A pilot study of surgical telementoring for leg fasciotomy.

INTRODUCTION: Acute extremity compartment syndrome requires rapid decompression. In remote locations, distance, weather and logistics may delay the evacuation of patients with extremity trauma beyond the desired timeline for compartment release. The aim of this study was to establish the feasibility of performing telementored surgery for leg compartment release and to identify methodological issues relevant for future research. METHODS: Three anaethetists and one critical care physician were recruited as operators. They were directed to perform a two-incision leg fasciotomy on a Thiel-embalmed cadaver under the guidance of a remotely located orthopaedic surgeon. The operating physician and the surgeon (mentor) were connected through software that allows for real-time supervision and the use of a virtual pointer overlaid onto the surgical field. Two experienced orthopaedic traumatologists independently assessed the adequacy of compartment decompression and the presence of iatrogenic complications. RESULTS: 14 of 16 compartments (in four leg specimens) were felt to have been completely released. The first evaluator considered that the deep posterior compartment was incompletely released in two specimens. The second evaluator considered that the superficial posterior compartment was incompletely released in two specimens. The only complication was a large laceration of the soleus muscle that occurred during a period of blurred video signal attributed to a drop in bandwidth. CONCLUSIONS: This study suggests that surgical telementoring may enable physicians to safely perform two-incision leg fasciotomy in remote environments. This could improve the chances of limb salvage when compartment syndrome occurs far from surgical care. We found interobserver variation in the assessment of compartment release, which should be considered in the design of future research protocols.

Ultrasound-assisted external fixation: a technique for austere environments.

INTRODUCTION: Ultrasound-assisted external fixation of long bones has the potential to enhance extremity damage control surgery in locations without fluoroscopy, such as forward surgical elements, the intensive care unit, and spacecraft. This pre-clinical study specifically sought to evaluate orthopaedic surgeons' ability to sonographically define fracture patterns and the associated zone of injury in order to improve surgical decision-making and safely insert Schanz pin percutaneously. METHODS: We encased small composite femurs in a cylindrical echogenic gelatin matrix to simulate a human thigh. Three orthopaedic trauma surgeons with no prior ultrasound experience were taught to use sonography to diagnose fractures and assist external fixation. The surgeons were then presented with five specimens in a randomized sequence: three diaphyseal fractures (32-A2, 32-C2 and 32-C3); a distal femur fracture (33-A1.2); and an intact femur, all encased in an opaque black gelatin matrix to blind the participants to the underlying pathology. If they diagnosed a diaphyseal fracture, the surgeons were instructed to insert two Schanz pins proximal and two distal to the fracture, no closer than 40 mm from the fracture edges. RESULTS: Fracture diagnosis and surgical decision-making were correct in all cases. All intact femurs were recognized as such. The need for a knee-spanning external fixator was recognized for all distal femur fractures. The three surgeons performed appropriate ultrasound-assisted pin placement in every case of diaphyseal fracture. The pins adjacent to the fracture site were on average 58 mm (SD ±11 mm) from the edge of the fracture. No pins were inserted in the fracture or in the knee joint. CONCLUSIONS: The current study results suggest that with minimal training, orthopaedic surgeons can use portable ultrasound to diagnose femur fractures, decide the appropriate external fixator configuration, and safely insert Schanz pins outside the zone of injury.

Minimally invasive dynamic hip screw: prospective randomized trial of two techniques of insertion of a standard dynamic fixation device.

OBJECTIVE: This study evaluates the safety and outcome of a minimally invasive technique for inserting a standard dynamic hip screw for intertrochanteric fractures. HYPOTHESIS: The use of standard plate in a minimally invasive technique is both possible and advantageous to patient outcome. DESIGN AND METHODS: Prospective surgeon-randomized blinded outcome clinical study comparing new technique to conventional technique. MAIN OUTCOME MEASURE: Pain, operative time and mean hemoglobin drop in percutaneous hip fixation. RESULTS: The minimally invasive technique had significantly less blood loss (P < 0.001), operative time (P < 0.001) and a trend to less morphine use. CONCLUSIONS: Minimal invasive technique significantly reduces blood loss and operative time for fixation of intertrochanteric hip fractures without sacrifice of fixation stability or bone healing.

Treatment of complex acetabular fractures through a modified extended iliofemoral approach.

OBJECTIVES: To assess the rate of anatomic reconstructions as well as approach-related morbidity and complications in the treatment of complex acetabular fractures through a modified extended iliofemoral approach. DESIGN: Prospective clinical study. SETTING: Level I trauma center, University Hospital. PATIENTS: Inclusion criteria were as follows: (a) associated acetabular fracture or transverse fracture with comminuted roof area stated as not sufficiently reconstructable through a single approach, and (b) age between sixteen and sixty-five years. A total of forty-nine patients with fifty complex acetabular fractures could be included out of the series of ninety-six acetabular fractures treated operatively from August 1992 to February 1996. Open reduction and internal fixation of complex acetabular fractures through the modified extended iliofemoral approach were performed. RESULTS: In 80 percent of the fifty fractures the reduction was anatomic with a remaining displacement of less than or equal to one millimeter, in eight cases there was a persistent displacement of two millimeters, and two fractures had a poor result with a three-millimeter displacement. Complications included 8 percent loss of reduction, 13 percent heterotopic ossification grade 3, and 4 percent avascular femoral head necrosis. At the two-year follow-up there were 74 percent good or excellent radiographic and clinical results. Two patients had already been reoperated with total hip replacement, and the two patients with femoral head necrosis are currently scheduled for arthroplasty. CONCLUSIONS: The modified extended iliofemoral approach proved to be appropriate to achieve anatomic reduction in complex acetabular fractures. The high rate of approach-related morbidity has to be considered carefully and may lead to a decreased incidence of extended approaches.

CT scans versus conventional tomography in acute fractures of the odontoid process.

Four different radiological diagnostic methods were compared as to their diagnostic relevance in the analysis of odontoid fractures. Thirty-one patients with fresh odontoid fractures were investigated using standard anteroposterior and lateral radiographs, conventional tomography, axial computerized tomography and two-dimensional reconstruction in the sagittal and the coronal planes. As a control, 13 patients without odontoid fractures were examined. The results of the different investigations were correlated with the actual (clinical and/or intra-operative) findings. The coefficients of correlation for the conventional tomography and two-dimensional reconstruction were kappa=0.774 and kappa=0.907, respectively. For conventional radiography and axial computerized tomography (CT), the coefficients were clearly lower, at kappa=0.364 and kappa=0.627, respectively. The less time-consuming CT examination with sagittal and coronal reconstructions is equivalent with respect to diagnostic accuracy and can, therefore, replace conventional tomography in the evaluation fractures.

The locked flexible intramedullary humerus nail in pediatric femur and tibia shaft fractures: a feasibility study.

There are several options for the treatment of long bone fractures in skeletally immature patients. Surgeon experience, type of fracture, and the possibility of damage to the physeal area dictate individual fracture management patterns. Notably, nail devices have not gained popularity in this patient group. Intramedullary locking nails have become the standard of care in adult patients due to decreased morbidity and mortality. A novel nail has been developed for humeral shaft fractures that uses a lateral starting position to avoid damage to the rotator cuff in humeral fracture fixation. This is possible because of the nail's transient flexibility during insertion. This study illustrates that it is feasible to insert this type of nail through multiple entry portals for both tibial and femoral fracture fixation, without damaging the physeal blood supply or growth areas.