Does Total Hip Arthroplasty Reduce the Risk of Secondary Surgery Following the Treatment of Displaced Acetabular Fractures in the Elderly Compared to Open Reduction Internal Fixation? A Pilot Study.

OBJECTIVES: The goal of open reduction and internal fixation (ORIF) is to anatomically reduce the facture and maintain a congruent hip joint. However, ORIF in the elderly is technically challenging. Therefore, there are advocates for acute total hip arthroplasty (THA) in this patient population. The primary purpose of this study was to evaluate the rate of revision surgery in elderly patients with acetabular fractures treated with ORIF or THA. The secondary purpose was to compare patient's self-reported functional outcomes. DESIGN: Retrospective review. SETTING: Two American College of Surgeons Level 1 trauma centers. PATIENTS/PARTICIPANTS: Thirty-three patients were treated with ORIF and 37 were treated with THA. The mean follow-up was 22 months (range 6-89 months). Patients were interviewed, and radiographs were examined. INTERVENTION: Treatment of displaced acetabular fractures with either ORIF or THA. MAIN OUTCOME MEASUREMENTS: Need for reoperation. Harris Hip Score and SF-36 questionnaire. RESULTS: Those treated with ORIF had a higher rate of reoperation (10/33, 30%) compared with those treated with THA (5/37, 14%); however, this was not statistically significant (P = 0.12). Patients reported better bodily pain scores as measured by SF-36 (48 vs. 39, P = 0.04), and a trend toward improved function as measured by patient reported Harris Hip Scores (82 vs. 63, P = 0.06) in those treated with THA compared with ORIF. CONCLUSIONS: Acute reconstruction of acetabular fractures with THA in the geriatric population seems to compare favorably with ORIF, with a similar rate of complications, but with improved pain scores. In addition, there was a high rate of conversion to THA within 2 years of injury when patients were treated with ORIF. Acute THA as primary treatment in this patient population merits further, more controlled, comparative study. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Disasters and mass casualties: II. explosive, biologic, chemical, and nuclear agents.

Terrorists' use of explosive, biologic, chemical, and nuclear agents constitutes the potential for catastrophic events. Understanding the unique aspects of these agents can help in preparing for such disasters with the intent of mitigating injury and loss of life. Explosive agents continue to be the most common weapons of terrorists and the most prevalent cause of injuries and fatalities. Knowledge of blast pathomechanics and patterns of injury allows for improved diagnostic and treatment strategies. A practical understanding of potential biologic, chemical, and nuclear agents, their attendant clinical symptoms, and recommended management strategies is an important prerequisite for optimal preparation and response to these less frequently used agents of mass casualty. Orthopaedic surgeons should be aware of the principles of management of catastrophic events. Stress is less an issue when one is adequately prepared. Decontamination is essential both to manage victims and prevent further spread of toxic agents to first responders and medical personnel. It is important to assess the risk of potential threats, thereby allowing disaster planning and preparation to be proportional and aligned with the actual casualty event.

Disasters and mass casualties: I. General principles of response and management.

Disaster planning and response to a mass casualty incident pose unique demands on the medical community. Because they would be required to confront many casualties with bodily injury and surgical problems, surgeons in particular must become better educated in disaster management. Compared with routine practice, triage principles in disasters require an entirely different approach to evaluation and care and often run counter to training and ethical values. An effective response to disaster and mass casualty events should focus on an "all hazards" approach, defined as the ability to adapt and apply fundamental disaster management principles universally to any mass casualty incident, whether caused by people or nature. Organizational tools such as the Incident Command System and the Hospital Incident Command System help to effect a rapid and coordinated response to specific situations. The United States federal government, through the National Response Plan, has the responsibility to respond quickly and efficiently to catastrophic incidents and to ensure critical life-saving assistance. International medical surgical response teams are capable of providing medical, surgical, and intensive care services in austere environments anywhere in the world.

Functional outcome after acute compartment syndrome of the thigh.

BACKGROUND: Acute compartment syndrome of the thigh is an uncommon condition that is associated with a high rate of morbidity. Because of its rarity, limited information is available on the long-term functional outcome for patients with this condition and the factors that affect the clinical result. METHODS: Eighteen patients with acute compartment syndrome of the thigh were evaluated at an average of sixty-two months after treatment. Functional outcome was evaluated by means of physical examination, isokinetic thigh-muscle testing, and validated functional outcome scores. RESULTS: Long-term functional deficits were present in eight patients, and only five patients had full recovery of thigh-muscle strength. The persistent dysfunction was reflected in worse overall functional outcome scores. High injury severity scores, ipsilateral femoral fracture, prolonged intervals to decompression, the presence of myonecrosis at the time of fasciotomy, and an age of more than thirty years were associated with increased long-term functional deficits, persistent thigh-muscle weakness, and worse functional outcome scores. CONCLUSIONS: Acute compartment syndrome of the thigh is often associated with considerable long-term morbidity. Several factors can affect the functional outcome, and knowledge of these factors can help in the development of a more effective clinical management strategy to reduce long-term morbidity.

Delayed presentation of acute compartment syndrome after contusion of the thigh.

