The hidden blood loss in proximal femur fractures is sizeable and significant.

BACKGROUND: Patients sustaining hip fractures experience blood loss as a direct result the fracture independent of surgery. The objective of this study was to quantify the expected non-surgical blood loss for proximal femur fractures using hemoglobin values. METHODS: A retrospective chart review of patients at a level 1 trauma center sustaining proximal femur fractures between October 2015 and January 2018 was performed. Patients were ≥30 years of age, had sustained intertrochanteric, subtrochanteric, or femoral neck fractures and had hemoglobin values documented at admission and after 12 h but before surgery. Patients with concomitant fractures, other hemorrhagic injuries, or blood transfusions before their second hemoglobin result were excluded. A multivariate linear regression model was constructed to evaluate the predictive ability of age, sex, BMI, number of comorbidities, fracture type, anticoagulation/antiplatelet therapy, admission hemoglobin, timing of surgical intervention and changes in electrolyte levels on subsequent hemoglobin values. Hemoglobin changes were compared between intertrochanteric, subtrochanteric, and femoral neck fractures and anticoagulant therapy types with Welch's tests. RESULTS: 119 patients were included. The mean age was 80.9 ± 10.81 years. Nearly 53% of subjects were using anticoagulation therapy. The mean drop in hemoglobin was 1.4 ± 1.03 g/dL. The multivariate linear regression model had statistically significant predictive ability (R = 0.91, p < 0.001). Independent predictors of hemoglobin decrease were number of comorbid conditions (p = 0.02), admission hemoglobin reading (p < 0.001), fracture type (p = 0.02), and time from admission to surgery (p = 0.03). Intertrochanteric fractures demonstrated the largest hemoglobin drops. Anticoagulation therapy had no effect on subsequent hemoglobin. CONCLUSION: Proximal femur fractures cause a significant amount of blood loss prior to surgical intervention. Patients at particular risk include those with comorbidities, intertrochanteric fractures, low admission hemoglobin values, and increased time to surgery. The identification of demographic, fracture type, and treatment characteristics may help surgeons identify patients at the greatest risk for blood loss, and provide more effective perioperative care.

Implications of Admission and Surgical Timing on Hospital Length of Stay in Patients with Hip Fractures.

INTRODUCTION: Hospital reimbursements for geriatric hip fractures are contingent on patient outcomes and hospital length of stay (LOS). This study examined if the day of the week (DOTW) and time of day (TOD) of both admission and surgery are associated with increased LOS. METHODS: LOS, time from admission to surgery, DOTW of admission/surgery, TOD of admission/surgery, and demographics were retrospectively collected. The average LOS was 4.5 days. Patients were grouped into cohorts of LOS 1 to 4 days (short-stay) and 5 to 12 days (long-stay). The percentage of short-stay patients was compared with the percentage of long-stay patients for each DOTW/TOD of admission/surgery with chi square tests. RESULTS: One hundred patients were included, 58 short stays and 42 long stays. Both groups were similar regarding demographics. Long-stay patients were 4.2 times more likely to have been admitted ([95% confidence interval 1.2 to 14.6], P = 0.02) and 4.8 times as likely to have undergone surgery ([95% confidence interval 1.0 to 5.6], P = 0.01) on a Thursday, respectively. TOD of admission/surgery did not demonstrate any association with LOS. DISCUSSION: Thursday admission/surgery was associated with longer LOS. Delayed surgical optimization coupled with insurance companies' observance of regular business hours may delay admission to inpatient rehab or skilled nursing facilities, resulting in avoidable healthcare expenditures.

A Proposal for a Standardized Nomenclature of the C-arm Movements.

No formal didactic source exists concerning terminology for movement of the C-arm in the operating room (OR). Many terminologies exist, breeding confusion among OR staff. The objective of this study was to survey the existing C-arm movement terminologies among orthopaedic surgeons and radiologic technologists and propose a standardized nomenclature moving forward. Methods: Forty-six orthopaedic surgeons and 70 radiologic technologists were surveyed. Pertinent product manuals and literature from PubMed were reviewed to find existing terms for the C-arm movement. A focus group of orthopaedic surgeons and radiologic technologists was formed and a standardized nomenclature of the C-arm terminology was developed using the Delphi method. Results: The survey response rate was 71%. The mean percentage of agreement on terms to describe movement was 47% (range, 13% to 83%). Agreement on terms to describe direction was 46% (range, 23% to 73%), and multiple frames of reference were described. No consensus was found by searching the product manuals. Using the Delphi method, we arrived at a standardized nomenclature for the C-arm movement that is reproducible and familiar. Discussion: A standardized terminology for the C-arm movement is described that will help fill a void in OR communication, combat confusion, and provide reproducible results during orthopaedic cases.

