The effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D: a prospective randomised trial.

AIMS: To evaluate the effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D and a long bone fracture. PATIENTS AND METHODS: Between July 2011 and August 2013, 113 adults with a long bone fracture were enrolled in a prospective randomised double-blind placebo-controlled trial. Their serum vitamin D levels were measured and a total of 100 patients were found to be vitamin D deficient (< 20 ng/ml) or insufficient (< 30 ng/mL). These were then randomised to receive a single dose of vitamin D3 orally (100 000 IU) within two weeks of injury (treatment group, n = 50) or a placebo (control group, n = 50). We recorded patient demographics, fracture location and treatment, vitamin D level, time to fracture union and complications, including vitamin D toxicity. Outcomes included union, nonunion or complication requiring an early, unplanned secondary procedure. Patients without an outcome at 15 months and no scheduled follow-up were considered lost to follow-up. The t-test and cross tabulations verified the adequacy of randomisation. An intention-to-treat analysis was carried out. RESULTS: In all, 100 (89%) patients had hypovitaminosis D. Both treatment and control groups had similar demographics and injury characteristics. The initial median vitamin D levels were 16 ng/mL (interquartile range 5 to 28) in both groups (p = 0.885). A total of 14 patients were lost to follow-up (seven from each group), two had fixation failure (one in each group) and one control group patient developed an infection. Overall, the nonunion rate was 4% (two per group). No patient showed signs of clinical toxicity from their supplement. CONCLUSIONS: Despite finding a high level of hypovitaminosis D, the rate of union was high and independent of supplementation with vitamin D3. Cite this article: Bone Joint J 2017;99-B:1520-5.

Osteogenic, stem cell and molecular characterisation of the human induced membrane from extremity bone defects.

OBJECTIVES: The biomembrane (induced membrane) formed around polymethylmethacrylate (PMMA) spacers has value in clinical applications for bone defect reconstruction. Few studies have evaluated its cellular, molecular or stem cell features. Our objective was to characterise induced membrane morphology, molecular features and osteogenic stem cell characteristics. METHODS: Following Institutional Review Board approval, biomembrane specimens were obtained from 12 patient surgeries for management of segmental bony defects (mean patient age 40.7 years, standard deviation 14.4). Biomembranes from nine tibias and three femurs were processed for morphologic, molecular or stem cell analyses. Gene expression was determined using the Affymetrix GeneChip Operating Software (GCOS). Molecular analyses compared biomembrane gene expression patterns with a mineralising osteoblast culture, and gene expression in specimens with longer spacer duration (> 12 weeks) with specimens with shorter durations. Statistical analyses used the unpaired student t-test (two tailed; p < 0.05 was considered significant). RESULTS: Average PMMA spacer in vivo time was 11.9 weeks (six to 18). Trabecular bone was present in 33.3% of the biomembrane specimens; bone presence did not correlate with spacer duration. Biomembrane morphology showed high vascularity and collagen content and positive staining for the key bone forming regulators, bone morphogenetic protein 2 (BMP2) and runt-related transcription factor 2 (RUNX2). Positive differentiation of cultured biomembrane cells for osteogenesis was found in cells from patients with PMMA present for six to 17 weeks. Stem cell differentiation showed greater variability in pluripotency for osteogenic potential (70.0%) compared with chondrogenic or adipogenic potentials (100% and 90.0%, respectively). Significant upregulation of BMP2 and 6, numerous collagens, and bone gla protein was present in biomembrane compared with the cultured cell line. Biomembranes with longer resident PMMA spacer duration (vs those with shorter residence) showed significant upregulation of bone-related, stem cell, and vascular-related genes. CONCLUSION: The biomembrane technique is gaining favour in the management of complicated bone defects. Novel data on biological mechanisms provide improved understanding of the biomembrane's osteogenic potential and molecular properties.Cite this article: Dr H. E. Gruber. Osteogenic, stem cell and molecular characterisation of the human induced membrane from extremity bone defects. Bone Joint Res 2016;5:106-115. DOI: 10.1302/2046-3758.54.2000483.

Outcome after fixation of ankle fractures with an injury to the syndesmosis: the effect of the syndesmosis screw.

