Reamed versus minimally reamed nailing: a prospectively randomised study of 100 patients with closed fractures of the tibia.

It is generally accepted that in tibial fractures the results of reamed intramedullary nailing are better than those of unreamed. However, it is not known whether the clinical effects of reaming are cumulative or if minimal reaming would induce the same beneficial effects as more extensive reaming. This international multicentre study has investigated the effects of different degrees of reaming. 100 patients with closed diaphyseal tibial fractures were prospectively randomised in two centres. Method of treatment was reamed nailing up to 12 mm inserting an 11 mm tibial nail (n: 50), and minimally reamed nailing up to 10 mm inserting a 9 mm tibial nail (n: 50). All patients included in the study had follow-up studies at 4,8,12,16,26 and 52 weeks after trauma. Sixty-six male and thirty-four female patients with an average age of 37.5 years were included in the study. Gender, age, and injury side were identical in both groups. There was no significant difference of complications in the two methods. The rate of deep wound infections was higher in the reamed group (n: 3) versus the minimally reamed group (n: 1). Union occurred earlier in the reamed group (17 wks) compared to patients with minimally reamed nailing (19 wks), and there were more patients with reamed nails in whom the fracture had healed by 16 weeks (57%) versus the minimally reamed group (43%), however, this was not statistically significant. Pain scales were similar for both groups from week 4 to week 52. A considerable number of outcome parameters including knee and ankle function, as well as the comparison of time intervals to restart certain activities, and return to work showed no significant statistical difference between the two groups. However, patients of the extensive reamed group returned earlier to running, training, and normal sports activities. This study found no significant evidence that more extensive reaming gave better results, however there seemed to be a tendency of more aggressive reaming to induce earlier fracture healing with a tendency of faster recovery times.

Percutaneous screw fixation versus conservative treatment for fractures of the waist of the scaphoid: a prospective randomised study.

We randomly allocated 60 consecutive patients with fractures of the waist of the scaphoid to percutaneous fixation with a cannulated Acutrak screw or immobilisation in a cast. The range of movement, the grip and pinch strength, the modified Green/O'Brien functional score, return to work and sports, and radiological evidence of union were evaluated at each follow-up visit. Patients were followed sequentially for one year. Those undergoing percutaneous screw fixation showed a quicker time to union (9.2 weeks vs 13.9 weeks, p < 0.001) than those treated with a cast. There was a trend towards a higher rate of nonunion in the non-operative group, although this was not statistically significant. Patients treated by operation had a more rapid return of function and to sport and full work compared with those managed conservatively. There was a very low complication rate. We recommend that all active patients should be offered percutaneous stabilisation for fractures of the waist of the scaphoid.

Displaced fractures of the proximal humerus in children require open/closed reduction and internal fixation.

Fractures of the proximal humerus in children are rare and constitute only 3% of all epiphyseal injuries. From 1992 to 2002 sixteen patients aged 4 - 15 years with a displaced fracture of the proximal humerus were treated at our level I trauma unit. The mean follow-up of the patients was 23.8 months (8 - 72). Ten children had a metaphyseal fracture and six a Salter and Harris Type II injury. Only one metaphyseal fracture was treated conservatively; the other patients underwent surgery (ORIF [= open reduction internal fixation] in ten patients, CRIF [= closed reduction internal fixation] in five patients). Follow-up examination showed no shortening or major angulation of the humerus in any of the sixteen cases. Fifteen children showed excellent and good results. There was only one average result in a polytraumatized child with additional injuries in both upper extremities. Based on the results of this study we suggest performing ORIF/CRIF in displaced fractures of the proximal humerus in children.

Ulnar procedures for post-traumatic disorders of the distal radioulnar joint.

Post-traumatic abnormality of the distal radioulnar joint (DRUJ) still presents a therapeutic challenge to orthopaedic surgeons. The most common difficulty is a failure to diagnose these injuries early, resulting in chronic post-traumatic disorders of the DRUJ. The main aim of therapy is to avoid adverse sequelae. This is of particular importance in malunion of the distal radius, the most common cause for post-traumatic disorders of the DRUJ. Distal radial malunion can be avoided by early appropriate treatment and the need for subsequent ulnar procedures reduced. Ulnar procedures for post-traumatic disorders of the DRUJ are intended to improve function and to decrease pain. Many methods to improve post-traumatic DRUJ function have been described. This article reviews the current state of the art in dealing with post-traumatic disorders of the distal radioulnar joint and presents algorithms to help in decision making.