Palliative Management of Nonoperative Femoral Neck Fractures With Continuous Peripheral Indwelling Catheters: Case-Control Series.

INTRODUCTION: This case-control study evaluates the success of indwelling pain catheters in nonoperatively treated femoral neck fractures (FNFs) for end-of-life pain management. METHODS: Patients older than 65 years with nonoperatively treated FNFs were retrospectively identified at a level 1 trauma center between March 2012 and September 2015. Twenty-three received indwelling continuous peripheral pain catheters (experimental) and 10 received traditional pain control modalities (control). Pain scores 24 hours before/after pain management interventions, ambulation status at admission and discharge, mortality at 30 days/1 year, and length of hospital stay (LOS) were compared between treatment groups. RESULTS: The experimental and control groups were similar with respect to demographics, differing only in pre-fracture ambulatory status (P = .03). The 30-day mortality was 52% versus 50% (odds ratio, OR: 1.1 [95% confidence interval, CI: 0.25-4.82], P = .99) and 1-year mortality was 87% versus 80% (OR: 1.67 [95% CI: 0.23-11.9], P = .63) for experimental and control groups, respectively. The LOS did not statistically significantly differ for experimental and control groups (5.3 ± 3.56 days vs 3.8 ± 1.81 days, P = .15), respectively. The experimental group experienced twice the improvement in ambulation status (1.0 ± 0.56 vs 0.5 ± 0.71, P = 0.03) and greater improvement in pain scores (4.5 ± 2.19 vs 1.2 ± 2.72, P = .002). DISCUSSION: Operative management of FNFs may not be indicated in patients with advanced age and comorbidities. Regardless, these patients require pain palliation and early mobilization while minimizing hospital LOS and opiate consumption. CONCLUSION: This case-control study demonstrates significant improvement in both pain level and ambulatory status for patients treated with indwelling continuous peripheral catheters. Future studies should further evaluate with a larger sample size; however, this study provides an excellent launching point for palliative management of this complex population.

Comparing fracture patterns of younger versus older riders involved in nonfatal motorcycle accidents.

OBJECTIVE: The motorcyclist demographic is shifting to a larger proportion of riders over the age of 40. We sought to identify differences in orthopedic injury distribution and severity between 3 age cohorts and identify independent factors that contribute to fractures following a motorcycle collision (MCC). METHODS: A trauma registry at a level 1 trauma center was queried for motorcycle-related orthopedic injuries between January 1, 2008, and December 31, 2014. Subjects were stratified into 3 age groups: Young (<40 years), middle-aged (40-59 years), and elderly (≥60 years). Age groups were compared with respect to gender, weight, mechanism of collision, helmet use, Glascow Coma Scale (GCS), fracture type and location, Injury Severity Score (ISS), and hospital length of stay (LOS). A logistic regression model was constructed to identify independent factors that contribute to fractures following MCCs. RESULTS: Five hundred sixty-seven patients received care for motorcycle-related injuries (219 young, 264 middle-aged, and 84 elderly). Patients were predominantly male (88.7%), were wearing a helmet at the time of collision (58.0%), and sustained a mean of 1.48 fractures per patient. The primary mechanism of collision was noncollision transport accidents (41.4%). Elderly riders weighed significantly more than middle-aged and young riders (P < .0001). There was a significant difference in mean GCS between age groups (P = .02), with elderly patients demonstrating the highest mean GCS (14.0 ± 3.3). Young patients sustained no fractures most frequently when compared with middle-aged and elderly riders (P = .002). There was a significant difference in the percentage of patients sustaining right-sided, lower body fractures between age groups (P = .02) for elderly, middle-aged, and young patients, respectively. There was also a significant difference between age groups in the percentage of riders sustaining fractures other than those of the extremities, pelvis, or spine (P = .0005). Only age was identified as an independent predictor of sustaining a fracture (P = .008). CONCLUSIONS: Elderly patients sustained fractures more frequently. There was no difference between age groups with respect to injury severity. Mechanism of collision may have more influence than age with respect to fracture type and location. Further research is warranted to develop a more widely generalizable characterization of motorcycle collision injury patterns, risk factors, and patient characteristics.

Looking for Holes in Sterile Wrapping: How Accurate Are We?

