Fixation with bioabsorbable screws for the treatment of fractures of the ankle.

One hundred and fifty-five patients who had a closed, displaced medial malleolar, bimalleolar, or trimalleolar fracture of the ankle were managed with medial malleolar fixation with use of either 4.0-millimeter orientruded polylactide screws (eighty-three patients, study group) or 4.0-millimeter stainless-steel screws (seventy-two patients, control group). All lateral malleolar fractures were stabilized with standard metallic implants. At an average of thirty-seven months (range, twenty-one to fifty-nine months), the radiographic and functional results in the two groups were equivalent. Differences between the two groups with regard to the rates of operative and postoperative complications were not statistically significant. Late spontaneous drainage of the hydrolyzed polylactide was not noted in any patient in the study group. The prevalence of late tenderness over the medial malleolar implant was lower in the patients in whom the fracture had been stabilized with polylactide screws. We conclude that polylactide screws are a safe and effective alternative to stainless-steel screws for the fixation of displaced medial malleolar fractures.

Intramedullary nailing with reaming to treat non-union of the tibia.

The records of fifty-one patients who were treated by intramedullary nailing with reaming for non-union of the tibia were retrospectively reviewed. The fractures had been treated initially by closed reduction and immobilization in a cast, external fixation followed by immobilization in a cast, fixation by pins incorporated in a plaster cast, minimum internal fixation and immobilization in a cast, dynamic compression plating, or intramedullary nailing with or without reaming. After the initial treatment had failed, intramedullary nailing with reaming was done to gain union. Although closed nailing of the tibia was preferred, in thirty-three patients, the site of the non-union was opened to improve alignment by performing an osteotomy or to remove failed hardware. Bone grafts from the iliac crest were used in ten patients, and a fibular ostectomy or osteotomy was done in thirty-three. Of thirty-four open fractures (fourteen grade I, seven grade II, and thirteen grade III), eight were infected at the time of intramedullary nailing. The average time of the diagnosis of a non-union was 9.6 months; the average length of follow-up after nailing was twenty months. In forty-nine (96 per cent) of the fifty-one patients, tibial union occurred at an average of seven months postoperatively. Complications included persistent infection (three patients), acquired infection after intramedullary nailing with reaming (three patients), fracture of the nail that necessitated an additional operation (two patients), shortening of more than one centimeter (two patients), malrotation of more than 15 degrees (one patient), peroneal palsy (one patient), and amputation (one patient). When used to treat non-union of the tibia, intramedullary nailing with reaming can produce union as effectively as other alternatives, while enabling the patient to function more normally without external immobilization or walking aids.

Early stabilization and decompression for incomplete paraplegia due to a thoracic-level spinal cord injury.

All patients treated between 1985 and 1990 for acute incomplete spinal cord injury between T2 and T11 were retrospectively studied. This level was chosen for study because by excluding cervical cord, conus, and cauda equina injuries, neurologic improvement could be attributed to improvement of spinal cord function. Only 14 patients with incomplete thoracic level paraplegia were identified, representing 1.2% of all spinal injuries. All 14 patients were treated by early operative reduction, stabilization, or decompression. Twelve patients had surgery within 24 hours of neurologic injury, one at 36 hours, and one at 5 days. Twelve patients had initial posterior instrumentation and fusion, one of whom subsequently had an anterior decompression. Two patients had initial anterior decompression and fusion. Both later had posterior instrumentation and fusion to treat progressive deformity. Follow-up averaged 20 months (range, 9-65 months). Neural function before surgery and at follow-up was given a Frankel grade and lower extremity motor index score. Of 13 surviving patients, seven were initially Frankel B and six Frankel C. Of the seven patients initially Frankel B, four recovered to Frankel E, two improved to Frankel D, and one remained Frankel B. Of the six patients originally Frankel C, five recovered to Frankel E and one improved to Frankel D. Average neurologic improvement was 2.2 Frankel grades per patient, lower extremity motor index improved from an average of 7 to 44. Early surgical reduction, stabilization, and decompression is safe and improves neurologic recovery in comparison to historical controls treated by postural reduction or late surgical intervention.

Failure of halo vest to prevent in vivo motion in patients with injured cervical spines.

