Pulmonary dysfunction in patients with femoral shaft fracture treated with intramedullary nailing.

BACKGROUND: This study was undertaken to determine whether alveolar dead space increases during intramedullary nailing of femoral shaft fractures and whether alveolar dead space predicts postoperative pulmonary dysfunction in patients undergoing intramedullary nailing of a femoral shaft fracture. METHODS: All patients with a femoral shaft fracture were prospectively enrolled in the study unless there was evidence of acute myocardial infarction, shock, or heart failure. Arterial blood gases were measured at three consecutive time-periods after induction of general anesthesia: before intramedullary nailing and ten and thirty minutes after intramedullary nailing. The end-tidal carbon-dioxide level, minute ventilation, positive end-expiratory pressure, and percent of inspired and expired inhalation agent were recorded simultaneously with the blood-gas measurement. Postoperatively, all subjects were monitored for evidence of pulmonary dysfunction, defined as the need for mechanical ventilation or supplemental oxygen (at a fraction of inspired oxygen of >40%) in the presence of clinical signs of a respiratory rate of >20 breaths/min or the use of accessory muscles of respiration. RESULTS: Seventy-four patients with a total of eighty femoral shaft fractures completed the study. Fifty fractures (62.5%) underwent nailing after reaming, and thirty fractures (37.5%) underwent nailing with minimal or no reaming. The mean alveolar dead-space measurements before canal opening and at ten and thirty minutes after canal opening were 14.5%, 15.8%, and 15.2% in the total series of seventy-four patients (general linear model, p = 0.2) and 20.5%, 22.7%, and 24.2% in the twenty patients with postoperative pulmonary dysfunction (general linear model, p = 0.05). Of the twenty-one patients with an alveolar dead-space measurement of >20% thirty minutes after nailing, sixteen had postoperative pulmonary dysfunction. According to univariate and multivariate analysis, the alveolar dead-space measurement was strongly associated with postoperative pulmonary dysfunction. CONCLUSIONS: According to our data, intramedullary nailing of femoral shaft fractures did not significantly increase alveolar dead space, and the amount of alveolar dead space can predict which patients will have pulmonary dysfunction postoperatively.

Humeral shaft nonunions treated with fibular allograft and compression plating.

The present study is a retrospective review of the treatment of 12 humeral shaft nonunions by using an intramedullary allograft with compression plating. The average age of the patients was 61 years (range, 36-82 years). Eight cases involved the proximal shaft, 3 cases were at the mid-diaphyseal level, and 1 case was at the distal one third. Follow-up averaged 30 months (range, 12-96 months). Ten patients (83%) went on to uneventful healing at an average of 3 months after surgery. Two failures involving patients with multiple medical conditions occurred secondary to reinjury. Two cases of postoperative radial nerve neuropraxia involved the posterior approach to the humerus. Each resolved with no long-term residual morbidity. One patient developed postoperative adhesive capsulitis of the shoulder that resolved with nonoperative treatment. We feel that a fibular allograft, along with compression plating, can give satisfactory results for humeral shaft nonunions. This technique can be especially helpful in proximal humeral nonunions and in nonunions involving osteoporotic bone. Patients with multiple medical problems at risk for refalls should be protected until complete healing has occurred.

Intraoperative fluoroscopy to evaluate fracture reduction and hardware placement during acetabular surgery.

OBJECTIVES: To evaluate use of intraoperative fluoroscopy during acetabular surgery to determine fracture reduction and accurate placement of screws. DESIGN: Retrospective. SETTING: Level I trauma center. PARTICIPANTS: Thirty patients with thirty-two acetabular fractures. INTERVENTION: Patients were evaluated with fluoroscopy during surgery to assess fracture reduction and screw placement. Anterior-posterior (AP), oblique, and lateral pelvic fluoroscopic images were obtained intraoperatively. Postoperative radiographs were used to verify fluoroscopic findings; computed tomography (CT) scans were used as the control to assess intraarticular screw placement. MAIN OUTCOME MEASUREMENTS: Radiographic and clinical assessment of fracture reduction and screw placement. RESULTS: Intraoperative fluoroscopy confirmed the extra-articular position of all screws evaluated. Postoperative CT scans confirmed the extra-articular placement of all screws assessed by fluoroscopy. Quality of reduction using intraoperative fluoroscopic images had a 100 percent correlation with reduction on final radiographs. One patient, with two screws placed without fluoroscopic evaluation, had intra-articular placement requiring revision surgery. CONCLUSIONS: Intraoperative fluoroscopy is effective in evaluating both acetabular fracture reduction and hardware placement.

Modern cement technique and the survivorship of total shoulder arthroplasty.

Thirty-eight consecutive Neer II total shoulder arthroplasties were performed in 35 patients by one surgeon using the so called modem cement technique and followed for a mean of 5 years (range, 2-9.5 years). The preoperative diagnosis was osteoarthritis or avascular necrosis in 22 shoulders, rheumatoid arthritis in 10 shoulders, and posttraumatic arthritis in 6 shoulders. The components were implanted using specific improved techniques for cement fixation initially described for total hip arthroplasty. Twenty-six metal-backed and 12 polyethylene glenoid components were used. The humeral component was implanted with cement in 32 shoulders. There were no intraoperative fractures or postoperative neurapraxias. At most recent followup, 36 shoulders had no or slight pain with activity. The mean increase in active forward elevation was 38 degrees and in active external rotation was 29 degrees. There have been no revisions, and all components remain in place. With failure defined as definite radiographic loosening of the components, there was 97% survivorship at 5 years, and 93% at 8 years. Radiolucent lines around more than 50% of the bone cement interface of the humeral component were present in only 3 shoulders. Radiolucent lines around more than 50% of the bone cement interface of the glenoid component were seen in only 2 shoulders. Both components in 1 severely osteopenic shoulder had a complete radiolucent line and a change in position. Meticulous attention to cement technique may improve the long term survival of cemented total shoulder arthroplasty components.

Growth and disinfestation of 6 different bacteria in embryogenic suspension cultures of cotton.

Growth of 6 different common laboratory bacteria (Escherichia coli, Flavobacterium balustrum, Xanthomonas maltophilia, Enterobacter cloacae, Pseudomonas fluorescens, and Agrobacterium tumefaciens) in a bacterial medium, fresh plant medium, and "spent" plant media was initially measured. In all cases, bacteria grew best in the bacterial medium followed by the fresh plant medium. The spent plant medium did not support growth of the bacteria and apparently was actively toxic to bacterial cells. Proliferating, embryogenic suspension cultures of cotton (Gossypium hirsutum) were then inoculated with these 6 different bacteria. Two to three d following bacterial inoculation, embryogenic tissues were placed in various concentrations of bleach for various amounts of time, rinsed with sterile water, and placed on a bacterial culture medium. Clumps of embryogenic tissue which showed no visible bacterial growth after 3 d of culture were then transferred to an agar-solidified plant tissue culture medium to determine viability of bleachdisinfested tissues. Viable, single pieces of the disinfested embryogenic tissue were then used to reinitiate embryogenic suspension cultures. Treatment of contaminated tissue with a 1% bleach solution for 1-5 min resulted in the highest recovery of viable, disinfested tissues using 5 of the 6 bacteria. It was not possible to remove F. balustrum from clumps of embryogenic tissue without also killing the plant tissue.