BACKGROUND: Defects in sterile surgical wrapping are identified by the presence of holes through which light can be seen. However, it is unknown how reliably the human eye can detect these defects. QUESTIONS/PURPOSES: The purpose of this study was to determine (1) how often holes in sterile packaging of various sizes could be detected; and (2) whether differences in lighting, experience level of the observer, or time spent inspecting the packaging were associated with improved likelihood of detection of holes in sterile packaging. METHODS: Thirty participants (10 surgical technicians, 13 operating room nurses, seven orthopaedic surgery residents) inspected sterile sheets for perforations under ambient operating room (OR) lighting and then again with a standard powered OR lamp in addition to ambient lighting. There were no additional criteria for eligibility other than willingness to participate. Each sheet contained one of nine defect sizes with four sheets allocated to each defect size. Ten wraps were controls with no defects. Participants were allowed as much time as necessary for inspection. RESULTS: Holes ≥ 2.5 mm were detected more often than holes ≤ 2 mm (87% [832 of 960] versus 7% [82 of 1200]; odds ratio, 88.6 [95% confidence interval, 66.2-118.6]; p < 0.001). There was no difference in detection accuracy between OR lamp and ambient lightning nor experience level. There was no correlation between inspection time and detection accuracy. CONCLUSIONS: Defects ≤ 2 mm were not reliably detected with respect to lighting, time, or level of experience. Future research is warranted to determine defect sizes that are clinically meaningful. LEVEL OF EVIDENCE: Level II, diagnostic study.

Incidence of Vacuum Phenomenon Related Intra-articular or Subfascial Gas Found on Computer-Assisted Tomography (CT) Scans of Closed Lower Extremity Fractures.

OBJECTIVES: To determine the incidence of vacuum phenomenon related intra-articular or subfascial gas found on computer-assisted tomography (CT) scans of closed lower extremity fractures. DESIGN: Retrospective Review. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: A total of 153 patients with closed lower extremity fractures. INTERVENTION: CT scans of identified individuals were reviewed for the presence or absence of gaseous accumulations. MAIN OUTCOME MEASUREMENTS: The presence or absence of gas on CT. RESULTS: Twenty seven (17.6%) of the 153 fractures were found to have intra-articular or subfascial gas on CT despite clear documentation, indicating a closed injury with no significant skin compromise. Of the intra-articular fractures (OTA/AO 33B/C, 41B/C and 43B/C), 20% (23 of 113) were found to have gas on CT. All cases were associated with fracture of the tibia (P = 0.002). CONCLUSIONS: Computed tomography demonstrated the presence of intra-articular or subfascial gas in 17.6% (27/153) of closed lower extremity fractures and in 20% (23/113) of closed intra-articular fractures. The possibility of vacuum phenomenon must be considered when using this imaging modality as the confirmatory test for open intra-articular fracture or traumatic arthrotomy. LEVEL OF EVIDENCE: Level IV.

Palliative Management of Nonoperative Femoral Neck Fractures With Continuous Peripheral Pain Catheters: 20 Patient Case Series.

INTRODUCTION: To identify the success of pain catheters in the management of pain in nonoperatively treated femoral neck fractures (FNFs) in supplement to current multimodal protocols for end-of-life pain management. METHODS: Twenty patients aged older than 50 years with FNFs were selected in a retrospective fashion at a level 1 trauma center. These patients were treated nonoperatively with indwelling continuous peripheral pain catheters to palliate pain. Adjunctive pain control for patients undergoing nonoperative management of FNFs was provided with an indwelling continuous intra-articular/peripheral nerve ropivacaine pain catheters. Pain scores 24 hours before/after continuous pain catheter placement, ambulation status before/after continuous pain catheter placement, mortality at 30 days/1 year, and length of hospital stay were measured. RESULTS: Twenty patients were identified with an average age of 84.55 years. The average length of stay was 4.85 days with a decrease of 4.45 points on the visual analog scale and an improvement of 90% in ambulation status. Thirty-day and one-year mortality were 65% and 95%, respectively. CONCLUSION: This case series provides orthopedic surgeons with an option for and data on the success of this adjunct to palliate patients who elect to undergo nonoperative management of FNFs. This study also helps define which patients may be candidates for nonoperative management of geriatric hip fractures.

Retrograde reamed femoral nailing.

