The Effect of Insertion Technique on Temperatures for Standard and Self-Drilling External Fixation Pins.

OBJECTIVES: No studies have assessed the effects of parameters associated with insertion temperature in modern self-drilling external fixation pins. The current study assessed how varying the presence of irrigation, insertion speed, and force impacted the insertion temperatures of 2 types of standard and self-drilling external fixation half pins. METHODS: Seventy tests were conducted with 10 trials for 4 conditions on self-drilling pins, and 3 conditions for standard pins. Each test used a thermocouple inside the pin to measure temperature rise during insertion. RESULTS: Adding irrigation to the standard pin insertion significantly lowered the maximum temperature (P <0.001). Lowering the applied force for the standard pin did not have a significant change in temperature rise. Applying irrigation during the self-drilling pin tests dropped average rise in temperature from 151.3 ± 21.6°C to 124.1 ± 15.3°C (P = 0.005). When the self-drilling pin insertion was decreased considerably from 360 to 60 rpm, the temperature decreased significantly from 151.3 ± 21.6°C to 109.6 ± 14.0°C (P <0.001). When the force applied increased significantly, the corresponding self-drilling pin temperature increase was not significant. CONCLUSIONS: The standard pin had lower peak temperatures than the self-drilling pin for all conditions. Moreover, slowing down the insertion speed and adding irrigation helped mitigate the temperature increase of both pin types during insertion.

Locking Compression Pilon Plate for Fixation of Comminuted Posterior Wall Acetabular Fractures: A Novel Technique.

Posterior wall acetabular fractures involving a large portion the wall's width and with extensive comminution are difficult fractures to manage operatively. Cortical substitution with a pelvic reconstruction plate and supplemental spring plates has been the traditional means of fixation for these fractures. This option, however, requires the use of multiple, unlinked plates and provides no reliable option for peripheral fixation in comminuted fragments. We describe a novel technique for operative fixation of large, comminuted posterior wall fractures using a single distal tibia pilon plate with the option for peripheral locking screw fixation and report on a series of 20 consecutive patients treated with this method.

Blocking wires facilitate freehand percutaneous plating of periarticular tibia fractures.

The authors describe the technique of blocking K-wires to facilitate the freehand percutaneous plating of periarticular tibia fractures. The blocking K-wires facilitate anatomic accuracy of plate placement, a limiting feature of percutaneous plating technique particularly in the absence of a plate-specific jig. The described technique is to be applied as part of a staged surgical protocol utilizing temporary external fixation and directed at the preservation of the periarticular soft-tissues of the tibia.

Measuring temperature rise during orthopaedic surgical procedures.

A reliable means for measuring temperatures generated during surgical procedures is needed to recommend best practices for inserting fixation devices and minimizing the risk of osteonecrosis. Twenty four screw tests for three surgical procedures were conducted using the four thermocouples in the bone and one thermocouple in the screw. The maximum temperature rise recorded from the thermocouple in the screw (92.7±8.9°C, 158.7±20.9°C, 204.4±35.2°C) was consistently higher than the average temperature rise recorded in the bone (31.8±9.3°C, 44.9±12.4°C, 77.3±12.7°C). The same overall trend between the temperatures that resulted from three screw insertion procedures was recorded with significant statistical analyses using either the thermocouple in the screw or the average of several in-bone thermocouples. Placing a single thermocouple in the bone was determined to have limitations in accurately comparing temperatures from different external fixation screw insertion procedures. Using the preferred measurement techniques, a standard screw with a predrilled hole was found to have the lowest maximum temperatures for the shortest duration compared to the other two insertion procedures. Future studies evaluating bone temperature increase need to use reliable temperature measurements for recommending best practices to surgeons.

Operative treatment of calcaneal fractures in elderly patients.

BACKGROUND: Operative intervention is an accepted treatment for fractures of the calcaneus. However, the literature discourages surgery for these fractures in the elderly. The purpose of this paper was to review the outcomes of surgical treatment of displaced fractures of the calcaneus in elderly patients. METHODS: Between November 1987 and June 2000, forty-two patients (forty-four fractures) who were sixty-five years of age or older underwent surgery for a calcaneal fracture. The mechanism of injury, fracture pattern, and medical comorbidities were recorded. Thirty-five patients with a total of thirty-seven fractures were available for follow-up, which was conducted with physical and radiographic examinations and outcomes assessment with the Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and the Short Musculoskeletal Function Assessment survey. RESULTS: The minimum duration of follow-up was two years, and the average duration was forty-four months. All but one fracture (97% of the fractures) healed at an average of 110 days. The average active range of motion was 38 degrees of plantar flexion, 10 degrees of dorsiflexion, 16 degrees of inversion, and 11 degrees of eversion. The average American Orthopaedic Foot and Ankle Society score was 82.4 points, the average SF-36 score was 52.8 points, and the average Short Musculoskeletal Function Assessment score was 20.4 points. Posttraumatic subtalar arthritis developed in twelve patients. There were twelve minor complications and four major complications (three cases of osteomyelitis and one nonunion), all of which were treated successfully. CONCLUSIONS: Open reduction appears to be an acceptable method of treatment for displaced calcaneal fractures in elderly patients. Careful patient selection is necessary because individuals presenting with severe osteopenia, those who are unable to walk or are able to walk only about the house, and those with a medical condition that precludes surgery may be better candidates for nonoperative care.

