Well-leg compartment pressures during hemilithotomy position for fracture fixation.

OBJECTIVE: To evaluate the relationship between the well-leg compartment pressures and time during hemilithotomy position for fracture fixation. DESIGN: Prospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Ten patients who underwent intramedullary nailing of a fractured femur in the hemilithotomy position (with a well-leg holder). INTERVENTION: Continuous pressure monitoring was achieved with in-dwelling slit catheters inserted into the calf compartments of the well leg. Baseline measurements were obtained in the supine position. After the leg was placed in the hemilithotomy position, compartment pressures were monitored throughout surgery. MAIN OUTCOME MEASUREMENTS: Calf compartment pressures at baseline, during hemilithotomy position, and post-hemilithotomy were compared. The association between body mass index and compartment pressure was analyzed. RESULTS: A consistent pattern was observed between compartment pressures and time. The curve was that of a step function in which the pressure increased as soon as the leg was placed in the well-leg holder and remained elevated until the leg was taken down. The pressure jumped from a baseline of 9.2 to 27.3 millimeters of mercury (mm Hg) (p<0.0001). While in the hemilithotomy position, the leg pressure trended slightly upward. Once the leg was taken down, the pressure immediately returned to a near-baseline level of 8.1 mm Hg (p<0.0001). A significant correlation was also found between the body mass index and leg pressure (R2 = 0.713; F = 0.002). CONCLUSIONS: The use of the well-leg holder to maintain hemilithotomy position increases the calf compartment pressures dramatically and significantly. Therefore, we recommend avoiding this position for fracture fixation in at-risk patients.

Computed tomographic scanning of cervical spine fractures: does it influence treatment?

OBJECTIVE: To determine whether the superior sensitivity of computed tomography (CT) results in changes in treatment plans for cervical spine fractures that have been diagnosed on plain films alone. DESIGN: Retrospective review of radiographic studies for cervical spine trauma. SETTING/PARTICIPANTS: An orthopaedic spine surgeon (SS), an orthopaedic traumatologist (OT), an orthopaedic spine fellow (SF), and an orthopaedic chief resident (CR) were independently presented thirty-nine cases of cervical spine trauma imaged with adequate plain radiographs and with CT. MAIN OUTCOME MEASURES: Agreement was measured by calculation of kappa coefficients. RESULTS: The detection rate of total fractures on plain radiographs alone ranged from 47 percent to 71 percent, and the diagnosis changed an average 53 percent of cases. Change in treatment plans ranged from 10 percent (SS) to 46 percent (CR) of cases. Of these changes, undertreatment occurred as follows: SS =3 percent, OT =8 percent, SF =36 percent, and CR = 46 percent. The mean kappa coefficient for intraobserver agreement of treatment plans was 0.69. The experienced observers demonstrated "excellent" agreement with an average kappa coefficient of 0.85, whereas the mean coefficient for inexperienced observers was 0.54 or "moderate" agreement. Complete diagnostic agreement occurred between the experienced observers after review of both the plain films and CT scans. The interobserver agreement of treatment plans for the experienced observers increased from 0.79 to 0.88. CONCLUSIONS: CT scanning afforded additional information for all observers. Experienced observers can reliably determine treatment plans for cervical spine trauma diagnosed on plain films alone, whereas inexperienced observers are less reliable. For the experienced observers, interobserver agreement on treatment plans increased after the addition of CT.

Impact of CT scan on treatment plan and fracture classification of tibial plateau fractures.

OBJECTIVE: To evaluate the interobserver and intraobserver agreement for both treatment plan and fracture classification of tibial plateau fractures using plain films alone and with computed tomography (CT) scans. DESIGN: Prospective study to assess the impact of an advanced radiologic study on the agreement of treatment plan and fracture classification of tibial plateau fractures. SETTING/PARTICIPANTS: Two orthopaedic traumatologists, two orthopaedic residents, and two skeletal radiologists were presented with twenty-one cases of tibial plateau fractures imaged with plain films and with CT scans. MAIN OUTCOME MEASURES: Agreement was measured using kappa coefficients. RESULTS: Using plain films alone, the mean interobserver kappa coefficient for classification was 0.62, which decreased to 0.61 after addition of CT scans. Using plain films alone for formulating a treatment plan, the mean interobserver kappa coefficient was 0.58, which increased to 0.71 after addition of CT scans. The mean intraobserver kappa coefficient for fracture classification using plain films was 0.70, which increased to 0.80 with addition of CT scans. The mean intraobserver kappa coefficient for treatment plan based on plain films alone was 0.62, which increased to 0.82 after addition of CT scans. Class was changed in an average of 12 percent of cases after addition of CT scans. Treatment plan was changed an average of 26 percent of the time after addition of CT scans. CONCLUSION: Addition of CT scans to plain roentgenograms increases the interobserver and intraobserver agreement on treatment plan.

Treatment of considerations in patients with compartment syndrome and an inherited bleeding disorder.