Forty-two patients with cervical spine injuries immobilized in halo vests were studied prospectively to determine in vivo vertebral segmental motion. Lateral radiographs taken in the supine and upright positions within 5 days of injury demonstrated intervertebral motion. At noninjured levels, the positional change accounted for an average 3.9 degrees of angulation with the greatest motion occurring between the occiput and C1 (8.0 degrees). At the injured levels, sagittal plane angulation averaged 7.0 degrees and translation averaged 1.7 mm between the two positions. Fracture site motion did not correlate with either the fracture type or the injury level. Fracture site motion greater than 3 degrees of angulation or 1 mm of translation was observed at 35 (77%) of 45 injured levels. When treating patients who have unstable cervical injuries with halo vests, supine and upright radiographs should be obtained. If excessive motion is present, alternative methods of treatment should be considered.

Posterior cervical arthrodesis with AO reconstruction plates and bone graft.

The efficacy of posterior arthrodesis of the cervical spine with AO reconstruction plates and autogenous bone graft was evaluated in a prospective study. The technique of surgical exposure and the application of the reconstruction plates fixed with screws to the lateral masses is described in detail. Of 30 patients with unstable cervical spines, all had solid fusions based on flexion and extension radiographs at follow-up averaging 17.8 months. No patient's neurologic function deteriorated. All incomplete spinal cord injuries improved at least one Frankel level. There were no neurologic or vascular complications. At follow-up, three patients had fusions extending one level longer than those instrumented. Three other patients had an increase in kyphosis compared with the operative reduction, which was not clinically significant. Although a single screw loosened in three other patients, none had an increased deformity, and all progressed to successful arthrodesis. This technique is particularly advantageous when spinous processes, laminas, and facets are injured or deficient, or when facet-type fusions are indicated.

Intra-articular distal humeral fractures in adults.

This article describes a technique of open reduction and internal fixation of intra-articular fractures of the distal humerus in adults. The historical treatment of these fractures is surveyed, including current classification systems. Anatomy is reviewed, specifically as it pertains to surgical intervention. The results in 23 consecutive patients stabilized through an intra-articular olecranon osteotomy exposure are reported.

Biomechanical comparison of methods of fixation of a midshaft osteotomy of the humerus.

Using paired humeri with a midshaft osteotomy, the biomechanical stiffness of four intramedullary internal fixation devices were compared with each other, a dynamic compression plate, and with the intact bone. In posterior and lateral bending and in torsion, flexible intramedullary pin fixed humeri (Enders and Hackethal) performed similarly and were less stiff than intact specimens were. Interlocking intermedullary nail constructs (Russell-Taylor and Seidel) also tested similarly to each other, and were stiffer than the flexible pins in all bending tests. Compared with the intact humerus, interlocking nails were stiffer in torsion, but in bending they more closely simulated the stiffness of the bone.

Treatment of humeral diaphyseal fractures with Hackethal stacked nailing: a report of 33 cases.

Hackethal's technique of stacked intramedullary (IM) nailing was used to treat 43 consecutive acute fractures of the humeral diaphysis. Of these, 6 were lost to follow-up and 4 additional patients were excluded for pathologic fractures. All of the remaining 33 traumatic fractures were followed until union. The average age was 34 years. Mean operative time was 90 min. Usually four or five 2- or 3-mm IM Kirschner wires were introduced in a retrograde manner, through a posterior unicortical window under radioscopic control. Closed reductions were performed in 28 patients, and open reductions were performed in the other five. Time to follow-up averaged 3 years 5 months (range 8 months to 13 years). There were no infections. There were three nonunions (9%), and two nails in 1 patient penetrated the greater tuberosity and one nail migrated distally in another patient. This method of internal fixation is not complicated and causes minimal trauma. It provides good stability at the fracture site and permits early mobilization of patients with excellent functional results.

Influences of some design parameters on the biomechanics of the unreamed tibial intramedullary nail.

Several questions relating to the biomechanics of the AO unreamed tibial nail were addressed in this study. These included the effects of the location of the nail bend on the reduction of a high proximal fracture, and the relation of proximal locking screw hole orientation and fracture component cortical contact to the mechanical stiffness of the construct. To measure fracture site malalignment with nail insertion, a motion transducer mounted on the distal tibial shaft was used to track the position of the proximal component during and after insertion of the nail. For studying the effect of screw hole orientation, the intramedullary (IM) nail was modified by drilling a second set of proximal screw holes with oblique instead of parallel alignment. The axial, torsional, and varus-valgus stiffnesses of the constructs with parallel or oblique screws and with or without fracture site contact were determined. In an experimental model with an osteotomy located proximal to the position of the bend in the nail when fully inserted, anterior displacement of the proximal fracture component (or posterior displacement of the distal component) of up to 1 cm was measured. Oblique proximal locking screws significantly decreased both varus/valgus angulation and medial/lateral translation under load, compared with the parallel screws. Constructs were 117% and 55% as rigid as the intact tibia in axial loading with and without cortical contact, and 6.5% and 3.1% as stiff in torsion.(ABSTRACT TRUNCATED AT 250 WORDS)

Operative management of intra-articular fractures of the distal humerus.