Temporary transarticular stabilization of a glenohumeral fracture dislocation: a technique revisited.

SUMMARY: A 93-year-old patient with an unstable fracture-dislocation of the glenohumeral joint and medical problems that precluded open surgery was first managed by an unsuccessful closed reduction. Temporary transarticular pin fixation then was used successfully, allowing the patient to return to early activities with minimal morbidity.

A simulator model for sacroiliac screw placement.

OBJECTIVE: Fixation with percutaneously placed sacroiliac screws has become a well-established technique for fixation of the posterior pelvic ring in the proper clinical setting. This technique, however, carries with it the risk of iatrogenic injury to neurovascular structures with aberrant screw placement. Given the potential risks involved with this technique, a model whereby the psychomotor skills involved could be refined before entering the operating room may be of benefit. The purpose of the current study is (1) to describe a simulator model for SI screw placement that can be assembled from readily available equipment and (2) to attempt to demonstrate the construct validity of such a simulator. DESIGN: A simulator was assembled using readily available equipment found in the hospital and at a hardware store, and the cost of set up is less than $50. Orthopedic surgeons and novice operators were then observed using the simulator and results were recorded. SETTING: Tertiary referral teaching hospital. PARTICIPANTS: Orthopedic surgery residents, resident faculty, x-ray technicians. RESULTS: This simulator has been found to be a safe and effective model for teaching junior residents the technique of sacroiliac (SI) screw placement. An added benefit to this module is that it helps train new C-arm technicians to learn how to obtain the necessary views for this procedure. CONCLUSIONS: This model can be a valuable component of orthopedic training programs whereby technical and psychomotor skills necessary for percutaneous SI screw placement can be developed in a controlled setting.

Locked plating of periprosthetic femur fractures above total knee arthroplasty.

BACKGROUND: Fractures of the femur above a total knee arthroplasty (TKA) are becoming increasingly common in the osteoporotic, aging populations of developed countries. Treatment of these fractures is complicated by the presence of a knee prosthesis, frequently limiting the bone available for distal fracture fixation. The recent application of minimally invasive surgical techniques and locked plate technology to this problem offers the promise of stable, fixed-angle fixation of small distal fracture fragments with limited surgical exposure. The purpose of this study is to report the clinical and radiographic outcomes of fracture fixation using this technique in patients with periprosthetic femur fractures above TKA. METHODS: Fifty-three patients presenting with periprosthetic femur fractures above a TKA were treated with osteosynthesis. One patient was lost to follow-up resulting in 52 patients with complete data. Thirty-four patients were treated with plate fixation and 18 patients underwent retrograde intramedullary nail fixation (RIMN). Using a comprehensive electronic medical record, we recorded data regarding patient-related demographics, nature of the fractures, the operative treatment, and clinical and radiographic outcomes for all patients treated with osteosynthesis. RESULTS: Successful fracture healing occurred in 75% of patients (39 of 52). Mean operating time was 91.6 ± 6.8 minutes in the RIMN group and 87.4 ± 6.4 minutes in the locked plating (LP) group (P = 0.46). Mean intraoperative blood loss was 182 ± 31.6 mL in the RIMN group and 177.5 ± 23.4 mL in the LP group (P = 0.91). The mean time to bone union was 3.7 ± 0.30 months in the RIMN group and 4.0 ± 0.27 months in the LP group (P = 0.95). The most common cause of treatment failure was patient death within 6 months (9 patients [17%]); three of 18 were treated with a nail and 6 of 34 with a plate (P = 1.0). In the LP group, three (9%) sustained fracture nonunions, three (9%) sustained fracture malunions, and two (6%) sustained surgical site infections. In the RIMN group, one (6%) failed to unite as a result of infection and two (11%) developed fracture malunions. There were no significant differences between patients treated with LP and those treated with RIMN. CONCLUSIONS: Despite significant advances in surgical technique and implant design, the treatment of periprosthetic femur fractures above a TKA remains a challenge. LP using an indirect reduction technique is applicable to most patients and prosthetic designs and can provide similar favorable results as compared with treatment with a RIMN in periprosthetic femoral fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Host classification predicts infection after open fracture.

UNLABELLED: We propose that the classification commonly used in patients with osteomyelitis, the Gustilo classification, also is applicable to patients with open fractures as a method of identifying increased risk of infection because of comorbid medical illness. The records of 174 adult patients sustaining open fractures of long bones were retrospectively reviewed. Each patient was sorted into Class A, B, or C based on 14 immune system compromising factors. Class A has no compromising factors, Class B has one or two compromising factors, and Class C has more than three compromising factors. The association between class and infection was examined. The incidence of infection was 4%, 15%, and 30% in patients in Classes A, B, and C, respectively. Patients in Class B were 2.86 times more likely to have an infection, and patients in Class C were 5.72 times more likely to have an infection when both groups of patients were compared with patients in Class A. The Gustilo classification, location of fracture, and tobacco use are all factors associated with infection. Patients in Class B or C are at markedly increased risk of infection and may benefit from additional or alternative therapies that decrease the risk of infection. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.