Injury

Editorial Board

2010-03-01

Retirement after an intense surgical career: Options and dilemmas. A surgeon's perspective

G. Hartofilakidis — 2010-03-01

The career of any doctor in a surgical specialty, particularly the career of a trauma and orthopaedic surgeon, is characterised by an intense workload and many operating sessions out of hours. Any surgeon can easily remember countless times being up all night treating fractures, fracture/dislocations and polytraumatised people with life- and limb-threatening injuries, in addition to numerous session in the operating theatre performing prolonged reconstruction procedures.

Orthopaedic trauma in the obese patient

T.J.S. Chesser, R.B. Hammett, S.A. Norton — 2010-03-01

Obesity is usually defined in terms of body mass index (BMI). This equates to weight in kilograms divided by height in metres2. Obesity is defined as BMI ≥30 and morbid obesity as BMI ≥35 in the presence of an obesity related co-morbidity or ≥40 without.

Distal tibial fractures treated with hybrid external fixation

2010-03-01

Abstract: Management of distal tibia fractures remains challenging. The purpose of this study was to evaluate whether hybrid external fixation, as definite treatment, was associated with satisfactory results and low rate of complications. Between November 1999 and October 2006, 48 patients (33 men and 15 women) with a mean age of 45.6 years and a median ISS of 14.3 were admitted to our department with a distal tibia fracture and treated with the use of a hybrid external fixator. Eight patients had an open fracture. Mean follow-up was 14 months (range, 9–36 months). In 40 patients, radiographic evidence of union was observed at 3.6 months (range, 3–6 months). Delayed union was observed in three patients. There were five non-unions (10.4%) with three of them were septic. When compared to previously reported series, with conventional open reduction and internal fixation, the use of hybrid external fixation with or without open reduction and internal fixation of the fibula, was associated with satisfactory clinical and radiographic results and limited complications.

Investigation on the distal screw of a trochanteric intramedullary implant (Fi-nail) using a simplified finite element model

2010-03-01

Abstract: Numerous studies have been published concerning the characteristics and the behaviour of the intramedullary devices in the treatment of the intertrochanteric hip fractures. However, there is still room for further exploration and exploitation concerning the implant behaviour with respect to the parts of the implant assembly (nail, lag screw and distal screw). Towards this direction, the present paper aimed at revealing the effect of the position of the distal screw on the mechanical behaviour of the fixation device. For this purpose, a simplified model was developed and analysed with the finite element method. In total, five different locations for the distal screw were examined. In all cases, the bone was fixed at its distal end while the external load was applied at the tip of the lag screw towards the hip and in the form of orthonormal force components applied individually. The results of the FE analyses were illustrated in appropriately formed plots revealing the sensitivity of the behaviour of the implant with respect to the location of the distal screw. The main conclusion derived from the present investigation was that moving the distal screw apically decreases the stresses on the distal screw but increases the stresses on the lag screw. In turn, this indicates the existence of a location for the distal screw that compromises these two effects in an optimum way.

Management of traumatic sacral fractures: A retrospective case-series study and review of the literature

2010-03-01

Abstract: Background: Being the result of high-energy trauma in most cases, traumatic sacral fractures are rare, difficult to recognise and frequently misdiagnosed. Furthermore they may lead to vascular injuries, mechanical instability, neurological impairment and increased morbidity. As a result, patients with traumatic sacral fractures may suffer major socio-economic consequences.Objective: This retrospective case-series study evaluated the functional, neurological, mental and emotional status of patients who had suffered traumatic sacral fractures and either followed conservative or underwent operative treatment at our department.Patients and methods: We evaluated the clinical and radiographic results of all patients who had suffered traumatic sacral fractures between December 2003 and June 2007. The case-notes of all patients were reviewed, all co-existing injuries were registered and an ISS was calculated for each patient. At the latest follow-up visit, all patients completed the Short Form-36 questionnaire as well.Results: Sixteen patients (eleven male, five female) were included in this study. At the time of initial admission, the mean age of the patients was 30 years (range: 14–53) and the mean ISS was 33.2 points (range: 21–59). The mean follow-up period was 24.1 months (range: 13–40). Six patients were treated operatively (four patients diagnosed with some type of neurological impairment at their initial physical examination and two patients due to pelvic instability). The mean ISS of the patients who were treated operatively was 41.1 points (range: 21–59), whereas of those who were treated conservatively was 28.5 points (range: 21–45). No patient had any neurological deficit at his/her latest re-evaluation. Patients who were treated conservatively achieved the best scores in every domain of the SF-36 questionnaire, when compared with those who were treated operatively.Conclusion: The diagnosis and management of sacral fractures may pose several dilemmas in everyday's clinical praxis. Patients suffering from traumatic sacral fractures who were treated conservatively seem to have better functional and mental/emotional outcomes, probably because their injuries were less severe than those of the patients who were treated conservatively.