Over a 5-year period (1979-1984), 33 patients with intra-articular fractures of the distal humerus underwent open reduction and internal fixation of their fractures. Twenty-two (67%) of the patients had multiple injuries. Fourteen (42%) of the fractures were open (1 was Grade I, 8 were Grade II and 5 were Grade III). The mean age was 32 years (range: 15-61 years), which is significantly younger than in other series. A subgroup of 25 of the patients was evaluated clinically at a mean of 18.3 months postoperatively. "Excellent" and "good" functional results occurred in 23 patients (92%). "Poor" results were seen in the remaining two patients (8%). Complications occurred in 15 patients (45%). Nine of these complications related to fixation of the transolecranon osteotomy, which was used in 29 patients. The method by which reduction and stabilization was achieved was not as important as obtaining sufficient rigidity, which permitted early motion.

External fixation of the sternum for thoracic trauma.

A flail chest with a manubriosternal separation in a man with multiple injuries was treated with an external fixator applied to the sternum and the manubrium. Pain and ventilatory function were improved, permitting immediate postoperative extubation and prompt patient mobilization. The external fixator was removed after fracture union at 2 months. One year after injury, the patient's pulmonary function was normal. External fixation is an alternative to other methods of sternal fracture stabilization.

Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates.

OBJECTIVES: To compare the clinical and radiographic results for locked intramedullary (IM) nails and plates used in the treatment of humeral diaphyseal fractures. DESIGN: Prospective randomization by sealed-envelope technique of eighty-four patients into two study groups: those treated by intramedullary nailing (IMN group; n = 38) and those treated by compression plating (PLT group; n = 46). SETTING: Patients admitted consecutively to a university-affiliated Level I trauma center. PATIENT/PARTICIPANTS: All skeletally mature patients admitted to Harborview Medical Center with acute humeral shaft fractures requiring surgical stabilization. Fractures of the diaphysis were defined as being at least three centimeters distal to the surgical neck and at least five centimeters proximal to the olecranon fossa. INTERVENTION: Treatment with locking antegrade intramedullary humeral nails (Russell-Taylor design [Smith and Nephew Richards]) or with 4.5-millimeter dynamic compression and limited contact dynamic compression plates (AO design [Synthes]). MAIN OUTCOME MEASUREMENTS: Clinical outcome measurements included fracture healing, radial nerve recovery, infection, and elbow and shoulder discomfort. Radiographic measurements included fracture alignment, time to healing, delayed union, and nonunion. RESULTS: Follow-up averaged thirteen months. Forty-two fractures (93 percent) in the PLT group were healed by sixteen weeks versus thirty-three fractures (87 percent) in the IMN group (p = 0.70). Shoulder pain and a decrement in shoulder range of motion (ROM) were significant associations with IMN (p = 0.007 for both variables) but not with PLT. A decrement in elbow ROM was significantly associated with PLT (p = 0.03), especially for fractures of the distal third of the diaphysis, whereas elbow pain was not (p = 0.123). The sum of other complications demonstrated nearly equal prevalence for both treatment groups. CONCLUSIONS: For patients requiring surgical treatment of a humeral shaft fracture, intramedullary nailing and compression plating both provide predictable methods for achieving fracture stabilization and ultimate healing.

Biomechanical evaluation of methods of internal fixation of the distal humerus.

The best results following fractures of the distal humerus are provided by anatomic reduction and rigid internal fixation. Plates of two designs placed in five different fixation configurations were used to determine the construct that would maximize rigidity of fixation of the distal humerus. Using a cadaver distal humerus osteotomy, with and then without cortical contact, motion of the distal fragment was measured with respect to the proximal fragment in axial and torsional loading, anterior to posterior and posterior to anterior bending, and lateral to medial and medial to lateral bending. With cortical contact, two plates when placed medial and lateral or at 90 degrees to each other provided equivalent rigidity. However, with a cortical gap, the combination of a specially designed anatomic lateral buttress "J" plate and a medial reconstruction plate gave the greatest rigidity (ANOVA, p < 0.05). Two-plate constructs do not require placement at 90 degrees to obtain sufficient rigidity, but do require placement on separate bony pillars and different surfaces.