Predictive geometric factors in a standardized model of femoral neck fracture. Experimental study of cadaveric human femurs.

An experimental study was performed on 20 cadaveric human proximal femurs to investigate both the reproducibility of their mechanical behavior under uniaxial compression and the correlation of mechanical properties with geometric dimensions and bone density. These variables were assessed by radiography, physical measurement, and dual-energy X-ray absorptiometry (DEXA). The specimens were immobilized, loaded to the point of fracture, and analyzed with the help of a materials testing machine. The fractures invariably showed a similar pattern both in location (i.e. at the femoral neck) and in nature (i.e. "axial-shear" type according to the AO classification system). The mechanical properties of the tested proximal femurs correlated negatively with age (r = -0.39) and positively with sex (male femurs were stronger and correlated more closely than female femurs, P = 0.005). They showed a strong positive correlation with head diameter (r = 0.713, P = 0.0004), a moderate positive correlation with both neck axis length (r = 0.63) and neck diameter (r = 0.502), and a slight positive correlation with femoral neck-shaft angle (r = 0.326). All DEXA-based densitometry measures turned out to be powerful predictors of fracture force. The establishment of this solidly reproducible fracture model based on standardized loading conditions should have implications for future research on osteopenia/osteoporosis and preventive stabilization techniques.

A new modular testing system for biomechanical evaluation of tibial intramedullary fixation devices.

This biomechanical study was performed to evaluate a new modular, tibial testing system developed for analysis of tibial nails and their locking screws.A new testing system, consisting of five modules, was designed to simulate a tibia. For this study one module was removed to simulate a 55-mm distal tibial defect inducing maximum loading on the distal portion of the implant and locking bolts. The tibial load offsets were 23 mm proximally and 10 mm distally medial to the centreline of the tibial shaft to simulate the location of the expected resultant load during the peak loading and inversion torque on the ankle during the gait cycle. Four solid tibial nails (STN, Stryker-Howmedica-Osteonics, Kiel, Germany) were tested to static failure and 15 nails were tested dynamically. Our results showed that the solid tibial nails fractured in the testing device in the same manner and location as they do in clinical series. Evaluation of the results showed the mean fatigue limit of the STN to be 1.4 kN for 500,000 cycles with a standard deviation (S.D.) of 0.33 kN. This biomechanical study establishes a standard technique for the biomechanical testing of tibial nails, in a clinically relevant manner, avoiding the inconsistency of cadaver bone tests. As it is a standardised test set-up this new modular testing system could serve as a standard by which small diameter tibial nails and other devices could be evaluated and compared with other systems currently in use.

Rates and odds ratios for complications in closed and open tibial fractures treated with unreamed, small diameter tibial nails: a multicenter analysis of 467 cases.

OBJECTIVE: A multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails. DESIGN: Retrospective. SETTING: Four Level I trauma centers. PATIENTS: Four hundred sixty-seven tibial fractures were included in the study. There were fifty-two proximal fractures, 219 midshaft fractures, and 196 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred sixty-five were closed fractures and 202 were open fractures. OUTCOME MEASUREMENTS: Clinical and radiographic analysis. METHODS: 467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of open or closed diaphyseal fractures. The operating surgeons decided whether or not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center 1 preferred to treat AO Type A and B fractures with unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures were treated in approximately the same ratio. RESULTS: Analysis showed five (1.1 percent) deep infections (with a 5.4 percent rate of deep infections in Gustilo Grade III open fractures), forty-three delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compartment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail in three cases (0.6 percent). CONCLUSIONS: Fracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diameter nails as this increases the odds of having a delayed union by twelve times (p < 0.001) and a nonunion by four times (p = 0.057). There was a significant increase of complications in the group of Grade III open fractures (p < 0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low.

The standard Gamma nail: a critical analysis of 1,000 cases.

