacement.

Orthopaedic injury analysis in the 2010 Yushu, China Earthquake

Ting Li, Xieyuan Jiang, Hui Chen, Zheng Yang, Xiaobo Wang, Manyi Wang — 2012-06-01

Abstract: Objective: By analysing the injuries of the orthopaedic wounded during the 2010 Yushu earthquake, we aim to provide useful medical information for the rational application and allocation of medical resources and better implementation of medical relief in earthquake-stricken areas.Patients and methods: Five hundred and eighty-two orthopaedic patients injured during the earthquake. The clinical data, injury conditions and epidemiological features (including age composition, gender ratio, distribution of injury, etc.) were collected and analysed.Results: Altogether 582 orthopaedic patients were analysed. The average age for all patients was 38.8±13.08 years (0–86 years). Adults accounted for 81.62%. There was no gender difference. The most common injuries included limb fractures, pelvic/acetabular fractures and spinal fractures. Fractures accompany with nerve injury were relatively low, only 17 patients account for 2.92%. Fractures complicated by crush syndrome were even lower, only 7 patients account for 1.20%.Conclusion: The patients who experienced fractures in the Yushu earthquake were mostly adults. This was correlated with population composition in Yushu area. This time all the orthopaedic injuries were relative mild with less complication as nerve injury or crush syndrome mainly because of the characteristics of the house structure in Yushu area.

The epidemiology of open fractures in adults. A 15-year review

2012-06-01

Abstract: There is little information available about the epidemiology of open fractures. We examined 2386 open fractures over a 15-year period analysing the incidence and severity of the fractures. The majority of open fractures are low energy injuries with only 22.3% of open fractures being caused by road traffic accidents or falls from a height. The distribution curves of many open fractures are different to the overall fracture distribution curves with high-energy open fractures being commoner in younger males and low energy open fractures in older females. The mode of injury and the different demographic characteristics between isolated and multiple open fractures are also discussed.

Finite element analysis of Puddu and Tomofix plate fixation for open wedge high tibial osteotomy

2012-06-01

Abstract: The use of open wedge high tibial osteotomy (HTO) to correct varus deformity of the knee is well established. However, the stability of the various implants used in this procedure has not been previously demonstrated. In this study, the two most common types of plates were analysed (1) the Puddu plates that use the dynamic compression plate (DCP) concept, and (2) the Tomofix plate that uses the locking compression plate (LCP) concept. Three dimensional model of the tibia was reconstructed from computed tomography images obtained from the Medical Implant Technology Group datasets. Osteotomy and fixation models were simulated through computational processing. Simulated loading was applied at 60:40 ratios on the medial:lateral aspect during single limb stance. The model was fixed distally in all degrees of freedom. Simulated data generated from the micromotions, displacement and, implant stress were captured. At the prescribed loads, a higher displacement of 3.25mm was observed for the Puddu plate model (p<0.001). Coincidentally the amount of stresses subjected to this plate, 24.7MPa, was also significantly lower (p<0.001). There was significant negative correlation (p<0.001) between implant stresses to that of the amount of fracture displacement which signifies a less stable fixation using Puddu plates. In conclusion, this study demonstrates that the Tomofix plate produces superior stability for bony fixation in HTO procedures.

Finger injuries caused by power-operated windows of motor vehicles: An experimental cadaver study

2012-06-01

Abstract: The aim of this experimental cadaver study was to investigate which kinds of lesions could occur in jam events between the glass and seal entry of power-operated motor vehicle side door windows at two different closing forces.Ten hands of fresh cadaver specimens were used. Three different hand positions chosen to simulate real events in which a finger is jammed between the glass and seal entry of the window of a current motor vehicle were examined. The index, middle, ring, and little finger of each hand were separately jammed both at the proximal and distal interphalangeal joint at closing forces of 300 and 500N with a constant window glass closing speed of 10cm/s. Macroscopically visible injuries were documented and radiographs of all fingers were obtained in two standard planes.At a closing force of 300N, contusion marks of the skin, palmar joint instabilities and superficial skin lesions occurred, whilst at 500N superficial skin lesions, superficial and deep open crush injuries, and fractures were observed. The results of this study experimentally demonstrate the kinds of finger injuries that could be expected in real jam events between the glass and seal entry in automatic power-operated windows.