Closed retrograde Hackethal nail stabilization of humeral shaft fractures.

We retrospectively reviewed 48 consecutive humeral shaft fractures treated with Hackethal stacked, flexible, intramedullary (IM) nails. The indications for fixation were polytrauma or fracture patterns not amenable to bracing. The average age of patients was 40 years. Eight had associated primary nerve injuries. All fractures were reduced closed, and the nails were inserted retrograde through a distal posterior cortical window. Follow-up was possible in 33 patients. Ninety-seven percent (32 of 33) had healed at 1 year. There were no iatrogenic nerve palsies. There was one delayed union, one nonunion, one deep infection, and three occurrences of heterotopic ossification at the entry portal. Two patients with distal nail migration required second operations. Clinical examination showed normal range of motion at the shoulder and an average of 5 degrees loss of extension at the elbow. Hackethal's bundled IM nailing was shown to be a reliable, inexpensive, and relatively atraumatic method for stabilization of simple and comminuted humeral shaft fractures.

A comparison of malreduction after plate and intramedullary nail fixation of forearm fractures.

A study was performed to compare the degree of malreduction after intramedullary nail and plate fixation of the forearm and to determine if the degree of malreduction was clinically significant. Eight matched pairs of forearms, including the wrist and elbow joints, were harvested from cadaver upper extremities. The forearms were put through a full range of motion, and physiological loads were applied to simulate those during normal use. Standardized anteroposterior and lateral radiographs of each forearm were obtained with the specimen intact, and after an osteotomy and internal fixation of one bone, both bones, and with gap at the osteotomy sites. In each forearm pair, plating was randomly performed in one specimen and intramedullary nailing was performed in the matching contralateral specimen. Forearm architecture was assessed by quantification of the magnitude and location of maximum radial bow and radial angulation. In this study, plate fixation was superior to nail stabilization in restoration of the normal radial architecture. Plating did not change any of the radiographic indices (magnitude and location of maximum radial bow and radial angulation) at any stage of testing. None of the radiographic indices was changed by nailing of only one of the forearm bones. The magnitude of maximum radial bow and the radial angulation were changed by nailing both forearm bones after osteotomy and both forearm bones with a gap (p < 0.05). Despite this, both techniques were well within the limits of what is radiographically acceptable for reduction.(ABSTRACT TRUNCATED AT 250 WORDS)

Flexion distraction and chance injuries to the thoracolumbar spine.

Seat belt legislation has resulted in increased restraint use by passengers in automobiles in Washington State. At Harborview Medical Center in Seattle, we have observed an increased incidence of seat belt-related injuries. Twenty cases of Chance-type thoracolumbar flexion-distraction fractures were reviewed retrospectively. Thirteen patients (65%) had associated life-threatening intra-abdominal trauma. Twelve of these patients had bowel wall injury. Ninety percent of the children had combined abdominal and spinal injury. Operative treatment of the spinal injury resulted in correction of lumbar kyphosis and lower incidence of back pain than nonoperatively managed cases. We recommend careful physical and radiographic examination of all patients with significant abrasion or bruising about the pelvis or abdomen related to seat belts. Victims of automobile crashes who are treated for bowel injury require thoracolumbar radiographs. Similarly, patients with Chance-type fractures should undergo diagnostic peritoneal lavage or computerized abdominal tomography.

A biomechanical comparison of two methods of fixation of fractures of the forearm.

In this study two different types of forearm internal fracture fixations were compared: limited-contact dynamic compression (DC) plates and fluted intramedullary (IM) rods. Eight matched pairs of intact forearms, consisting of the distal part of the humerus, elbow joint, radius, ulna, interosseus membrane, wrist joint, and metacarpals, were randomly separated into two groups. Each was placed into a custom-designed apparatus and subjected to medial bending, supination, pronation, axial compression, and distraction loading. Loads were applied by a materials testing system, and angular displacements were measured by inclinometers. The procedure consisted of first testing specimens intact, then retesting after osteotomizing and fixing the radius with either a plate or rod in half of the group and retesting after osteotomizing and fixing the ulna in the other half. Testing was continued by osteotomizing and remaining intact bone to create a two-bone fracture, fixing them, and retesting after creating a 5-mm gap at the osteotomy sites. These tests showed that the intact ulna contributes more to forearm stability in bending and torsion than does the radius. Therefore, if the radius is fractured but the ulna remains intact, IM rodding will produce constructs with greater stiffnesses, particularly in torsion, than if the ulna is fractured and the radius is intact. In the case of a two-bone fracture, implantation of rods will result in a construct with significantly less stiffness in torsion, as well as distraction and compression (in the case of a fracture gap), than if the fractures were plated.(ABSTRACT TRUNCATED AT 250 WORDS)