BACKGROUND: The continuous increase in the number of fractures of the proximal femur is directly attributable to the worldwide increase in life expectancy. The standard version of the Gamma Interlocking-Nail (standard Gamma nail [SGN], 200-mm length, 10-degree valgus curvature, two distal locking bolts) was designed because of the demands in orthopedic hip surgery to develop an implant stable enough to mobilize old patients as soon as possible to avoid further morbidity and mortality. METHODS: Between the years 1992 and 1998, 1,000 consecutive patients with peritrochanteric fractures were stabilized by using the SGN and included in this study. Special emphasis was given to the evaluation of the learning curve of the department of traumatology (not of single surgeons) and the influence of prognostic factors on the outcome of such operations. RESULTS: The results of this study show that increasing "department experience" resulted in a reduction of the intraoperative complication rate by a factor of 0.5 (p = 0.0001) per year. This means that even an inhomogeneous mass of 78 surgeons can lower the rate of intraoperative complications by 50% per year because of increased experience. The number of early postoperative complications annually decreased by a factor of 0.8 (p = 0.0042). CONCLUSION: Late postoperative complications correlate negatively with the patient's age (odds ratio, 0.9; p = 0.0001).

The fatigue strength of small diameter tibial nails.

This study was performed to evaluate the fatigue strength of commonly used small diameter tibial nails. Five types of small diameter tibial nails (7 mm aap Biorigid Nail, 8 mm aap Biorigid Nail, 8 mm Ace UTN, 8 mm RT Tibial Nail, 8 mm Synthes UTN) with a sample size of 30 implants (six samples of each nail type) were tested with a new modular testing system. One module of the testing system was removed, simulating a 55-mm distal tibial defect, to induce maximum loading on the distal portion of the implant and locking bolts. The average yield strengths were obtained from static, single cycle tests and revealed an average static ultimate load of 1072 N (aap7), 1820 N (aap8), 1812 N (Ace), 1942 N (R&T), and 1543 N (Syn). The fatigue limits were evaluated by cyclic, sinusoidal loading and revealed a fatigue strength of 750 N (aap7), 1092 N (aap8), 906 N (Ace), 971 N (R&T), and 771 N (Syn) to endure 500000 cycles. Our results showed that the solid tibial nails fractured in the testing device in the same manner and location as they do in the clinical series. This study showed that all the small diameter tibial nails tested are obviously able to transmit loads of more than average body weight. The fatigue strength of the implants is relatively high, which means that patients without bone defects could be mobilised with full weight bearing as tolerated by pain. However, according to the results of this study, early mobilisation with full weight bearing in a normal gait cycle can not be suggested in patients with segmental tibial fractures or fractures with defect zones.

Implant failure of the gamma nail.

The gamma nail is a temporary implant characterised by a limited life expectancy under continuous dynamic stress. We reviewed a series of 839 patients with gamma nail stabilisation and found two fatigue fractures (0.2%) at the aperture of the distal locking holes. This complication has not been described in the literature. Metallurgic and scanning electron microscopic examinations proved that the fatigue zones occurred at the clover-leaf grooves, which is where the diameter of the gamma nail is reduced. The clover-leaf diameter is of no biomechanical use in gamma nail stabilisation. We suggested product modification of the gamma nail to produce implants with a round diameter instead of a clover-leaf shape. A modified implant is already in use at our institution.

Fatigue strength of locking screws and prototypes used in small-diameter tibial nails: a biomechanical study.

BACKGROUND: One major problem with the use of small-diameter nails in the treatment of tibial fractures is the high rate of fatigue fractures of the locking screws. The objective of this study was to correlate such parameters as diameter of locking screws, influence of notch effect, and material with fatigue strength and fatigue limit. METHODS: In a biomechanical study, the mechanical properties of 11 different locking screws and screw designs to be used in solid tibial nails were tested under typical fatigue conditions. RESULTS: The results showed that an increase in the screw's diameter significantly increased the fatigue strength of the tested locking screws and prototypes (p < 0.0005). A 20% increase of diameter improved fatigue strength by 25 to 70%. Absence of thread at the location where the screw contacts the nail's aperture (where the main load is transmitted to the screw and where the screw, therefore, usually tends to break) may double the fatigue strength and fatigue limit by avoiding the negative notch effect of the screw's thread. It was further significant that titanium alloys had a higher fatigue strength compared with stainless steel alloys (p < 0.001). However, the fatigue strength of titanium implants is massively reduced by minimal damage to the surface. CONCLUSION: Optimizing the core diameter of the locking screws at the aperture of the solid tibial nail by using screws without a continuous thread generates a fatigue strength two to three times higher compared with screws with a continuous thread. Increasing fatigue strength of locking screws might decrease malunion in fractures stabilized by small-diameter nails.