The purpose of this study was to compare the clinical and radiological outcome of patients with intact, broken and removed syndesmosis screws after Weber B or C ankle fracture with an associated injury to the syndesmosis. We hypothesised that there would be no difference. Of a possible 142 patients who fulfilled our inclusion criteria, 52 returned for clinical and radiological assessment at least one year after surgery. Of these, 27 had intact syndesmosis screws, ten had broken screws, and 15 had undergone elective removal of the screw. The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 83.07 (sd 13.59) in the intact screw group, 92.40 (sd 12.69) in the broken screw group, and 85.80 (sd 11.33) in the removed screw group (p = 0.0466). There was no difference in clinical outcome of patients with intact or removed syndesmotic screws. Paradoxically, patients with a broken syndesmosis screw had the best clinical outcome. Our data do not support the removal of intact or broken syndesmosis screws, and we caution against attributing post-operative ankle pain to breakage of the syndesmosis screw.

Indometacin as prophylaxis for heterotopic ossification after the operative treatment of fractures of the acetabulum.

Our study was designed to compare the effect of indometacin with that of a placebo in reducing the incidence of heterotopic ossification in a prospective, randomised trial. A total of 121 patients with displaced fractures of the acetabulum treated by operation through a Kocher-Langenbeck approach was randomised to receive either indometacin (75 mg) sustained release, or a placebo once daily for six weeks. The extent of heterotopic ossification was evaluated on plain radiographs three months after operation. Significant ossification of Brooker grade III to IV occurred in nine of 59 patients (15.2%) in the indometacin group and 12 of 62 (19.4%) receiving the placebo. We were unable to demonstrate a statistically significant reduction in the incidence of severe heterotopic ossification with the use of indometacin when compared with a placebo (p = 0.722). Based on these results we cannot recommend the routine use of indometacin for prophylaxis against heterotopic ossification after isolated fractures of the acetabulum.

Attitudes of orthopaedic trauma surgeons regarding current controversies in the management of pelvic and acetabular fractures.

A closed-ended questionnaire was mailed to all 363 active members of the Orthopaedic Trauma Association. It directed, toward practicing pelvic and acetabular surgeons, questions pertaining to practice demographics and preferred methods for detection and prevention of deep venous thrombosis (DVT), nerve injury, and heterotopic ossification (HO). Questionnaires were received from 226 surgeons (62 percent). Of the surgeons who responded, 181 (80 percent) perform pelvic-fracture and acetabular-fracture surgery; only questionnaires from this group were analyzed. Standard statistical methods were used to perform both univariate and multivariate analyses. Preoperative DVT screening was performed by 48 percent of the surgeons; ultrasound was the most commonly used modality (82 percent). Preoperative DVT prophylaxis was administered by 88 percent of those surveyed; the majority (78 percent) used sequential compression devices. Postoperative prophylaxis was used by 99 percent; the most commonly used modality was sequential compression devices. Analysis suggests that fellowship-trained surgeons and surgeons in practice for fewer than twenty years are more likely to use preoperative DVT prophylaxis. HO prophylaxis was administered by 88 percent; the most commonly used modality was indomethacin. Intraoperative nerve monitoring was performed by only 15 percent of the respondents. Most surgeons employed prophylactic measures to prevent DVT and HO. The wide variation in type of prophylaxis and reasons for use suggests that controversy will continue, and a standard of care for these conditions has yet to be defined. Very few surgeons use intraoperative nerve monitoring routinely.

The floating shoulder: clinical and functional results.

BACKGROUND: Displaced ipsilateral fractures of the clavicle and the glenoid neck are a complex injury pattern that is usually the result of high-energy trauma. The treatment of these injuries is controversial, as good results have been reported with both operative and nonoperative treatment. METHODS: Nineteen patients who had sustained a displaced fracture of the glenoid neck with an ipsilateral clavicular fracture or acromioclavicular separation (floating shoulder) were retrospectively evaluated. The treatment was nonoperative in twelve patients and operative in seven. At the time of final follow-up, standard radiographs were made and all patients were examined by a physical therapist and either a fellowship-trained shoulder surgeon or an orthopaedic traumatologist. In addition, each patient responded to three different validated objective functional outcome measures: the Short Form-36, the American Shoulder and Elbow Surgeons Shoulder Scale, and the Disabilities of the Arm, Shoulder and Hand Questionnaire. Isokinetic strength-testing was performed, and strength in internal and external rotation was compared with that of the uninvolved shoulder. The main outcome measures included fracture-healing, functional outcome, patient satisfaction, and muscular strength. RESULTS: With regard to range of motion, only the amount of forward flexion was found to be significantly greater in the operatively treated group (p = 0.03). The operatively treated shoulders were found to be weaker in external rotation at 300 degrees /sec and weaker in internal rotation at 180 degrees /sec. When normalized to hand dominance, however, the numbers were too small to identify any significant difference. There was no significant difference between groups with regard to the three functional outcome measures. CONCLUSIONS: Good results may be seen both with and without operative treatment. Therefore, we cannot universally recommend operative treatment for a double disruption of the superior suspensory shoulder complex. Treatment must be individualized for each patient.