Biomechanical effects of internal fixation of the distal tibiofibular syndesmotic joint: comparison of two fixation techniques.

This biomechanical study compares two methods of internal fixation of the tibiofibular syndesmosis used in Weber type C malleolar fractures of the ankle. The transverse syndesmotic 3.5-mm screw was compared with two 1.5-mm Kirschner wires introduced obliquely across the distal tibiofibular syndesmosis. The influence of implants on distal tibiofibular joint motion and contact characteristics of the intact ankle joint were determined. Up to 1.25 mm of lateral displacement and 2 degrees of external rotation of the lateral malleolus during uninjured ankle dorsiflexion was recorded. Both techniques stabilized the injured syndesmotic joint and limited its normal motion during flexion and extension of the ankle. Pressure distribution displaced laterally in internally stabilized ankles compared with intact specimens, regardless of the type of fixation used. Therefore, both techniques alter joint biomechanics equivalently compared with the intact ankle.

The role of fibular fixation in combined fractures of the tibia and fibula: a biomechanical investigation.

OBJECTIVES: To determine whether adjunctive plating of the fibula with tibial fixation enhanced the stability of the construct under combined compressive and bending loads in simulated fractures of both the tibia and fibula. METHODS: Each of twelve fresh cadaveric specimens (six pairs) with an intact knee, lower extremity, and foot was mounted on the table of a materials testing machine. An intramedullary (IM) rod locked in the distal femur allowed combined compression, and flexion, valgus bending, or varus bending loads to be transmitted from the actuator of the testing machine to the knee. Three displacement measurement transducers were mounted on the tibia at anterior, posterolateral, and posteromedial positions. Intact tibial deformations under load were measured. Then, in one specimen of each pair a 2 cm osteotomy was created near the tibial midshaft, which was stabilized with an external fixator. Tibial gap displacements were measured under the following conditions: (a) intact fibula, (b) osteotomized fibula, (c) fibula fixed with a plate, (d) fibula fixed with an Enders IM nail. In the other specimen of the pair, tibial fixation was performed with an interlocked unreamed IM nail, with the same successive stages of fibular fixation. RESULTS: Osteotomy of the fibula significantly increased tibial defect motion when external fixation was used, and plating the fibula in this case significantly decreased motion. Using an Enders rod to stabilize the fibula instead of a plate, with tibial external fixation, produced smaller decreases in tibial defect site motion. With IM rod fixation of the tibia, osteotomizing the fibula had no effect on defect site motion or on its subsequent stabilization using a plate or IM rod. CONCLUSION: Plating the fibula can decrease motion across a tibial defect, but only when less rigid (i.e., external) fixation is used.

Immediate internal fixation of open, complex tibial plateau fractures: treatment by a standard protocol.

A retrospective review of 46 consecutive patients with complex (Schatzker V and VI) tibial plateau fractures treated at Harborview Medical Center between 1984 and 1989, disclosed a subset of 14 grade II or III (Gustilo) open injuries. We wished to determine the incidence of infection, union rate, and the number of operations required to achieve a satisfactory result, based on a treatment protocol: alignment and splinting of fracture at the scene of injury if possible, antibiotics administered in the emergency room (ER) and continued for 48 h, and admission of patient to the operating room as quickly as possible for irrigation and thorough debridement of the wound, immediate rigid internal fixation, and delayed primary closure at 5 days. No acute deep infection or radiographic evidence of implant loosening was noted. The final outcome was graded by Hospital for Special Surgery (HSS) Knee Rating Score at an average follow-up of 2 years 7 months. Radiographs were reviewed for reduction and evidence of postoperative change in reduction. The average HSS Functional Score was 81.5, and Knee Score was 84.6. Of 14 limbs, 10 had an excellent radiographic grade that did not change at follow-up, 2 had a satisfactory grade, and 2 had a poor grade.