Ipsilateral femoral shaft and neck fractures: are cephalomedullary nails appropriate?

A retrospective review was conducted to examine rates of malreduction and nonunion in ipsilateral femoral neck and shaft fractures using different fixation strategies. Twenty-two consecutive patients with 23 fractures were identified. Participants were treated with various fixation strategies for ipsilateral femoral neck and shaft fractures. Cephalomedullary devices were used in 13 cases, while cannulated screws and a retrograde femoral nail were used in nine cases. One patient was treated with cannulated screws and external fixation of the femoral shaft. Radiographic assessment of the quality of reduction and union of both fractures was evaluated. Clinical and radiographic follow-up was available in 20 fractures (87%) with a mean of 12 months (range 3-50). Two femoral neck nonunions occurred; both had fair reductions of the fractures obtained by closed maneuvers, and two-device fixation was used in each. One femoral shaft nonunion occurred in a fracture treated with a cephalomedullary nail. All three united after revision surgery. No cases of osteonecrosis or conversion to hip arthroplasty were noted. A combination of retrograde femoral nailing and screw fixation of the femoral neck or placement of a cephalomedullary nail can provide excellent reduction and rate of union in the treatment of this injury pattern. Excellent reduction of the femoral neck fracture is key to preventing femoral neck nonunion.

Direct cellular vs. indirect pager communication during orthopaedic surgical procedures: a prospective study.

BACKGROUND: Cellular phone use within the hospital setting has increased as physicians, nurses, and ancillary staff incorporate wireless technologies in improving efficiencies, cost, and maintaining patient safety and high quality healthcare [11]. Through the use of wireless, cellular communication, an overall improvement in communication accuracy and efficiency between intraoperative orthopaedic surgeons and floor nurses may be achieved. METHODS: Both communication types occurred while the surgeon was scrubbed in the operating room (OR). Indirect communication occurred when the pager call was answered by the OR circulating nurse with communication between the surgeon, circulating nurse, and floor nurse. Direct communication consisted of cell phone and Jabra Bluetooth BT200 wireless ear piece used by the surgeon. The surgeon answered the floor nurse's cellular call by phone ring-activated automatic answering. The study was conducted during scheduled orthopaedic procedures. An independent observer measured time variables with a stop-watch while orthopaedic nurses randomly called via pager or cell phone. The nurses asked for patient caregiver confirmation and answers to 30 different patient-care questions. RESULTS: Sixty trials were performed with 30 cell and 30 page communications. Direct cellular communication showed a better response rate than indirect page (Cell 100%, Page 73%). Indirect page communication allowed a 27% and 33% error rate with patient problem and surgeon solution communications, respectively. There were no reported communication errors while using direct wireless, cellular communication. When compared to page communications, cellular communications showed statistically significant improvements in mean time intervals in response time (Cell = 11s, Page = 211s), correct patient identification (Cell = 5s, Page = 172s), patient problem and solution time (Cell = 13s, Page = 189s), and total communication time (Cell = 32s, Page = 250s) (s = seconds, all P < 0.001). Floor nurse satisfaction ratings (dependent on communication times and/or difficulties) were improved with direct cellular communication (Cell = 29 excellent, Page = 11 excellent). Intraoperative case interruptions (defined as delaying surgical progress) were more frequent with indirect page communication (10 page v. 0 cell). CONCLUSION AND SIGNIFICANCE: Our study demonstrates that direct wireless communication may be used to improve intraoperative communication and enhance patient safety. Direct wireless, cellular intraoperative communication improves communication times, communication accuracy, communication satisfaction, and minimizes intraoperative case interruption. As a result of this study, we hope to maintain our transition to direct wireless, cellular intraoperative orthopaedic communication to reduce medical errors, improve patient care, and enhance both orthopaedic surgeon and nursing efficiencies.

Metacarpophalangeal collateral ligament reconstruction after band saw amputation: case report with review of MCP anatomy and injury.

Reconstruction of the radial border of the index metacarpophalangeal (MCP) joint after band saw amputation is described. The entire radial MCP collateral ligament unit was cleanly retained within the amputated segment, still attached to wafers of corticocancellous bone from the radial aspect of the metacarpal head and base of the proximal phalanx. Acute bone to bone osteosynthesis of the amputated segment led to successful osseous integration of both bone fragments and restoration of stability of the joint. Surgical repair of the radial collateral ligament of the index MCP joint is crucial in achieving an optimal outcome after such an injury.

Band saw injury in a butcher.