A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores.

BACKGROUND: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems. METHODS: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation. RESULTS: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation. CONCLUSIONS: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.

Characterization of patients with high-energy lower extremity trauma.

PURPOSE: (a) to report the demographic, socioeconomic, behavioral, social, and vocational characteristics of patients enrolled in a study to examine outcomes after high-energy lower extremity trauma (HELET) and to compare them with the general population; (b) to determine whether characteristics of patients undergoing limb salvage versus amputation after HELET are significantly different from each other. DESIGN AND STUDY POPULATION: A prospective study of 601 patients admitted with high-energy lower extremity trauma to eight Level I trauma centers. PROCEDURES: Patients were evaluated during the initial hospitalization. They are being followed up for 24 months postinjury. Study patients are compared with the general population by using census information, population survey data, and published norms. Characteristics of patients undergoing limb salvage versus amputation are also compared. RESULTS: Most patients were male (77 percent), white (72 percent), and between the ages of twenty and forty-five years (71 percent). Seventy percent graduated from high school (compared with 86 percent nationally) (p < 0.05). One fourth lived in households with incomes below the federal poverty line, compared with 16 percent nationally (p < 0.05). The percentage with no health insurance (38 percent) was also higher than in the general population (20 percent) (p < .05). The percentage of heavy drinkers was over two times higher than reported nationally (p < 0.01). Study patients were slightly more neurotic and extroverted and less open to new experiences. When patient characteristics were compared for those undergoing amputation versus limb salvage, no significant differences were found among any of the variables (p > 0.05). CONCLUSION: In conclusion, LEAP patients differ in important ways from the general population. However, the decision to amputate verus reconstruct does not appear to be significantly influenced by patient characteristics.

Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures.

OBJECTIVE: To determine the effectiveness of exchange reamed nails for treatment of aseptic femoral delayed unions and nonunions. DESIGN: Retrospective chart review. PATIENTS: Nineteen patients admitted to the Carolinas Medical Center Level I trauma center from 1990 to 1996 for repair of femoral shaft fracture nonunion following contemporary locked nailing performed at least six months previously. These patients showed no radiographic evidence of progression of fracture healing for three months and had clinical symptoms of nonunion. INTERVENTION: Exchange reamed nails to treat ununited femoral shaft fracture. MAIN OUTCOME MEASUREMENTS: Radiographic and clinical evidence of union of the fracture or of the necessity for additional procedures. RESULTS: In 53 percent of the patients the secondary procedure resulted in fracture union, whereas in 47 percent, one or more additional procedures were required. Eight of the nine fractures that did not unite with exchange nailing united after a subsequent procedure (bone grafting, compression plating, or nail dynamization). Neither the type of nonunion, the location of the shaft fracture, the use of static versus dynamic cross-locking, nor the use of tobacco products was statistically predictive of the need for additional procedures. CONCLUSIONS: Reevaluation of routine exchange nailing as the recommended treatment for aseptic femoral delayed union or nonunion may be required. A significant number of patients who undergo reamed exchange nailing will require additional procedures to achieve fracture healing.

Evaluation of standard surgical preparation performed on superficial dermal abrasions.