Closed, reamed, antegrade nailing remains the standard of care for femoral shaft fractures. This technique however, may be less attractive in the management of femoral shaft fractures associated with (a) ipsilateral acetabular, pelvis, or femoral neck fractures; (b) poly trauma requiring multiple simultaneous surgical procedures; and (c) pregnancy. We now report on our experience with the retrograde femoral nailing as a treatment option in these situations. Between 4/88 and 10/90, 29 retrograde femoral nailing in 24 patients were attempted. Average age was 29.3 (16-74) years. Five fractures were open. Fracture location was isthmal in 14 and infraisthmal in 15. The comminution was classified according to Winquist and Hansen: I(10), II(7), III(7), and IV(5). Nailing was possible in 28/29 cases. Insertion was made through an extraarticular medial condylar portal. Nail diameter ranged from 10 to 13 mm. An AO Universal Femoral Nail was used in the first 11 cases; all subsequent fractures were stabilized using an AO Universal Tibial Nail because its design appeared better suited to this technique. Follow-up was possible for 25 fractures in 21 patients and averaged 16.0 (range, 11-27); months 23/25 (92%) fractures healed within 12 weeks. No case was associated with an infection, loss of reduction, or nail failure. Knee flexion averaged 122°; only two knees had an extensor lag of >5°. Intraoperative complications included three cases of crack propagation at the insertion site, and four infraisthmal malreductions (two valgus, two flexion). Based on these results, we feel that retrograde reamed femoral nailing is a suitable alternative to antegrade nailing and should be considered in situations where proximal access is neither possible nor desirable.

Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 months follow-up.

OBJECTIVE: To evaluate the clinical and radiographic results associated with the use of a percutaneous suprapatellar (SP) portal and accompanying instrumentation for tibial intramedullary nail (IMN) insertion using a semiextended approach. DESIGN: Prospective, nonrandomized, nonconsecutive study. SETTING: Level 1 trauma center. PATIENTS AND METHODS: From June 2007 to January 2011, 56 fractures (55 patients) underwent intramedullary nailing of a tibia fracture with a semiextended approach through a SP portal. Radiographic and clinical follow-up examinations were performed at a minimum of 1 year after the index procedure. Measurements included bone healing, tibial alignment, knee range of motion, pain drawings, pain scoring (visual analogue scale), functional outcome (Lysholm and SF-36 scoring), evaluation of prenail and postnail insertion arthroscopic images of the patella-femoral (PF) joint (subgroup of study patients), and 1-year follow-up magnetic resonance imaging (MRI) scans (STIR and T2 gradient echo) of the knee to evaluate the PF joint cartilage. MRI scans were reviewed by an independent bone radiologist, whereas arthroscopic images were evaluated by an independent sports medicine fellowship-trained orthopaedic surgeon. RESULTS: Thirty-six patients (37 fractures) were available for follow-up at a minimum of 1 year (range: 12-49 months) after the index procedure. All but 2 fractures healed after the index procedure (94.6%). There was 1 radiographic malunion (2.7%). The mean Lysholm knee score was 82.14. Mean SF-36 physical and mental scores were 40.8 and 46.0, respectively. Mean arc of knee motion was 124.4 degrees for the affected extremity compared with 127.2 degrees for the contralateral knee. One patient (2.7%) complained of mild pain at the scar, but no patient complained of anterior knee pain either at the PF joint or at the anterior proximal tibia. In 13 of 15 patients undergoing an arthroscopic assessment of the PF joint, prenail and postnail insertion, no cartilage changes, or pressure points were seen either at the patella or at the trochlea groove. Two patients had grade II chondromalacia of the trochlea immediately after the procedure, but these did not correspond with either MRI scans or clinical findings at 1 year. When the remainder of the 1-year MRI scans were reviewed, 1 knee (2.7%) in a patient that did not have an arthroscopic examination was found to have grade II chondromalacia in the PF joint, but this did not correlate with the clinical examination, which was normal. CONCLUSIONS: This is the first paper to critically document clinical and radiographic results using the percutaneous SP portal with the semiextended approach for IMN of the tibia. Our 1 year results indicate that the procedure resulted in excellent tibial alignment, union, and knee range of motion, with rare sequelae in the PF joint based on immediate arthroscopy and 1-year MRI scans and clinical examinations. Even more interesting was the absence of anterior tibial pain often found when a tibial nail is inserted in a standard fashion.

Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 months follow-up.