Results of spinal cord decompression and thoracolumbar pedicle stabilisation in relation to the time of operation.

Short-segment pedicle stabilisation, transpedicular disc resection and autologous cancellous bone grafting is performed in trauma patients being transferred to our trauma centre with thoracolumbar fracture/dislocations. A follow-up examination of 88 patients, who were operated during the years of 1985-1992, took place after an average time of 5.6 years. Our results suggest that the earlier operative decompression and spine stabilisation takes place, the better is the recovery rate in patients with neurologic deficits. The highest neurologic recovery rates were found in patients operated within 8 h after the initial trauma. High remission rates were still found, if the patients had been operated within 48 h. After this time there was no significant difference in the neurologic outcome compared to the time of operation.

Limited diagnostic value of macroradiography in suspected scaphoid fractures.

In a prospective study 60, patients having suspected occult scaphoid fractures, but with normal conventional scaphoid radiographs, also underwent macroradiography. Clinical and conventional radiographic follow-up examinations and MRI identified 8 occult scaphoid fractures and 23 nonscaphoid lesions. Macroradiography identified only 50% of the occult scaphoid fractures.

Unreamed nailing of tibial fractures with the solid tibial nail.

In 1993 a solid 7.5-mm tibial nail was developed and is composed of a wrought stainless steel alloy. In a preclinical testing series its static and dynamic mechanical properties proved to be superior to other small diameter nails. The clinical application of the Solid Tibial Nail in 70 cases of acute tibial diaphyseal fractures showed promising results. Neither severe intraoperative complications nor infections were observed. The entire series, including seven Grade I, eight Grade II, four Grade IIIA, and nine Grade IIIB open fractures, revealed a union rate of 95% at 6 months postoperative. After dynamization in one case and reaming and renailing in three cases, the fractures with delayed healing progressed to union within the following 3 months. There was no need for bone grafting in any of the cases. Locking screw breakage was observed in 10 (14%) cases 8 to 24 weeks postoperatively. This did not lead to any additional complications. No nail failures were observed. The excellent results of unreamed nailing with the Solid Tibial Nail consequently led to its use as the primary method of treatment for tibial fractures associated with soft tissue injury at the authors' institution.

Obturator prostheses after cancer surgery: an approach to speech outcome assessment.

PURPOSE: This article describes a speech assessment protocol for patients using either obturator prostheses or speech aid prostheses for surgically acquired defects due to cancer of the maxilla and/or soft palate. METHODS: This protocol is structured according to the executive summary of "Disability in America: Toward a National Agenda For Prevention" a report formulated by the Institute of Medicine that describes four levels of disorder: (1) pathology, (2) impairment, (3) functional limitation, and (4) disability. Assessment instruments included (1) the Sentence Intelligibility Test to measure the rate and understandability of speech, (2) a speech physiology system to measure appropriate separation of the nasal/nasopharyngeal and oral compartments, (3) a 13-point interval scale to rate speech nasality, and (4) a scale to rate self-perceptions of communication effectiveness. RESULTS: The results from two patients are reported to illustrate the outcome assessment protocol.

[Prospective comparison of MRI vs. direct magnification radiography in occult fractures of the scaphoid bone]. / Prospektiver Vergleich MRT vs. direkte Vergrösserungsradiographie bei okkulten Frakturen des Os scaphoideum.

The diagnosis of occult fractures of the scaphoid bone is even more challenging than that of conventional fractures of the scaphoid. This study aimed to compare prospectively the gold standard method (plain radiographs in four projections, after about 14 days) and the primary findings with direct magnification radiography (DIMA) and magnetic resonance imaging (MRI). Primary MRI showed much higher diagnostic power than plain radiography at 10-14 days in occult scaphoid fractures and in detection of associated carpal injuries. This may lead to a decreasing time of disease. DIMA was inferior in detecting occult fractures of the scaphoid.

Trauma of the wrist.