OBJECTIVES: To determine the difference, if any, between the reduction of bacteria on contaminated normal skin and contaminated superficially abraded skin following standard surgical preparations at clinically relevant time points after injury. DESIGN: Prospective animal study. SETTING: Laboratory. SUBJECTS: Thirty-two New Zealand white rabbits. INTERVENTION: Two sites, two by two centimeters, one abraded and one nonabraded (control), were studied on each rabbit. Both were inoculated with encapsulated Staphylococcus aureus strain Wood 46. Four six-millimeter punch biopsies were obtained after inoculation, immediately before surgical scrub, and five minutes and then two hours after completion of the surgical scrub. The rabbits were divided into four cohort groups with surgical scrubs performed at six, twelve, twenty-four, and forty-eight hours after inoculation. Bacterial counts were determined. MAIN OUTCOME MEASUREMENTS: Numbers of bacteria on surgical sites. RESULTS: Before surgical preparation, the amount of bacteria on the normal skin (control sites) dropped significantly (p<0.02) except in the six-hour group (p<0.20). At the abraded skin sites, the bacteria flourished. The surgical scrub dropped bacterial counts at both the abraded and nonabraded skin sites significantly (p<0.05) except for the abraded site in the twenty-four-hour group (p<0.08). However in the twelve-, twenty-four-, and forty-eight-hour groups, the bacterial counts (colony-forming units) were still markedly elevated (>1x10(5) at abraded sites) when compared with the nonabraded skin sites (p<0.008) at the respective time intervals. Only at the six-hour interval were the bacterial counts reduced similarly at both the abraded and nonabraded skin sites. CONCLUSIONS: In a rabbit model the standard surgical preparation using povidone-iodine at six hours after inoculation is effective in reducing the bacterial count on abraded skin to that of surgically prepared nonabraded skin. Beyond that time, the standard surgical preparation is ineffective in reducing counts to those of nonabraded skin at similar time intervals.

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.

Pulmonary gas exchange during intramedullary fixation of femoral shaft fractures.

BACKGROUND: This study was undertaken to determine if the alveolar dead space fraction (Vd/Vt) or the alveolar-arterial oxygen gradient (A-a DO2) increased during intramedullary fixation of femoral shaft fractures. METHODS: Fifty hemodynamically stable patients with femur fractures were prospectively enrolled. Three serial measurements of Vd/Vt and A-a DO2 were obtained immediately before femoral nailing (Pre), 30 minutes after nailing (+30), and 120 minutes after nailing (+120). Vd/Vt was determined by simultaneously measuring PaCO2 and the steady-state end-tidal CO2 (PetCO2), where Vd/Vt = (1 - PetCO2/PaCO2). RESULTS: Vd/Vt before nailing was 0.09 +/- 0.09 (mean +/- SD); at +30 and +120, Vd/Vt was 0.10 +/- 0.06 and 0.08 +/- 0.07, respectively (p > 0.2; paired t test, both time points). A-a DO2 before nailing was 84 +/- 85 mm Hg, and it did not change significantly at +30 (89 +/- 69 mm Hg; p = 0.51 vs. Pre; paired t-test) or at +120 (51 +/- 45 mm Hg). No difference in data was found with analysis by fracture classification or number of reamer passes. Vd/Vt and A-a DO2, however, were both significantly increased in patients with lung contusion (n = 6) before nailing, but neither measurement increased after nailing. One patient developed fat embolism (Vd/Vt of 0.35 at Pre and 0.31 at +120), and another patient experienced postoperative pulmonary thromboembolism (Vd/Vt increased from 0.06 at Pre to 0.17 at +120). CONCLUSION: The process of femoral nailing does not cause enough pulmonary embolization to alter pulmonary gas exchange as measured by Vd/Vt and A-a DO2. If Vd/Vt is increased preoperatively, the likelihood of subsequent pulmonary dysfunction secondary to either preoperative lung injury or fat embolism is increased.

Comparison of mechanical loads produced by current intramedullary reamer systems.

OBJECTIVE: This study evaluated the mechanical loading experienced by four clinically used intramedullary reamer cutter designs to evaluate the effects of variations in speed and feed rate on reamer system performance. DESIGN: Biomechanical laboratory study. SETTING: Research laboratory. MAIN OUTCOME MEASURE: Four clinically used reamer systems with detachable cutters were tested using a computer-controlled machining system at representative reaming and drilling speeds of 250 and 750 revolutions per minute (RPM), respectively. Hard oak blocks with mechanical properties similar to cortical bone were reamed using cutter heads with diameters from nine to fourteen millimeters (in 0.5-millimeter increments) at feed rates of 1.0 and 7.6 centimeters per second. Reactive axial loads and torques were recorded and analyzed. RESULTS: All systems demonstrated reduced maximal loads/torques for small reamer sizes (9 to 10.5 millimeters) at drilling speeds rather than reaming speeds. Individual systems demonstrated measurable differences in sensitivity to alterations in operating speed, indicating that some designs are not amenable to operation at increased speeds. In tests where reamer head cutting characteristics were isolated by using identical solid drive shafts, the deeply fluted design with a long lead taper and a rounded, burrlike body consistently produced significantly lower mechanical loading at all speeds and feed rates. In addition, two of the four systems tested use a larger flex shaft diameter for reamer head sizes of thirteen millimeters or greater. There was no indication of a need to use larger flex shafts for the larger reamers, based on mechanical load/torque data for those systems. CONCLUSIONS: The tests performed demonstrate that appropriate control of reaming speeds (RPM) can be used to minimize mechanical loading for all systems. Caution should be exercised, however, so that any operational changes that reduce resistive loads and torques do not lead the surgeon to increased feed rates. Additional study is required to investigate the variable effects of increasing the operating speed of each system on localized thermal changes.