OBJECTIVE: To evaluate the clinical and radiographic results associated with the use of a percutaneous suprapatellar (SP) portal and accompanying instrumentation for tibial intramedullary nail (IMN) insertion using a semiextended approach. DESIGN: Prospective, nonrandomized, nonconsecutive study. SETTING: Level 1 trauma center. PATIENTS AND METHODS: From June 2007 to January 2011, 56 fractures (55 patients) underwent intramedullary nailing of a tibia fracture with a semiextended approach through a SP portal. Radiographic and clinical follow-up examinations were performed at a minimum of 1 year after the index procedure. Measurements included bone healing, tibial alignment, knee range of motion, pain drawings, pain scoring (visual analogue scale), functional outcome (Lysholm and SF-36 scoring), evaluation of prenail and postnail insertion arthroscopic images of the patella-femoral (PF) joint (subgroup of study patients), and 1-year follow-up magnetic resonance imaging (MRI) scans (STIR and T2 gradient echo) of the knee to evaluate the PF joint cartilage. MRI scans were reviewed by an independent bone radiologist, whereas arthroscopic images were evaluated by an independent sports medicine fellowship-trained orthopaedic surgeon. RESULTS: Thirty-six patients (37 fractures) were available for follow-up at a minimum of 1 year (range: 12-49 months) after the index procedure. All but 2 fractures healed after the index procedure (94.6%). There was 1 radiographic malunion (2.7%). The mean Lysholm knee score was 82.14. Mean SF-36 physical and mental scores were 40.8 and 46.0, respectively. Mean arc of knee motion was 124.4 degrees for the affected extremity compared with 127.2 degrees for the contralateral knee. One patient (2.7%) complained of mild pain at the scar, but no patient complained of anterior knee pain either at the PF joint or at the anterior proximal tibia. In 13 of 15 patients undergoing an arthroscopic assessment of the PF joint, prenail and postnail insertion, no cartilage changes, or pressure points were seen either at the patella or at the trochlea groove. Two patients had grade II chondromalacia of the trochlea immediately after the procedure, but these did not correspond with either MRI scans or clinical findings at 1 year. When the remainder of the 1-year MRI scans were reviewed, 1 knee (2.7%) in a patient that did not have an arthroscopic examination was found to have grade II chondromalacia in the PF joint, but this did not correlate with the clinical examination, which was normal. CONCLUSIONS: This is the first paper to critically document clinical and radiographic results using the percutaneous SP portal with the semiextended approach for IMN of the tibia. Our 1 year results indicate that the procedure resulted in excellent tibial alignment, union, and knee range of motion, with rare sequelae in the PF joint based on immediate arthroscopy and 1-year MRI scans and clinical examinations. Even more interesting was the absence of anterior tibial pain often found when a tibial nail is inserted in a standard fashion. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Use of temporary partial intrailiac balloon occlusion for decreasing blood loss during open reduction and internal fixation of acetabular and pelvis fractures.

Patients with pelvic and/or acetabular fractures can sustain significant blood loss at the time of their injury and during surgery. We report on the technique, effect on blood loss, and complications with the use of temporary partial intrailiac balloon occlusion during open reduction and internal fixation of pelvic and acetabular fractures in a series of patients refusing allogeneic blood products for philosophical or religious reasons. An intra-arterial balloon is positioned in the common iliac artery immediately preoperatively, ipsilateral to the fracture in the interventional radiography suite. This balloon is then periodically inflated and deflated throughout the case by the anesthesiologist to mitigate operative blood loss. For anterior approaches, average blood loss was significantly less for those patients operated with temporary partial intrailiac balloon occlusion compared with those without. For posterior approaches, blood loss was not significantly different. One complication occurred in a patient who developed an arterial thrombus requiring surgical removal by the vascular surgery service at the conclusion of the orthopaedic surgery. He had no further sequelae. Although not recommended for routine use in all pelvic and acetabular fractures, we feel the use of temporary partial intrailiac balloon occlusion merits further study and may be beneficial in reducing blood loss during anterior pelvic or acetabular procedures in those patients who are opposed to allogeneic blood products and cell saver or those who cannot tolerate an anticipated massive blood loss.

Suprapatellar versus infra-patellar intramedullary nail insertion of the tibia: a cadaveric model for comparison of patellofemoral contact pressures and forces.

PURPOSE: To quantify patellofemoral contact pressures and forces during infrapatellar (IP) and suprapatellar (SP) intramedullary tibial nail insertion. METHODS: Fresh-frozen hemicadavers with intact lower extremities and pelves were used for this study. A standard IP entry portal was used on nine tibiae, whereas an SP entry portal was used in eight tibiae. A digital electronic pressure sensor system was used to dynamically measure peak pressures within the patellofemoral joint during each procedure. Data were continuously recorded from the start to completion of each procedure. Mean pressure and force as well as peak contact pressures recorded were then compared between the two techniques. RESULTS: Mean patellofemoral pressures and forces as well as peak contact pressures were higher in the SP group than the IP group. The mean peak contact pressure was 0.90 MPa (range, 0.48-1.26 MPa) during IP nailing. The mean peak contact pressure on the patella and femoral condyles was 1.84 MPa (range, 1.09-2.95 MPa) and 2.13 MPa (range, 1.10-2.86 MPa), respectively, during SP nailing. CONCLUSIONS: It is known that structural integrity of articular cartilage is compromised at impact loads exceeding 25 MPa, and chondrocyte apoptosis can occur at sustained loads of as little as 4.5 MPa in immature bovine cartilage. The results of this study indicate that although the patellofemoral contact pressures are higher with SP nail insertion, they remain below the values reported to be detrimental to articular cartilage. Based on these data, we do not believe that the SP entry portal poses a significant risk to the viability or structural integrity of the articular cartilage of the patellofemoral joint. Clinical correlation is needed.

Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis.

PURPOSE: Growth disturbance of the distal femur is the most common complication after distal femoral growth plate fracture. The purpose of our study was to pool data from the literature to determine the incidence of growth disturbance in relation to the Salter-Harris (SH) classification. Additionally, we evaluated the potential influence of fracture displacement and treatment method. METHODS: A structured PubMed search was performed to identify all reports on distal femoral growth plate fractures published in the English language literature, from 1950 to 2007. Reference lists from identified articles and bibliographies from standard pediatric fracture texts were also scrutinized. For a study to be included in this review, it needed to have at least 10 patients with a minimum of 1 year follow-up and be published in the English language. A total of 16 articles met the criteria for inclusion, which accounted for 564 fractures. RESULTS: Of the 564 fractures, 291 (52%) had a growth disturbance. Growth disturbance occurred in 36% of SH 1 fractures, 58% in SH 2, 49% in SH 3, and 64% in SH 4 fractures. In studies with patient-level data, there was growth disturbance in 65% of fractures with displacement and 31% of the fractures with no displacement had growth disturbance. The odds of a displaced fracture having growth arrest was 4 times greater than that of a nondisplaced fracture having a growth arrest. (P = 0.0015) In the studies with patient-level data, 58% (70/121) of fractures treated without fixation developed a growth disturbance, with 37% (45/121) being a clinically significant disturbance. Of the patients treated with fixation, including those who were initially treated without but lost reduction, 63% (19/30) developed a growth disturbance, with 27% (8/30) being clinically significant. Significant growth disturbance was defined as a leg length discrepancy equal to or greater than 1.5 cm and/or 5 degrees of varus or valgus deformity. SH 4 fractures had the greatest incidence of developing a leg length discrepancy greater than 1.5 cm (9/37). Twenty-two percent (112/506) of all distal femoral growth plate fractures developed a leg length discrepancy of greater than 1.5 cm. CONCLUSION AND SIGNIFICANCE: Fifty-two percent of distal femoral growth plate fractures had some form of growth disturbance. Twenty-two percent (112/506) of all distal femoral growth plate fractures developed a leg length discrepancy of greater than 1.5 cm. SH 1 fractures had the lowest incidence of growth disturbance (36%), whereas SH 4 fractures had the highest rate of growth disturbance at 64%. Although there is a greater incidence of growth disturbance in patients who were treated with fixation (58% versus 63%), there was a decreased incidence of significant growth disturbance (37% versus 27%).

Intramedullary nailing versus percutaneous locked plating of extra-articular proximal tibial fractures: comparison of 56 cases.

OBJECTIVE: To compare extra-articular proximal tibial fractures treated with intramedullary nailing (IMN) or percutaneous locked plating (PLP) and assess the ability of each technique to obtain and maintain fracture reduction. DESIGN: Retrospective clinical study. SETTING: : Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Beginning with the first use of PLP of the proximal tibia at our institution, all skeletally mature patients with surgically treated proximal extra-articular tibial fractures were reviewed. Between August 1999 and June 2004, 29 patients treated with intramedullary nails and 43 patients treated with percutaneous locked plates were identified. Patients with at least 1-year follow-up included 22 IMN and 34 PLP cases, which formed the final study group. MAIN OUTCOME MEASUREMENTS: Final outcomes were assessed for the IMN and the PLP groups by comparing rates of union, malunion, malreduction (defined as >5 degrees angulation in any plane), infection, and removal of implants. RESULTS: The IMN and PLP groups showed similar age and gender demographics. Average length of follow-up was 3.4 years in the IMN group (15-67 months) and 2.7 years in the PLP group (12-66 months). Open fractures made up 55% of the IMN group and 35% of the PLP group. Final union rates (after additional procedures for nonunions after the index procedure) were similar between groups (IMN = 96% and PLP = 97%). Implant removal in the PLP group was 3 times greater than in the IMN group, (P = 0.390), whereas an apex anterior (procurvatum) malreduction deformity occurred twice as frequently in the IMN group (P = 0.103). Additional surgical techniques (eg, blocking screws) were frequently used during reduction within the IMN group and infrequently used within the PLP group (P = 0.0002). Neither technique resulted in a statistically significant loss of final reduction confirming the stability of each construct. CONCLUSIONS: Neither IMN or PLP showed a distinct advantage in the treatment of proximal extra-articular tibial fractures. Apex anterior malreduction however was the most prevalent form of malreduction in both groups. Additional surgical reduction techniques were frequently needed with IMN, whereas removal of implants seems to be more commonly needed with PLP.