In wrist injury, plain radiographs form the basis of diagnostic imaging, and can provide definitive answers in most cases. MR imaging is the method of choice for several diagnostic problem cases. These problems can include radiographically occult fractures where MRI enables early diagnosis compared to follow-up radiographs. Early stage diagnosis of a post-traumatic avascular osteonecrosis with high sensitivity and specificity, is only possible with MRI. In these instances, radiographs are only sensitive in later stages and scintigraphy is quite nonspecific. Stress fractures, invisible with other modalities, are also demonstrable with MRI. In addition, MRI is helpful in special circumstances with regard to non-union or pseudarthrosis. In wrist instability, radiographs in combination with stress views and fluoroscopy are still the initial diagnostic step. MRI, with the advantage of direct visualization of the wrist ligaments and triangular fibrocartilage complex, offers very promising results in this area. Generally, for the evaluation of wrist injury, MRI can be considered the most important second-step procedure in patients where radiographs are nondiagnostic.

Diagnosis of lateral ankle ligament injuries. Comparison between talar tilt, MRI and operative findings in 112 athletes.

We evaluated the reliability of the radiographic talar tilt test by MRI examinations in 112 athletes with injuries to the lateral ligaments of the ankle. 25 athletes with a talar tilt > 15 degrees were treated operatively. Intraoperative findings and the talar tilt test were compared with MR imaging results. Our results suggest that MRI is a reliable method for diagnosing injuries of the lateral ankle ligaments. The talar tilt test cannot evaluate the specific pathology of lateral ankle ligaments, but it was reliable in indicating complete double-ligament ruptures (anterior talofibular and calcaneo-fibular ligaments), when talar tilt was 15 degrees or more than on the uninjured side.

Radiographically occult scaphoid fractures: value of MR imaging in detection.

PURPOSE: To evaluate the diagnostic value of magnetic resonance (MR) imaging in patients with clinical suspicion of scaphoid fractures and normal initial plain radiographs. MATERIALS AND METHODS: MR imaging was performed within 7 days after trauma in 42 patients with clinical suspicion of scaphoid fractures and normal plain radiographs. T1-weighted spin-echo, T2*-weighted gradient-echo, and short inversion time inversion-recovery (STIR) sequences were performed. MR images were evaluated independently by two radiologists. Six-week follow-up radiographs were used as a standard to diagnose fractures. RESULTS: MR imaging depicted occult fractures of the scaphoid bone in 14 patients (33%), the capitate bone in four (10%), the trapezium in one (2%), and the distal radius in two (5%). All wrist fractures were detected with a combination of STIR and T1-weighted spin-echo sequences. The sensitivity and specificity for detection of radiographically occult fractures of the wrist were 100% each for the first and 95% and 100%, respectively, for the second radiologist with an almost perfect interobserver agreement (K = 0.953). CONCLUSION: MR imaging has a high sensitivity for detection of fractures of the scaphoid bone and wrist not evident on plain radiographs and may enable early diagnosis and treatment.

MRI of the sinus tarsi in acute ankle sprain injuries.

PURPOSE: Our goal was to evaluate the visibility and incidence of traumatic abnormalities of the sinus tarsi in patients with acute ankle sprain injuries and compare these findings with the extent of lateral ankle ligament injuries on MRI. METHOD: Sixty athletically active patients (aged 18-45 years) with recent inversion trauma (< or = 7 days) underwent MRI. Replacement of fat tissue in the sinus tarsi was recorded. Inter/intraobserver agreement was calculated (kappa-statistics). Injuries of the three lateral ligaments, evaluated by MRI, were graded according to partial (1 point) or complete (2 points) tears for each of three lateral ligaments (together 0-6 points) and were compared with sinus tarsi abnormalities. RESULTS: In 26 patients (43%), replacement of sinus tarsi fat tissue was depicted by MRI. Inter/intraobserver agreement for MR changes of the sinus tarsi was good to moderate (kappa = 0.675/0.584). Grade of lateral ankle ligament injury showed a statistically significant difference (p = 0.033) between the two sinus tarsi groups (normal/abnormal). CONCLUSION: Acute ankle sprain injuries, evaluated by MRI, are associated with acute abnormalities of the sinus tarsi in 43% of patients and correlate with the extent of lateral ankle ligament tears.