Efficacy of surgical wound drainage in orthopaedic trauma patients: a randomized prospective trial.

OBJECTIVE: To study the efficacy of closed suction drainage in clean nonemergent surgical fracture fixation or bone grafting on the extremities or pelvis. DESIGN: A prospective randomized trial. SETTING: The orthopaedic trauma service of a Level I trauma hospital. PATIENTS: Patients were older than age eighteen years and undergoing clean nonemergent surgical fracture fixation or bone grafting procedures on the extremities (excluding hands and feet) or pelvis. INTERVENTION: The application of a surgical drain. MAIN OUTCOME MEASUREMENTS: Wound drainage, edema, hematoma and erythema, dehiscence, infection, and need for surgery or readmission were followed for six weeks. A univariate analysis with Student's t test for continuous variables and chi-squared analysis for all categorical data were used, with a p value of < or = 0.05 considered statistically significant. RESULTS: A total of 202 patients were randomized to 102 patients with no drain and 100 patients with a drain. There was no significant difference between the groups with regard to injury severity, systemic disease, age, body weight, physical status, or estimated blood loss. There was no significant difference between the drain and no-drain groups in any of the parameters evaluated. CONCLUSION: There is no significant difference between drained and nondrained wounds in clean, nonurgent orthopaedic trauma surgery. It appears that drainage systems can be safely eliminated in this group.

Does bacteremia occur during high pressure lavage of contaminated wounds?

The risk of bacteremia secondary to high pressure lavage of contaminated wounds was assessed. Twenty canines were divided randomly into four treatment groups. A 10-cm incision was made over the left shoulder of each dog. The deltoideus muscle was disrupted and traumatized. Groups A and B (n = 8) had wound contamination with 1.4 x 10(9) Staphylococcus aureus followed 75 minutes later by high pressure lavage or bulb syringe irrigation, respectively. Groups C and D (n = 2) had no contamination, followed by the same treatment. Bacterial counts were obtained before and after wound irrigation. Blood cultures were obtained before, during, and 15 minutes after irrigation. Positive control cultures were obtained during injection of bacteria into the antecubital vein. A detectable bacteremia did not occur during or after high pressure lavage or bulb syringe irrigation of acute contaminated wounds but did occur in 18 of 20 positive controls. Bacterial levels were reduced by an average of 70% +/- 10% by high pressure lavage and 44% +/- 50% by bulb irrigation. Reduction of wound bacteria was achieved more consistently with high pressure lavage than with bulb syringe irrigation.

Removal of a broken Synthes proximal spiral blade.

Use of cephalomedullary nails is an option for treatment of subtrochanteric femur fractures. However, the magnitude of bending forces in this area of the femur often can lead to implant failure before union. We report on a case of hardware failure of a specific device (Synthes spiral blade) and a method for removal.

Effects of surgical approaches for acetabular fractures with associated gluteal vascular injury.

OBJECTIVES: To examine the viability of the abductor muscles following extensile exposures to the acetabulum in the presence of superior gluteal artery (SGA) or vein (SGV) injury. DESIGN: In vivo animal study. INTERVENTION: Twenty-two dogs underwent either an extensile or combined two-incision acetabular approach; either the SGA, the SGV, or no vessel was ligated. MAIN OUTCOME MEASUREMENTS: Blood flow to the affected gluteal region was evaluated by angiography, laser Doppler flowmetry, and fluorescent microspheres, and histologic and wet weight analyses were performed on the abductor muscles. RESULTS: Complete ischemic necrosis of the abductor muscles did not occur in any specimen; however, there were statistically significant reductions in immediate postoperative gluteal muscle perfusion (-47 percent, p < 0.01), loss of abductor muscle mass (-41 percent, p < 0.001), and histologic evidence of moderate to severe necrosis in five of seven specimens with extensile exposures and SGA ligation (p = 0.01). Extensile exposure and SGV ligation also caused a significant loss of muscle mass (-25 percent, p < 0.02), with moderate to severe necrosis occurring in four of seven specimens (p < 0.04). Dogs with SGA ligation undergoing the two-incision approach had no significant changes in muscle mass (-3 percent) or perfusion. Moderate to severe necrosis occurred in only one of four specimens. CONCLUSIONS: This study fails to support the hypothesis that extensile approaches to complex acetabular fractures eliminate abductor collateral circulation when performed in the presence of SGA injury.