The effect of suture pattern and tension on cutaneous blood flow as assessed by laser Doppler flowmetry in a pig model.

OBJECTIVE: To determine the effects of various suture patterns on cutaneous blood flow (CBF) at the wound edge as increasing tension is applied through the suture. METHODS: Four different suture patterns commonly used for wound closure (simple, vertical mattress, horizontal mattress, and Allgower-Donati) were placed individually after a full-thickness incision was made in an anesthetized pig. A laser Doppler flowmeter (LDF) was placed on the skin edge after the suture was passed. Baseline CBF was recorded. Increasing tension was applied to the wound edge via the suture through a tensionometer in 0.5-lb (0.23-kg) increments from 0 to 2.5 lb (1.13 kg). CBF was then recorded as a function of tension for each suture pattern. RESULTS: The Allgower-Donati suture pattern affected CBF significantly less than the other three suture patterns did for all tensions from 0.5 to 2.0 lb (0-0.9 kg; P < 0.05). There were no significant differences between vertical mattress, horizontal mattress, and simple suture patterns. CONCLUSIONS: The Allgower-Donati suture pattern had the least effect on CBF with increasing tension in this model. Further study is warranted on the benefits of this suture pattern because it may decrease wound complications in traumatized tissues.

Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle.

OBJECTIVE: Results of surgical treatment for clavicle injuries using standard approaches have shown relatively high complication rates including loss of fixation, persistent nonunion, implant related problems, and the need for subsequent surgeries are common. The purpose of this study is to evaluate the clinical results of patients treated for clavicle fractures and painful clavicular nonunions with anterior-inferior plating using a 3.5 mm plate. DESIGN: Consecutive clinical series. SETTING: 3 tertiary care academic trauma centers (Level 1 and 2). PATIENTS: Eighty consecutive patients with a middle-third fracture or painful nonunion of the clavicle. INTERVENTION: Open reduction and internal fixation using an anterior-inferior plating technique with a precontoured 3.5 mm plate and lag screw(s). Nonunions received autologous bone grafts. MAIN OUTCOME MEASUREMENTS: Patients were evaluated using physical and radiographic examination, the American Shoulder and Elbow Surgeons Shoulder Assessment (ASES), and the Short Form-36 (SF-36) outcomes questionnaire. RESULTS: Fifty-eight patients had sufficient records and follow-up of at least 24 months (mean 49 months). Clinical and radiographic union was present at a mean of 9.5 weeks for patients treated for acute fracture and 10.5 weeks those treated for nonunion. Complications included 1 failure of fixation, 1 nonunion, and 3 infections. Two patients underwent implant removal for bothersome hardware. Shoulder motion was good or excellent in all patients except those with neurologic injury. Functional results (ASES and SF-36) were good or excellent for the vast majority of patients, except those with neurologic injury. CONCLUSIONS: Anterior-inferior plating of acute middle-third fractures of the clavicle and clavicular nonunions using a plate and lag screws typically results in early healing, few complications and an excellent return of function. Advantages of this technique include stable bony fixation with instrumentation directed away from potentially dangerous infraclavicular structures and a minimal incidence of implant prominence problems.

A staged protocol for soft tissue management in the treatment of complex pilon fractures.