The tendon of the long head of the biceps in complex proximal humerus fractures: A histological perspective

2010-03-01

Abstract: We have studied the histologic and immunohistochemical changes of the long head of the biceps brachii tendon (LHB) in low-energy complex proximal humerus fractures. Our objective was to detect histological features, which may be correlated to pain generation.Biopsy samples were obtained during hemiarthroplasty procedures from 11 patients who suffered a complex proximal humerus fracture. The control group consisted of 10 samples harvested from human cadavers with no history of premortem shoulder problems and no gross shoulder pathology. Histologic investigation included quantitative measurement of tendon degeneration, cellularity, neoangiogenesis, inflammation and metaplasia, as well as immunohistochemical detection of cells with neural differentiation within the tendon tissue proper with S-100 protein and neuropeptide Y (N-Y).The found lesions were significantly more in the group of tendons from fractures compared to the control group (p<0.001). These lesions were also statistically correlated to each other, indicating a possible neural differentiation of tendon stromal cells.The LHB is a potential source of pain and the routine use of tenotomy/tenodesis of this tendon in hemiarthroplasty procedures for fracture may be reinforced by the results of this study.

Systematic effects of surgical treatment of hip fractures: Gliding screw-plating vs intramedullary nailing

2010-03-01

Abstract: Aim: Numerous studies have been published regarding the comparison between intramedullary nail and the dynamic hip screw and plate for the fixation of intertrochanteric fractures in elderly patients. In this paper we present a comparative study of these two methods regarding their systemic effects on this group of patients.Materials–methods: This is a randomized trial of 120 consecutive patients with an intertrochanteric fracture treated with either extramedullary fixation (dynamic hip screw and plate; DHS, Synthes-Stratec, Oberdorf, Switzerland) or intramedullary nail (Gamma nail, Stryker Howmedica, Freiburg, Germany and Endovis BA, Citieffe, Bologna, Italy).The parameters that we assessed pre-operatively, in addition to their demographics, included their mental state (MMSE), their nutritional and immune state and their pulmonary function. Intra-operatively we calculated the amount of radiation exposure, the amount of blood loss and the length of operative time for each procedure. Postoperatively we repeated the calculation of the mental and pulmonary state and the blood loss, during days 1, 3, and 10 and related them to the ease of the patient's mobilization.Results: Decreased bleeding and post-operative pain, reduced post-operative morbidity and faster recovery of function were better but not significant in the group of intramedullary fixation (all p>0.05). However, in the same group there were slightly more patients in whom the MMSE was falling, together with their pulmonary function, suggesting that this method probably predisposes to higher chances of pulmonary dysfunction and the possibility of pulmonary embolism.Conclusion: We found no significant differences between the two methods of stabilization of these fractures regarding their systemic effects perioperatively. The classic dynamic hip screw can preserve its position as a safe and effective solution for these already vulnerable patients having sustained a trochanteric fracture against the novel intramedullary techniques.