Displaced paediatric distal radius fractures—When should we use percutaneous wires?

R.W. Jordan, D.J. Westacott — 2012-06-01

Abstract: Purpose: To establish the intra-operative radiographic parameters that predict the need for percutaneous wire fixation to prevent redisplacement following manipulation for displaced paediatric distal radius fractures.Materials and methods: A retrospective study of 105 children, assessing pre-, intra- and post-operative radiographs. Optimal reduction was defined as less than 10% residual translation and less than 5° of angulation on anteroposterior and lateral radiographs. Redisplacement was defined as more than 20° angulation or 50% translation on either view.Results: No fracture that was optimally reduced redisplaced. 40% of fractures with suboptimal reduction redisplaced. Initial translation was significantly associated with redisplacement.Conclusions: If our criteria for optimal reduction are met, closed reduction and casting can be confidently employed. If not, percutaneous wires should be employed to avoid redisplacement, especially in cases with a high grade of initial translation.

Cross-sectional area of the posterior extensor muscles of the cervical spine in whiplash injury patients versus healthy volunteers – 10year follow-up MR study

2012-06-01

Abstract: Introduction: Long-term follow-up studies focusing on the posterior extensor muscles in patients suffering from whiplash injury are scarce. The purpose of this study was to elucidate the changes in the posterior extensor muscles 10years after whiplash injury.Methods: Twenty-three patients who had suffered from whiplash injury in 1994–1996 and had undergone MRI using a 1.5-T superconductive imager participated in this follow-up study (13 males, 10 females, mean age 51.8years, mean follow-up 11.5years). In addition, 60 healthy volunteers who had undergone MRI in the same period were included as controls (36 males, 24 females, mean age 47.8years, mean follow-up 11.1years). All participants underwent follow-up MRI. The cross-sectional areas of the deep posterior muscles (CSA) including the multifidus, semispinalis cervicis, semispinalis capitis, and splenius capitis were digitally measured at C3-4, C4-5, and C5-6 using NIH image. The long-term changes in the CSA were compared between the two groups. In addition, correlations between the CSA and cervical spine-related symptoms were evaluated.Results: The mean total CSA per patient (the sum of the area from C3-4 to C5-6) was 4811.6±878.4mm2 in the whiplash patients and 4494.9±1032.7mm2 in the controls at the initial investigation (p=0.20), and 5173.4±946.1mm2 and 4713.0±1065.3mm2 at the follow-up (p=0.07). The mean change in CSA over time was 361.8±804.9mm2 in the whiplash patients and 218.1±520.7mm2 in the controls (p=0.34). Ten whiplash patients (43.5%) had neck pain and 11 (47.8%) had shoulder stiffness. However, there was no difference in the change in CSA over time between the symptomatic and asymptomatic patients.Conclusions: There was no significant difference in the change in CSA between whiplash patients and healthy volunteers after a 10-year follow-up period. In both groups, the cross-sectional area slightly increased at follow-up. In addition, there was no association between the change in CSA and clinical symptoms such as neck and shoulder pain. These results suggest that whiplash injury is not associated with symptomatic atrophy of the posterior cervical muscles over the long term.