OBJECTIVE: To determine whether open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol results in minimal surgical wound complications. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Between January 1991 and December 1996, 226 pilon fractures (AO types 43A-C) were treated, of which 108 were AO type 43C. Fifty-six fractures were included in a retrospective analysis of a treatment protocol. Injuries were divided into Group 1, thirty-four closed fractures, and Group II, twenty-two open fractures (three Gustilo Type 1, six Type II, eight Type IIIA, five Type IIIB). METHODS: The protocol consisted of immediate (within twenty-four hour) open reduction and internal fixation of the fibula when fractured, using a one-third tubular or 3.5-millimeter dynamic compression plate and application of an external fixator spanning the ankle joint. Patients with isolated injuries were discharged after initial stabilization and readmitted for the definitive reconstruction. Polytrauma patients remained hospitalized and were observed. Formal open reconstruction of the articular surface by plating was performed when soft tissue swelling had subsided. Complications were defined as wound problems requiring hospitalization. All affected limbs were then evaluated via chart and radiograph review, patient interviews, and physical examination until surgical wound healing was complete, for a minimum of twelve months. RESULTS: Group I (closed pilon): Follow-up was possible in twenty-nine out of thirty fractures (97 percent). Average time from external fixation to open reduction was 12.7 days. All wounds healed. None exhibited wound dehiscence or full thickness tissue necrosis requiring secondary soft tissue coverage postoperatively. Seventeen percent (five out of twenty-nine patients) had partial-thickness skin necrosis. All were treated with local wound care and oral antibiotics and healed uneventfully. There was one late complication (3.4 percent), a chronic draining sinus secondary to osteomyelitis, which resolved after fracture healing and metal removal. Group II (open pilon): Follow-up was possible in seventeen patients with nineteen fractures (86 percent). Average time from external fixation to formal reconstruction was fourteen days (range 4 to 31 days). By definition, all Gustilo Type IIIB fractures required flap coverage for the injury. Two patients experienced partial-thickness wound necrosis. These were treated with local wound care and antibiotics. All surgical wounds healed. There were two complications (10.5 percent), both deep infections. One Type I open fracture developed wound dehiscence and osteomyelitis requiring multiple debridements, intravenous antibiotics, subsequent removal of hardware, and re-application of external fixator to cure the infection. One Type IIIA open fracture of the distal tibia and calcaneus developed osteomyelitis and required a below-knee amputation. CONCLUSION: Based on our data, it appears that the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotation flaps, or free tissue transfers in our series. This technique appears to be effective in closed and open fractures alike.

Open reduction and stable fixation of isolated, displaced talar neck and body fractures.

BACKGROUND: The purpose of this retrospective review was to evaluate the long-term results of surgical treatment of isolated, displaced talar neck and/or body fractures with stable internal fixation. METHODS: The study included twenty-five patients with a total of twenty-six displaced fractures isolated to the talus that had been treated with open reduction and stable internal fixation and followed for a minimum of forty-eight months after the injury. The final follow-up examination included standard radiographs, computed tomography, and a clinical evaluation. Variables that were analyzed included wound type, fracture type, Hawkins type, comminution, timing of the surgical intervention, surgical approach, quality of fracture reduction, Hawkins sign, osteonecrosis, union, time to union, posttraumatic arthritis, and the AOFAS scores including subscores (pain, function, and alignment). RESULTS: The average duration of follow-up was seventy-four months. Surgical intervention resulted in sixteen fractures with an anatomic reduction, five with a nearly anatomic reduction, and five with a poor reduction. All eight noncomminuted fractures were anatomically reduced. The overall union rate was 88%. All closed, displaced talar neck fractures healed, regardless of the time delay until surgical intervention. Posttraumatic arthritis of the subtalar joint was the most common finding and was seen in all patients, sixteen of whom had involvement of more than one joint. Osteonecrosis was a common finding, seen after thirteen of the twenty-six fractures overall and after six of the seven open fractures. CONCLUSIONS: Open reduction and internal fixation is recommended for the treatment of displaced talar neck and/or body fractures. A delay in surgical fixation does not appear to affect the outcome, union, or prevalence of osteonecrosis. Posttraumatic arthritis is a more common complication than osteonecrosis following operative treatment. Patients with a displaced fracture of the talus should be counseled that posttraumatic arthritis and chronic pain are expected outcomes even after anatomic reduction and stable fixation. This is especially true following open fractures.

Infrapectineal plating for acetabular fractures: a technical adjunct to internal fixation.

Acetabular fractures with medial displacement patterns, particularly medial displacement of the quadrilateral surface, may be technically challenging to treat. Minimal bone stock, limited anatomic access, and difficulty in obtaining stable internal fixation in the true pelvis contribute to the surgical challenge of open reduction and internal fixation. Applying a medial buttress plate across the quadrilateral plate below the iliopectineal line in the true pelvis can be a helpful adjunct to internal fixation in these fractures. The quadrilateral plate is approached from the opposite side of the injury through a standard ilioinguinal approach or a modified Stoppa approach. An undercontoured plate is secured posteriorly along the sciatic buttress posterior to the joint and the quadrilateral plate and anteriorly on the posterior surface of the pubic ramus. By resisting medial secondary redisplacement, this technique adds to stable fixation for acetabular fractures involving medial displacement, particularly of the quadrilateral plate.