Ankle and foot osteomyelitis: Treatment protocol and clinical results

2010-03-01

Abstract: Introduction: A management protocol for ankle and foot osteomyelitis and the outcome in 84 patients treated in a unit with special interest in musculoskeletal infection, is presented.Patients and methods: Patients’ mean age was 50.7±16.5 years and mean follow-up 31.5±18.2 months. Systemic antibiotics were administered initially empirically, and later according to cultures. Surgical treatment included surgical debridement and bead-pouch technique, minor amputation (ray or toe), below knee amputation, and joint fusion. “Second-look” procedures were performed after 48–72h. Vascularised grafts or Ilizarov's technique were used for bone defect reconstruction. Soft tissues were managed according the ‘reconstructive ladder’ concept.Results: Host-type (Cierny's classification) was A in 25, B in 53 and C in 6 patients. Seventy-six infections were chronic. Causes were: open trauma without fracture (45/84), open fractures (9/84), ORIF of closed fractures (25/84) and elective surgery (5/84). Patients underwent 3.0±1.5 (range 1–10) operative procedures and spent 14.8±12.2 (range 3–60) days in hospital. Two (host-C) patients died. Complications requiring reoperations occurred in 20/84 (2/25 host-A, 16/53 host-B, 2/6 host-C; significant difference between host-A versus host-B and -C patients, p<0.001). Infection recurrence occurred in 12 (none host-A; significant difference between host-A versus host-B and -C patients, p<0.001). Multiple organisms were isolated in 39/84. Ankle arthrodesis using external fixation was performed in 9 (fusion rate 8/9). The free vascularised fibula graft was used in 2 and distraction osteogenesis in 8 patients with a mean bone defect of 5.4cm (range 3–13). Below knee amputations were performed in 5/84 (3/53 host-B, 2/6 host-C) and foot ray amputations in 8/84 (6/53 host-B, 2/6 host-C). Soft tissue coverage required: free muscle flap transfer in 6/84, reverse soleus flap in 1/84, local fasciocutaneous flaps in 7/84, split thickness skin grafts in 5/84, and vacuum assisted closure in 5/84 patients. Eighty-two surviving patients, including amputees, were able to mobilise independently and were satisfied with the result of treatment.Conclusions: Host-B and -C patients had more complications and infection recurrences and occasionally required amputations. Reconstructive procedures were performed for limb salvage in patients with soft tissue and bone defects and restoration of a functional limb was achieved.

The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method

2010-03-01

Abstract: The purpose of this study was to demonstrate the effectiveness of the Ilizarov method and circular external fixator in order to eradicate the infection and restore bone union, limb anatomy and functionality in cases with infected nonunion of the tibia following intramedullary nailing.During 7 years nine patients suffering from infected nonunion of the tibia after intramedullary nailing were treated in our department. The series comprised seven men and two women with an average age of 39.7 years (range 21–75 years). The patients had previously undergone an average of 4.8 operations (range 3–6 operations). Active purulent bone infection occurred in all nine patients. Bone defect was present in all patients with a mean size of 5cm (range 2–12cm). In three cases with bone defect less than 2cm, monofocal compression osteosynthesis technique was used. In the rest cases where bone defect exceeded 2cm, bifocal consecutive distraction–compression osteosynthesis technique was applied. Three patients required a local gastrocnemius flap. The mean follow-up period was 26.6 months (range 13–42 months). Results were evaluated using Paley's functional and radiological scoring system.Bone union was achieved in all nine patients without recurrence of infection during the follow-up period. Bone results were graded as excellent in five cases and good in the rest four cases. Functional results were graded as excellent in three cases, good in four and fare in two cases. Mean external fixation time was 187.4 days (range 89–412 days) and mean lengthening index was 32 days/cm (range 27–39 days/cm). Complications observed included eight grade II pin tract infections, axial deformity at the lengthening site in two cases and at the nonunion site in another two cases. Ankle joint stiffness was detected in five cases.The Ilizarov method may be an effective method in infected nonunions of the tibia following intramedullary nailing.

Computer-assisted three-dimensional correlation between the femoral neck-shaft angle and the optimal entry point for antegrade nailing