BACKGROUND: While treating an unusual amputation caused by a meat band saw in a 35-year-old butcher, we sought information from the medical literature that would be useful to other physicians who might encounter similar occupational injuries. METHODS: Using the Medline database and relevant search terms, we reviewed the literature concerning occupational saw blade injuries and porcine microbiology as they related to this injury. RESULTS: Among meat workers using powered cutting equipment, hand injuries and distal fingertip amputations appear to be common. The greatest risk for a wound infection after open exposure to raw pork meat appears primarily related to environmental flora rather than enteric-borne porcine pathogens. CONCLUSIONS: Decision-making strategy when formulating a treatment plan for debridement or reconstruction of saw blade amputations should rely on a detailed understanding of the injury and occupational environment to achieve an optimal patient outcome. When considering operative and antibiotic treatment for porcine meat-related amputation injury, surgeons should adhere to open fracture-related guidelines, since porcine-borne illnesses are most often caused by ingestion rather than transcutaneous inoculation.

Combined fractures of the scaphoid and distal radius: a revised treatment rationale using percutaneous and arthroscopic techniques.

Revision of the treatment rationale for combined fractures of the scaphoid and distal radius is based on evolution of treatment goals. The trend toward early recovery of hand function requires rigid fixation of both fractures before the start ofa hand therapy program. It is clear that prolonged immobilization of the scaphoid fracture jeopardizes early motion protocols for the distal radius. The fixation of unstable distal radius fractures with volar locking plates appears to offer the most stable construct to permit early motion. Evaluation, reduction, and fixation should be accomplished without disruption of the uninjured ligaments required for stable motion or the soft tissue envelope required for healing. Minimally invasive or percutaneous techniques are the meth-ods required. The tools needed are a clear understanding of anatomy, minifluoroscopic imaging units, and small-joint arthroscopy instruments. Many investigators advocate these techniques for scaphoid and distal radius fractures. It is only natural that these techniques should be used for these combined injuries. The key to success is a three-step process: (1)percutaneous reduction of the scaphoid fracture and provisional stabilization with a guide wire placed along its central axis, (2) percutaneous/arthroscopic reduction and rigid fixation of the distal radius fracture to permit early motion, and(3) fixation of the scaphoid fracture. This final step is accomplished by dorsal percutaneous implantation of a cannulated headless compression screw along the central scaphoid axis. Dorsal percutaneous fixation of scaphoid fractures with headless compression screws and rigid fixation of unstable distal radius fractures with a volar lock-ing plate system offer the most secure fixation. This small series suggests that the goals of early recovery of hand function can be accomplished using percutaneous/miniopen techniques for fracture reduction with rigid fixation and minimal risks.

Material considerations for intervertebral disc replacement implants.

Cervical and lumbar disc replacements are being performed with increasing frequency. Much of the background for the development for these implants is drawn from the literature of other joint replacements that have been in evolution and use for decades. Important variables for the function and longevity of such disc arthroplasty implants are clearly defined by the material properties of the components used for their production. The most frequently considered materials are cobalt-chrome alloys, titanium alloys, stainless steels, polyethylene, polyurethane and ceramics. In addition to implant materials, the interfaces of such materials must be considered. The bearing surfaces of an implant, in particular, are at risk of wear and failure. Overall, successful, long-term total disc arthroplasty requires a thorough understanding of biomaterials and how they can be used to achieve their desired goals.

Use of a lateral offset short-leg walking cast before high tibial osteotomy.

The clinical results after high tibial osteotomy for the treatment of symptomatic varus gonarthrosis are unpredictable. Although preoperative gait analysis has been shown to be useful in predicting successful outcome after high tibial osteotomy, there are no readily available preoperative clinical tests for predicting success. The authors did a study to determine the effects of an offset short-leg walking cast as a potential predictor of clinical success after high tibial osteotomy. Specifically, the authors evaluated the effect of an offset short-leg walking cast on pain relief and changes in the peak external adduction moments in patients with symptomatic varus gonarthrosis indicated for high tibial osteotomy. Nineteen consecutive patients indicated for high tibial osteotomy were enrolled and completed the study. All patients had precast gait analysis to determine baseline parameters. Immediately after gait analysis, a short-leg lateral offset walking cast was applied and worn for 3 days to allow time for adaptation. Gait analysis then was repeated. Western Ontario and McMaster Universities Osteoarthritis Index pain scores were obtained before and after the cast was applied. The cast resulted in a mean reduction in pain of 53%, and a mean reduction in the peak external adduction moment of 36% in the 17 of 19 patients who tolerated the cast. The reduction in pain was correlated with the reduction in the peak adduction moment (r = 0.63). The authors conclude that an offset short-leg walking cast results in pain reduction that correlates with changes in external adduction moments about the knee. Therefore, an offset short-leg walking cast may prove to be an effective tool for predicting patients who ultimately will benefit from valgus high tibial osteotomy.