Cerclage wiring in displaced associated anterior column and posterior hemi-transverse acetabular fractures

Hsi-Hsien Lin, Shih-Hsin Hung, Yu-Ping Su, Fang-Yao Chiu, Chien-Lin Liu — 2012-06-01

Abstract: Purpose: The effects of cerclage wiring in the open reduction and internal fixation of displaced associated anterior column and posterior hemi-transverse acetabular fractures were evaluated.Methods: This is a retrospectively clinical study of such cases where the main surgical strategy was open reduction and internal fixation with cerclage wire and reconstruction plates. Data on 12 cases treated between 1992 and 2011 were collected. The mean follow-up period was 32 (12–132) months.Results: Reduction with a fracture gap of less than 2mm without articular stepping and solid union was achieved in all 12 cases. Postoperative complication developed in one case of symptomatic arthritis. Excluding the case with symptomatic arthritis, the other cases had good to excellent final D’Aubigne and Postel functional results.Conclusions: Cerclage wiring is very useful and effective in the reduction and fixation of displaced associated anterior column and posterior hemi-transverse acetabular fractures, and supplemental fixation with reconstruction plates and screws is necessary.

Biomechanical analysis of locked and non-locked plate fixation of the clavicle

K.J. Little, P.E. Riches, U.G. Fazzi — 2012-06-01

Abstract: Introduction: During plate fixation of clavicular fractures the brachial plexus and subclavian vessels are vulnerable to injury beneath the clavicle. Locking plate fixation allows for mono-cortical fixation, theoretically reducing the risk of injury to these structures. Biomechanical analysis of the performance of such fixation is limited, and this study was designed to explore this further as a treatment option in clavicle fractures.Materials and methods: Fixation of fifteen simulated mid-shaft fractures was undertaken using a combination of mono-cortical locked, bicortical locked and bicortical non-locked plating methods in cadaveric clavicles. Samples were then tested via three-point bending to destruction, and the performance of each with respect to failure load, bending stress, bending stiffness and Young's modulus was then analysed. The influence of the number of cortices engaged and locking was also assessed.Results: Clavicles fixed with monocortical locking plates displayed a significantly lower bending stress (12±1MPa) than both the bicortical locking (28±3MPa, p=0.015) and non-locking specimens (24±3MPa, p=0.002). Engaging two cortices with the fixation produced a significant increase in failure load (291±28N vs 138±48N, p=0.018) and bending stress (26±2MPa vs 9.9±3.5MPa, p=0.002) compared to single cortex fixation.Discussion: The greatest influence upon the performance of the fixation was the number of cortices engaged, with bicortical fixation performing significantly better than mono-cortical. Whether or not the fixation device was a locking one did not have a significant bearing upon the performance.Conclusion: This in vitro biomechanical analysis demonstrates that mono-cortical locked plating fails at significantly lower levels of load and stress than bicortical locked and non-locked plating in mid-shaft fractures of the clavicle, and caution would therefore be advised in its use as a fixation modality for these injuries.

Patterns of triangular fibrocartilage complex (TFCC) injury associated with severely dorsally displaced extra-articular distal radius fractures

Johan H. Scheer, Lars E. Adolfsson — 2012-06-01

Summary: Purpose: The aim of the study was to examine triangular fibrocartilage (TFCC) injury patterns associated with unstable, extra-articular dorsally displaced distal radius fractures.Methods: Twenty adult patients with an Arbeitsgemeinschaft für Osteosynthesefragen (AO), type A2 or A3, distal radius fracture with an initial dorsal angulation greater than 20° were included. Nine had a tip fracture (distal to the base) of the ulnar styloid and 11 had no such fracture. They were all openly explored from an ulnopalmar approach and TFCC injuries were documented. Eleven patients also underwent arthroscopy and intra-articular pathology was recorded.Results: All patients had TFCC lesions of varying severity, having an extensor carpi ulnaris subsheath avulsion in common. Eighteen out of 20 also displayed deep foveal radioulnar ligament lesions, with decreasingly dorsal fibres remaining. The extent of this foveal injury could not be appreciated by radiocarpal arthroscopy.Conclusions: Severe displacement of an extra-articular radius fracture suggests an ulnar-sided ligament injury to the TFCC. The observed lesions concur with findings in a previous cadaver study. The lesions follow a distinct pattern affecting both radioulnar as well as ulnocarpal stabilisers.

