Treatment of tibial plateau fractures by limited internal fixation.

Seventy-five adults who sustained 76 tibial plateau fractures were treated according to a prospective protocol using instability in extension as the principal indication for operative fixation. Patients showing instability underwent closed manipulative reduction under fluoroscopic guidance. If significant joint depression persisted after reduction, elevation of the fracture was performed either from below using bone punches through a cortical window or via limited arthrotomy. Iliac crest bone graft was used to buttress depressed fractures. Fixation was then secured using 7-mm cannulated screws with washers or buttress plates and screws. Postoperatively, 58 of 76 knees were managed in a hinged knee brace, allowing the patient early range of motion and protected weightbearing for 8 weeks. Patients who were found to have a stable knee were treated with Bledsoe braces according to the postoperative protocol. In the 75 patients, 18 of the 76 knees were unsuitable for percutaneous screw fixation because of fracture complexity requiring plates, severe open injuries, or inadequate reductions with limited fixation had been done. A minimum followup of 12 months was obtained in 55 patients (range, 12-59 months). All fractures had healed at the time of followup. Eighty-seven percent of the patients at followup had a successful outcome using Rasmussen's criteria. Fourteen of these patients had arthroscopic assisted reduction or evaluation. All seven patients who had poor outcomes had AO Type C3 fracture patterns. Severely depressed or comminuted fractures or fractures with significant metaphyseal diaphyseal extension may not be suitable for this technique and require the addition of an external fixation device or buttress plate to maintain the reduction and allow for early range of motion.

Comparison of reconstruction nails for high subtrochanteric femur fracture fixation.

Subtrochanteric osteotomies were created in 18 matched pairs of embalmed cadaveric femora. The femora were stabilized with a Synthes, Zimmer, or Richards second generation femoral reconstruction nail with retrograde blade or screws. The femoral pairs were randomly assigned to groups based on nails used: Synthes versus Zimmer, Synthes versus Richards, and Zimmer versus Richards. The reconstructions were cyclically loaded in bending for 2000 cycles and then loaded to failure. The mean stiffness of the Synthes, Zimmer, and Richards reconstructions was 17%, 40%, and 40% of the intact femora, respectively. The Richards construct was the strongest, and predominately failed by fracture at the distal interlocking screw hole. The Zimmer construct failed by bending of the nail at the osteotomy site and fracture of the proximal femoral shaft. The Synthes construct was the most flexible and least strong and failed by bending of the spiral, retrograde blade with concomitant fracture of the femoral neck. This study indicates that fixation of subtrochanteric femur fractures with a Synthes spiral blade or Richards or Zimmer reconstruction nails provides stable fixation for postoperative loading conditions. However, the Richards and Zimmer nails were able to withstand higher loads than was the Synthes nail before failure.

A technique for intramedullary nailing of proximal third tibia fractures.

Twelve of 14 proximal third tibial shaft fractures were successfully treated with a new technique for intramedullary nailing of these fractures. The average anterior displacement was 3.0 mm (range 0-17). The average coronal plane alignment was 2.0 degrees valgus (range 2 degrees varus to 12 degrees valgus). There was one nonunion. The technique's success is dependent on neutralizing the primary factors causing malreduction: wide effective diameters of tibial nails, narrow diameter of the medial tibial metaphysis, and a posteriorly directed sagittal plane entrance angle.

The effects of femoral intramedullary reaming on pulmonary function in a sheep lung model.

Two methods of intramedullary fixation of fractures of the middle of the femoral shaft were evaluated in a sheep model to determine the effect of femoral reaming on pulmonary function. The effect of a modified reamer was also studied. A second experiment with the same model was performed to evaluate the relationship between embolization and pulmonary dysfunction. This experiment involved two groups of sheep--those with normal lungs and those with contused lungs--divided into subgroups--those that had nailing with reaming and those that had nailing without reaming. Intracardiac ultrasound was used to measure the magnitude and duration of transvenous particulate embolization during the operations. Both experiments involved hemodynamic monitoring during and after the nailing. The pulmonary tissue was examined histologically after the animals were killed. The hemodynamic monitoring revealed only a transient increase in pulmonary vascular resistance in the animals that had femoral nailing with reaming in both experiments. The modified reamer had no effect on the pulmonary response. Histological analysis of pulmonary tissue demonstrated a significant increase in the number of fat emboli in both the animals that had nailing with reaming and the animals that had nailing without reaming compared with the control animals. Intravascular ultrasound revealed that the operative maneuver associated with the greatest number of emboli was opening of the intramedullary canal with the awl. The first two passes of the reamer produced more emboli and embolism of longer duration than did the later passes. Pulmonary confusion did not increase the risk of pulmonary dysfunction due to intramedullary nailing in this model.

The segmental tibial fracture.

A series of 31 segmental tibial fractures is reported. Eighty-four percent of the patients sustained multiple trauma and 80% of these were open fractures. The series includes treatment with 20 external fixators, seven unreamed intramedullary nails, two casts, and two amputations. Complications included a 48% incidence of elevated compartment pressures necessitating fasciotomy. Despite rapid early decompression, there was a 19% incidence of residual motor and sensory deficit. Other complications observed were a 35% incidence of wound infection, nonunion, and malunion. Eighty-one percent of delayed or nonunions occurred at the distal fracture site. Intramedullary nailing produced the fewest complications. The segmental tibial fracture is at high risk for complications. Close observation of the limb for high compartment pressures is advisable. Treatment for compartment syndrome includes prompt decompression and stabilization of the fracture and, as indicated, intramedullary rods without preliminary reaming.

Partial calcanectomy for the treatment of osteomyelitis of the calcaneus.

Seven patients underwent partial calcanectomy for chronic osteomyelitis. An average of 20 months followup demonstrated no recurrences, 80% excellent, and 20% good results. Gait assessment, range of motion, and manual motor testing demonstrated minimal functional deficits and full return to preoperative activities. Partial calcanectomy for chronic osteomyelitis of the calcaneus is a simple procedure with low morbidity, rapid convalescence, and good functional results. The high success rate and patient acceptance define it as a well tolerated alternative to more complex procedures.