Incidence of sciatic nerve injury in operatively treated acetabular fractures without somatosensory evoked potential monitoring.

OBJECTIVE: The authors investigated the incidence of sciatic nerve injury associated with the operative repair of acetabular fractures without somatosensory evoked potential (SSEP) monitoring. DESIGN: Retrospective case review of prospectively documented pre- and postoperative physical examinations. SETTING: A level I trauma hospital. PATIENTS: All the cases were reviewed of patients with open reduction and internal fixation of acetabular fractures who underwent posterior or extensile approaches (129) performed by the three senior authors from January 1991 through March 1995. INTERVENTION: Intraoperative SSEP monitoring was not used during any of the procedures. The procedures included sixty-five Kocher-Langenbeck approaches, thirty-four combined Kocher-Langenbeck and iliofemoral approaches, four extended iliofemoral approaches, and four triradiate approaches. RESULTS: One case of iatrogenic nerve injury resulted in a sensory deficit. No patient suffered an exacerbation of a preexisting nerve injury. CONCLUSION: The results of this study indicate that open reduction and internal fixation of acetabular fractures, using current techniques with visualization and protection of the sciatic nerve, can reduce the incidence of neurologic injury to a negligible level. There does not appear to be justification for the addition of SSEP or electromyograph modalities to the operative routine of experienced surgeons.

Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study.

Multiply injured patients (an Injury Severity Score of 17 points or more) who were admitted to one of two level-I regional trauma centers between 1983 and 1994 because of a fracture of the femoral shaft with a thoracic injury (an Abbreviated Injury Scale score of 2 points or more) or without a thoracic injury were studied retrospectively. The patient populations and the protocols for the treatment of trauma were similar at the two centers; however, the centers differed with regard to the technique that was used for acute stabilization of the fracture of the femoral shaft. At Center I intramedullary nailing with reaming was used in 217 (95 per cent) of the 229 patients, whereas at Center II a plate was used in 206 (92 per cent) of the 224 patients. This difference was used to investigate the effect of acute femoral reaming on the occurrence of adult respiratory distress syndrome in multiply injured patients who had a chest injury. Three groups of patients were evaluated: those who had both a fracture of the femur and a thoracic injury, those who had a fracture of the femur but no thoracic injury, and those who had a thoracic injury without a fracture of the femur or the tibia. The third group was studied at each center to determine if there was a difference between the institutions with regard to the rate of adult respiratory distress syndrome. Patients who had diabetes, chronic obstructive pulmonary disease, asthma, hepatic or renal failure, or an immunosuppressive condition were excluded from the study. The records were abstracted to determine the Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Score for each patient. Requirements for fluid resuscitation were calculated for the first twenty-four hours; these included the number of units of packed red blood cells, fresh-frozen plasma, and platelets that were transfused and the volume of crystalloid that was used. The duration of intubation, the duration of hospitalization, and the occurence of adverse outcomes (death, multiple organ failure, adult respiratory distress syndrome, pneumonia, and pulmonary embolism) were determined for each patient. The groups of patients were analyzed as a whole and then were stratified into subgroups (according to whether or not they had a thoracic injury and whether the Injury Severity Score was less than 30 points or 30 points or more) to determine if the type of fixation of the femoral fracture affected the rate of adult respiratory distress syndrome or mortality. Logistic regression models were used to analyze the data. The over-all occurrence of adult respiratory distress syndrome in the 453 patients who had a femoral fracture was only 2 per cent (ten patients). The rates of adult respiratory distress syndrome for the patients who had a thoracic injury but no femoral fracture (eight [6 per cent] of 129 patients at Center I, compared with ten [8 per cent] of 125 patients at Center II) did not differ between centers, suggesting that the institutions were comparable in their treatment of multiply injured patients. The occurrence of adult respiratory distress syndrome in the patients who had a femoral fracture without a thoracic injury did not differ substantially according to whether the fracture had been treated with a nail (118 patients) or a plate (114 patients). Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar regardless of whether nailing with reaming (117 patients) or a plate (104 patients) had been used. The use of intramedullary nailing with reaming for acute stabilization of fractures of the femur in multiply injured patients who have a thoracic injury without a major comorbid disease does not appear to increase the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.