Management of displaced fractures of the waist of the scaphoid: Meta-analyses of comparative studies

H.P. Singh, Nick Taub, J.J. Dias — 2012-06-01

Abstract: Introduction: Scaphoid fractures with displacement have a higher incidence of nonunion that can cause pain and reduced movement, strength and function. The aim of this study was to review the evidence available and establish the risk of nonunion associated with management of displaced fractures of the waist of the scaphoid.Methods: Electronic databases were searched using the Medical Subject Headings (MeSH) controlled vocabulary (scaphoid fractures, AND’d with displaced, or nonunion, or non-healing or cast immobilisation, or plaster or surgery). At present, there are no randomised, controlled trials or studies comparing fixation to plaster cast treatment of displaced fractures of the scaphoid. The search was therefore limited to observational studies of displaced fractures of the scaphoid treated in a plaster cast (non-operative group) or fixed surgically (operative group). The criterion for displacement was limited to gap or step of more than 1mm. In the non-operative group, we compared the outcome of displaced and undisplaced fractures of the waist of the scaphoid treated in a plaster cast. In the operative group, contingency table analysis was used to calculate the odds ratio of nonunion with plaster treatment compared to surgery.Results: In the non-operative group, seven studies were included in a meta-analysis with a total of 1401 scaphoids. Ninety-three percent (1311 scaphoids) of these scaphoid fractures healed in a plaster cast. A total of 207 (15%) of all scaphoid fractures showed displacement of at least 1mm (gap/step) between fracture fragments. Nonunion was identified in 18% (37/207) of displaced scaphoid fractures treated in a plaster cast. The pooled relative risk of fracture nonunion was 4.4 (95% confidence interval (CI): 2.3–8.7; p=0.00; I2=54.3%). In the surgical group, we identified six observational studies in which 157 ‘displaced’ fractures of the scaphoid were surgically fixed. Only two of these fractures did not heal. The odds of nonunion were 17 times higher with plaster cast treatment than surgery.Conclusions: Displaced fractures of scaphoid have a four times higher risk of nonunion than undisplaced fractures when treated in a plaster cast, and the patients should be advised of this risk. Nonunion is more likely if a displaced fracture of the scaphoid is treated in a plaster cast.

Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate

2012-06-01

Abstract: Background: Plate and screw fixation was introduced for complex fractures of the hand. Several risk factors for a poor functional outcome have been identified, but there is a paucity of evidence regarding predictors of finger stiffness in difficult hand fractures. The purpose of this prospective cohort study was to identify independent prognostic factors of the postoperative total active motion (%TAM) in the treatment of metacarpal and phalangeal fractures.Methods: Seventy-two patients (62 males, 10 females; 37±15years) with periarticular fractures involving metaphyseal comminution and displacement were evaluated at a minimum of 1 year following surgery. There were 49 phalangeal bone fractures, 30 intra-articular fractures and 20 associated soft-tissue injuries. The locations of plate placement were lateral in 42 patients and dorsal in 30. The mean duration from injury to surgery was 7.6 days (range, 0–40 days). There were eight examined variables related to patient characteristics (age, gender and hand dominance), fracture characteristics (fracture location, joint involvement and associated soft-tissue injury) and surgical variables (location of plate placement and duration from injury to surgery). Univariate and multivariate linear regression analysis were used to identify the degree to which variables affect %TAM at the final follow-up.Results: Univariate analysis indicated moderate correlations of %TAM with fracture location, associated soft-tissue injury and age. Multiple linear regression modelling including fracture location, age and associated soft-tissue injury resulted in formulae that could account for 46.3% of the variability in %TAM: fracture location (β=−0.388, p<0.001), age (β=−0.339, p<0.001) and associated soft-tissue injury (β=–0.296, p=0.002).Conclusion: Phalangeal fracture, increasing age and associated soft-tissue injury were important risk factors to identify the postoperative %TAM in the treatment of comminuted periarticular metacarpal or phalangeal fracture with a titanium plate.