2010-03-01

Abstract: Optimal entry point for antegrade femoral intramedullary nailing (IMN) remains controversial in the current medical literature. The definition of an ideal entry point for femoral IMN would implicate a tenseless introduction of the implant into the canal with anatomical alignment of the bone fragments. This study was undertaken in order to investigate possible existing relationships between the true 3D geometric parameters of the femur and the location of the optimum entry point. A sample population of 22 cadaveric femurs was used (mean age=51.09±14.82 years). Computed-tomography sections every 0.5mm for the entire length of femurs were produced. These sections were subsequently reconstructed to generate solid computer models of the external anatomy and medullary canal of each femur. Solid models of all femurs were subjected to a series of geometrical manipulations and computations using standard computer-aided-design tools. In the sagittal plane, the optimum entry point always lied a few millimeters behind the femoral neck axis (mean=3.5±1.5mm). In the coronal plane the optimum entry point lied at a location dependent on the femoral neck-shaft angle. Linear regression on the data showed that the optimal entry point is clearly correlated to the true 3D femoral neck-shaft angle (R2=0.7310) and the projected femoral neck-shaft angle (R2=0.6289). Anatomical parameters of the proximal femur, such as the varus-valgus angulation, are key factors in the determination of optimal entry point for nailing. The clinical relevance of the results is that in varus hips (neck-shaft angle ≤120°) the correct entry point should be positioned over the trochanter tip and the use stiff nails is advised. In cases of hips with neck-shaft angle between 120° and 130°, the optimal entry point lies just medially to the trochanter tip (at the piriformis fossa) and the use of stiff implants is safe. In hips with neck-shaft angle over 130° the anatomical axis of the canal is medially to the base of the neck, in a “restricted area”. In these cases the entry point should be located at the insertion of the piriformis muscle and the application of more malleable implants that could easily follow the medullary canal should be considered.

Treatment of unstable distal radius fractures with Ilizarov circular, nonbridging external fixator

2010-03-01

Abstract: Unstable distal radius fractures remain a challenge for the treating orthopaedic surgeon. We present a retrospective follow-up study (mean follow-up 12.5 months) of 20 patients with 21 unstable distal radius fractures that were reduced in a closed manner and stabilized with a nonbridging Ilizarov external fixator. Subsequent insertion of olive wires for interfragmentary compression was performed in cases with intra-articular fractures. According to the overall evaluation proposed by Gartland and Werley scoring system 12 wrists were classified as excellent, 6 as good, 2 as fair and 1 as poor. Grade II pin-tract infection in distal fracture fragment was detected in 3 wires from a total of 78 (3.8%) and in 4 half pins out of a total of 9 (44.4%). Pronation was the most frequently impaired movement. This was restricted in 4 patients (19%) in whom a radioulnar transfixing wire was applied. Symptoms of irritation of superficial sensory branch of the radial nerve occurred in 3 patients with an olive wire applied in a closed manner in the distal fragment.Ilizarov method yields functional results comparable to that of other methods whilst it avoids wrist immobilization, open reduction and reoperation for implant removal. The method is associated with a low rate of major complication and satisfactory functional outcome.

Shoulder reanimation in posttraumatic brachial plexus paralysis

2010-03-01

Abstract: Introduction: Posttraumatic brachial plexus paralysis invariably involves the upper roots leading to paralysis of the shoulder region musculature. Early neurotisation of the suprascapular and the axillary nerve should be one of the priorities in plexus reconstruction in order to reanimate the shoulder.Patients and methods: From 1998 to 2007, 78 patients with posttraumatic brachial plexus palsy were operated in our department. Forty-three patients presented with supraclavicular lesions with involvement of C5 and C6 roots in all cases. Reconstruction of the shoulder function was achieved with neurotisation of the suprascapular nerve in 41 patients. Extraplexus donors were utilised in 34 patients, while intraplexus donors via nerve grafts in 7 patients. Neurotisation of the axillary nerve was performed in 25 patients, utilising intraplexus donors in 16 patients, extraplexus donors in 4, and combination of intraplexus and extraplexus donors in 5 patients.Results: Suprascapular nerve neurotisation gave good or excellent results (supraspinatus>M3+ or shoulder abduction>40°) in 35 patients. Intraplexus donors regained good or excellent function in 5 out of 6 patients (83%), while extraplexus neurotisations achieved good or excellent function of the supraspinatus in 30 out of 34 patients (88%). Axillary nerve neurotisation offered good or excellent results (deltoid>M3+ or shoulder abduction>60°) in 14 patients (58%). Direct neurotisation of the axillary nerve via the motor branch for the long head of the triceps gave shoulder abduction of >110°, as well as external rotation of >30° in 3 out of 5 patients. Combined neurotisation of suprascapular and axillary nerves gave the best outcome achieving shoulder abduction of >60° as well as external rotation of >30°.Conclusions: Shoulder reanimation should be one of the first priorities in brachial plexus reconstruction. Early neurotisation of the suprascapular, and if possible the axillary nerve offers the best outcome.