Acute compartment syndrome has been described as a result of thigh contusion in several contact sports, and emergent fasciotomy has routinely been recommended. However, recent data suggest that thigh contusions in athletes presenting with isolated elevation of compartment pressures in the absence of neurovascular deficits may be treated expectantly. We describe a case of anterior thigh contusion, which initially presented with isolated compartmental hypertension without neurovascular symptoms. Under nonoperative treatment the patient developed delayed acute compartment syndrome from persistent muscular hemorrhage ten days after the initial trauma, requiring operative treatment. This case demonstrates that expanding hematoma formation may result in delayed increase of intramuscular pressures and compromise of myoneural perfusion in patients with severe thigh contusions. Early evacuation of the hematoma may help to prevent late development of compartment syndrome and reduce the risk for long-term complications.

Healthcare delivery aboard US Navy hospital ships following earthquake disasters: implications for future disaster relief missions.

OBJECTIVE: Since 2004, the US Navy has provided ship-borne medical assistance during three earthquake disasters. Because Navy ship deployment for disaster relief (DR) is a recent development, formal guidelines for equipping and staffing medical operations do not yet exist. The goal of this study was to inform operational planning and resource allocation for future earthquake DR missions by 1) reporting the type and volume of patient presentations, medical staff, and surgical services and 2) providing a comparative analysis of the current medical and surgical capabilities of a hospital ship and a casualty receiving and treatment ship (CRTS). DESIGN: The following three earthquake DR operations were reviewed retrospectively: 1) USNS Mercy to Indonesia in 2004, 2) USNS Mercy to Indonesia in 2005, and 3) USNS Comfort/USS Bataan to Haiti in 2010. (The USS Bataan was a CRTS.) Mission records and surgical logs were analyzed. Descriptive and statistical analysis was performed. Comparative analysis of hospital ship and CRTS platforms was made based on firsthand observations. RESULTS: For the three missions, 986 patient encounters were documented. Of 1,204 diagnoses, 80 percent were disaster-related injuries, more than half of which were extremity trauma. Aboard hospital ships, healthcare staff provided advanced (Echelon III) care for disaster-related injuries and various nondisaster-related conditions. Aboard the CRTS, staff provided basic (Echelon II) care for disaster-related injuries. CONCLUSIONS: Our data indicate that musculoskeletal extremity injuries in sex- and age-diverse populations comprised the majority of clinical diagnoses. Current capabilities and surgical staffing of hospital ships and CRTS platforms influenced their respective DR operations, including the volume and types of surgical care delivered.

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

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).

Prolonged femoral external fixation after natural disaster: successful late conversion to intramedullary nail aboard the USNS Mercy hospital ship.

After the 9.0 magnitude earthquake and tsunami of December 26, 2004, orthopaedic injuries were a major healthcare problem in parts of South East Asia. We report our late encounter with an Indonesian patient treated acutely with external fixation of a femur fracture. We describe our procedure for conversion of prolonged external fixation (59 days) to an intramedullary nail (IMN) aboard the USNS Mercy and provide two-year follow-up. A review of current literature on conversion of femoral external fixation to IMN is included. This report highlights the potential pitfalls of external fixation of femur fractures in an austere post-natural disaster environment where orthopaedic follow-up care may be delayed or nonexistent.

Planning for mass civilian casualties overseas: IMSuRT-International Medical/Surgical Response Teams.

The increased likelihood of mass casualties involving Americans living abroad has prompted the development of a mobile, civilian medical and surgical unit available for rapid deployment overseas. Using past experience derived from the National Disaster Medical Service, and from recent rescue efforts following the African embassy bombings in 1998, an International Medical-Surgical Response Team was developed. Organized under the Department of Homeland Security, it is staffed by civilian professionals from medical and bioengineering fields. Initial deployments to the World Trade Center (2001) and Guam (2002) have shown the ability to rapidly mobilize appropriate manpower and equipment to a mass casualty site, whether domestic or international. The goals of this organization are to work in cooperation with local authorities at the mass casualty site to provide rapid assessment and medical stabilization of injured persons. When the mass casualty is overseas, rapid evacuation of casualties is accomplished by the responding military air evacuation service.

Clinical spectrum of acute compartment syndrome of the thigh and its relation to associated injuries.

The reason for the described clinical variability of acute compartment syndrome of the thigh, with high morbidity and mortality in some patients and an uncomplicated clinical course in others, is not known. To better define the clinical spectrum and factors determining the clinical course of this rare clinical entity, we did a retrospective multicenter study of 28 patients with 29 thigh compartment syndromes. The leading cause of acute thigh compartment syndrome was blunt trauma from motor vehicle accidents (46%) or contusion (39%). Pain with passive motion was present in all patients who were conscious, followed by paresthesia (60%), and paralysis (42%). The anterior compartment was involved most frequently with mean compartment pressure of 58 +/- 3 mm Hg. Myonecrosis, sepsis, and need for skin grafting were observed more frequently in patients with ipsilateral femur fracture. Only 7% of patients with isolated thigh compartment syndromes had short-term complications compared with 57% of patients with ipsilateral femur fractures. The incidence of complications correlated with the time to fasciotomy. Mortality was limited to patients with high injury severity scores. The clinical spectrum of thigh compartment syndrome is comparable with that of other compartment syndromes and its clinical course is determined by its associated injuries.