Monoblock hemiarthroplasties for femoral neck fractures – A part of orthopaedic history? Analysis of national registration of hemiarthroplasties 2005–2009

Cecilia Rogmark, Olof Leonardsson, Göran Garellick, Johan Kärrholm — 2012-06-01

Abstract: This study from the Swedish Hip Arthroplasty Register (SHAR) compares cemented (Thompson®, Exeter Trauma Stem (ETS)®) and uncemented (Austin-Moore®) monoblock hemiarthroplasties (n=1116 and 616, respectively) with modular ones (n=18,659).Austin-Moore® prostheses lead to more re-operations (6.7%) compared to modular implants (3.5%) and Thompson®/ETS® (2.4%).A Cox regression analysis, adjusting for other risk factors, shows twice the risk of re-operation for Austin-Moore® implants (CI 1.5–2.8), in particular, due to periprosthetic fracture (5.4; CI 3.2–9.1) and dislocation (1.9; CI 1.3–3.0). The Thompson®/ETS® implants do not influence the overall risk of re-operation (0.7; CI 0.5–1.2) compared to modular implants and decrease the risk of re-operation due to infection (0.2;CI 0.04–0.7). An increased risk of re-operation is also seen in men, age groups 75–85 years and <75 years and after secondary fracture surgery.Both Swedish and Australian orthopaedic surgeons have decreased their use of Austin-Moore® implants after reports from their national arthroplasty registers identifying inferior outcome for this implant. Due to the increased risk of re-operations, it should not be used in modern orthopaedic care. Cemented Thompson® or ETS® implants could still be suitable for the oldest, low-activity patients. To finally decide if there is a place for them, patient-reported outcome must be analysed as well.

Drilling, not a benign procedure: Laboratory simulation of true drilling depth

2012-06-01

Abstract: Introduction: Drilling is an integral part of almost all boney operations. Various anatomical structures coursing close to the bone are at risk if the drill bit projects beyond the far cortex. Aim of this study was to evaluate and quantify the depth to which surgeons over drill beyond the far cortex.Materials and methods: During an AO course 153 (41 females, 112 males) surgeons and physicians were invited to participate in this study. Each participant performed 3 bicortical drillings on generic artificial bone. Polystyrene plates were mounted on the far cortex of the bone to allow for exact measurement of the over penetration of the drill bit.Results: A total of 462 bicortical drilling manoeuvres were analysed. The average projection of the drill bit beyond the far cortex was 6.31mm. No significant statistical correlation was noted between the specialty or the experience of the participant and depth of over drilling.Conclusions: It is remarkable that the mean and the range of far cortex over-penetration was quite similar amongst surgeons of differing grades and experience. The results of this study should return to mind to pay attention when drilling particularly in anatomical sites where nerve and vessels coursing close to the far cortex.

Donor site reconstruction in iliac crest tricortical bone graft: Surgical technique

Jorge Gil-Albarova, Raúl Gil-Albarova — 2012-06-01

Abstract: Background and purpose: Autogenous bone grafts from the iliac crest are frequently harvested for autologous bone transplantation, because this is still the gold standard in the treatment of many bone defects. However, significant donor site morbidity must be considered. We have developed a simple method to treat the bone defect in the donor site in order to reduce some of the morbidity. In this method, the bone defect size and shape determines its application.Method: After the conventional method of tricortical bone harvesting from the iliac crest, bone defect is repaired by means of a transversal fence of appropriate thin tricortical chips obtained from the posterior lateral wall of the bone defect itself. The mechanical stability of this fence results from impactation of the ends of the tricortical chips into both lateral cancellous bone walls of the repaired bone defect. Thus, no hardware is required, and both the bone defect and ilium contour are restored.Results: This simple method allows ilium bone defect healing and bone contour recovery after graft harvest, by using the same gold standard graft. Although not much time is necessary to reconstruct the donor site, the bone defect size and shape determine its application.Interpretation: This method may be a recommendable option for bone defect reconstruction after iliac crest tricortical bone graft harvest as the primary procedure. The advantages of this technique are bone defect healing and bone contour restoration with prevention of a visible deformity over the groin, with no foreign material insertion, thus avoiding additional cost.

Vacuum-assisted closure, dermal regeneration template and degloved cryopreserved skin as useful tools in subtotal degloving of the lower limb

2012-06-01

Abstract: The standard management of degloving injuries involves either immediate grafting with the avulsed skin or full- or split-thickness grafts at a later date. Alternative methods include pedicle and free flaps and revascularisation. The authors present an innovative technique of treating degloving injuries with cryopreserved split-thickness skin grafts harvested from degloved flap, artificial dermal replacement and vacuum-assisted closure (VAC therapy). To the authors’ knowledge, this is the first reported case of such bilaminar reconstruction of a degloving injury.

A simple way to determine appropriate implant size when fixing fractures

Peter Domos, Matthew J. Porteous — 2012-06-01

Using a correctly sized implant when internally fixing of fractures is crucial. Too long an implant may not fit and too short may compromise the strength and the stability of the fracture fixation. The mandatory introduction of presterilised and prepacked implants in sealed packages in the UK (often without suitable templates), and the increasing use of minimally invasive techniques, mean the opening and subsequent discarding of an expensive but under or oversized implant is a real risk.

Intramedullary nailing of trochanteric fractures—Operative technical tips

2012-06-01

Intertrochanteric fractures are very common fractures that occur in the elderly, owing to the fragile nature of their skeleton and are related to their propensity to falls. They are extra-articular fractures of the hip that occur between the extracapsular region of the femoral neck and just distal to the lesser trochanter. The choice of treatment falls into one of two options: fixation with an intramedullary device (cephalomedullary nail) or an extramedullary one (sliding hip screw, SHS). It is well established that in the case of stable, A1 AO-OTA (Arbeitsgemeinschaft für Osteosynthesefragen-Orthopaedic Trauma Association), intertrochanteric fractures, the optimal method of fixation is the SHS, whereas in the case of very unstable intertrochanteric fractures (A3 AO-OTA), intramedullary nailing is preferable. Moreover, a reverse obliquity fracture pattern is associated with a large posteromedial fragment and the use of an intramedullary nail is essential to compensate for the loss of the calcar buttress. The unique features of intramedullary nails are ease and speed of application combined with minimal exposure and a stable bone-device construct. These are appropriate when dealing with unstable trochanteric fractures, which is evident by the doubling in the use of intramedullary nails in the USA between 2000 and 2007. Despite the widespread use of cephalomedullary nails, there are no published technical notes concerning the management of specific intra-operative difficulties peculiar to the various fracture patterns. The purpose of this article is to suggest operative manoeuvres and manipulations that could overcome the difficulties of reduction and fixation frequently seen in dealing with unstable trochanteric fractures.

Percutaneous cerclage wiring for reduction of periprosthetic and difficult femoral fractures. A technical note

T. Apivatthakakul, C. Phornphutkul — 2012-06-01

Abstract: Background: Combining closed reduction techniques with minimally invasive plate osteosynthesis (MIPO) or intramedullary nailing is a technically challenging procedure, especially when dealing with complex femoral fractures such as periprosthetic fractures. Cerclage wiring is a well known adjunct for fracture reduction and fixation. However, it is usually performed by open reduction, requiring wide surgical exposures, that results in soft tissue stripping.Objectives: To present how a novel cerclage wiring technique, employing a new percutaneous cerclage system, helped reduce a periprosthetic femoral fracture, fixed with MIPO, and a difficult proximal femoral fracture, stabilized with an intramedullary nail.Conclusion: Percutaneous wiring is an alternative reduction technique to facilitate the reduction and maintenance of difficult femoral fractures, which reduces the radiation exposure to the surgeon.