In addition to consultation with an experienced hematologist, the following are recommendations regarding compartment syndrome in a patient with an inherited bleeding disorder. Von Willebrand's Disease. Humate-P (rich in von Willebrand factor) is the replacement therapy of choice for surgical procedures in patients with von Willebrand's disease. In general, in the perioperative period, factor VIII levels between 50% and 100% are ideal with a gradual tapering to maintain levels at 50% for approximately 2 weeks. Adjuncts to therapy are DDAVP and EACA. Hemophilia A. During the initial evaluation and with measurement of compartment pressures, factor VIII replacement to levels in the range of 40% to 60% of normal is appropriate replacement therapy. For fasciotomy, however, factor VIII levels greater than 50% to 100% are required. In patients who have developed antibodies to factor VIII, a number of options are available. With low titers of factor VIII inhibitor, higher doses of factor VIII may be successful in overriding the inhibitor. In patients with higher titers of inhibitor, activated factor VII or porcine factor VIII is recommended. Hemophilia B. Highly purified factor IX replacement aimed at keeping factor levels between 50% and 100% in the perioperative period, followed by maintenance at 50% for approximately 2 weeks, is optimal management. Treatment Algorithm: The Figure outlines an algorithm to aid in the diagnosis and treatment of compartment syndrome in the patient with an inherited bleeding disorder. In a suspected case of compartment syndrome due to a soft-tissue hemorrhage or injury, factor replacement as outlined above should be initiated. Unequivocal clinical findings in the normal patient usually would be an indication to proceed to fasciotomy without obtaining compartment pressures. In the patient with an inherited bleeding disorder, however, factor replacement and subsequent normalization of the clotting cascade may help lowe compartment pressures. Therefore, we advocate obtaining initial pressures even with clinical findings of an acute compartment syndrome. At our institution, we advocate using an automated handheld pressure monitor (Stryker, Ontario, Canada) or the needle injection technique as described by Whitesides et al. In interpreting the obtained pressures, we choose to use the guidelines as described by Heppenstall et al. Briefly, Heppenstall et al determined that the pressure threshold at which cellular damage occurred was related more closely to the difference between the mean arterial blood pressure and compartment pressure than with the absolute compartment pressure alone; this measurement is called delta P. If delta P is > 30 mm Hg, then one should continue factor replacements and perform serial clinical and pressure examinations. Pressures should be taken every hour for 2 hours total. If the patient worsens in either respect, then the physician should enter the other limb of the algorithm for delta P < 30 mm Hg. For the patient with a delta P < 30 mm Hg, the amount of time since onset of symptoms must be considered. Since the patient may improve with adequate factor replacement, a delta P < 30 mm Hg mercury does not dictate automatic fasciotomy. An adequate time trial of replacement therapy may be attempted. In patients whose pressures do not begin normalizing, we advocate proceeding to fasciotomy. Patients who begin to normalize pressures during a 2-hour trial can be followed with serial clinical and pressure examinations. Any worsening in either scenario is an indication for fasciotomy; otherwise, observation and factor replacement may be continued. After initial decompression, staples may be placed in both wound edges with an elastic vascular loop woven between the two edges in a "shoelace" pattern. Then while waiting for closure, the loops can be gradually tightened at the bedside. Definitive closure should be attempted around the fifth postoperative day. All closure techniques should be pre

Compartment syndrome after isolated perfusion of the leg: a case report.

The authors present a case of a lower leg compartment syndrome that developed after a regional chemotherapy technique was used for recurrent melanoma of the foot in a 74-year-old woman. The diagnosis was based on the results of physical examination, with confirmation by intracompartmental pressures. Prompt consultation of orthopedic surgeons and fasciotomy helped avoid potentially crippling sequelae.

The effect of antecedent ischemia on the tolerance of skeletal muscle to increased interstitial pressure.

This study used an experimental model (canine hind limb) of compartment syndrome, monitored with phosphorus 31 nuclear magnetic resonance spectroscopy, to determine the pressure threshold for metabolic deterioration in skeletal muscle previously subjected to ischemia. Our results show that muscle subjected to 6 h of antecedent ischemia has a lower tolerance to increased tissue pressure than otherwise normal muscle. The threshold was found to occur at a delta P (difference between mean blood pressure and limb compartment pressure) of 40 mm Hg, compared with a delta P of 30 mm Hg in muscle that was not subjected to antecedent ischemia. In addition, once the critical pressure threshold of postischemic muscle was crossed, there was a more rapid rate of high-energy phosphate depletion than that seen in normal muscle pressurized to the same degree beyond its delta P threshold. For compartment syndromes that appear after relatively atraumatic ischemia (i.e., drug overdose-induced limb compression, proximal arterial trauma causing distal limb ischemia, etc.), of < or = 6 h, fasciotomy should be performed at a delta P < or = 40 mm Hg. Compartment pressure elevation after local blunt muscle trauma and ischemia may well require earlier or even prophylactic fasciotomy. Fasciotomy in ongoing postischemic compartment syndromes should be considered particularly urgent owing to the rapid rate of metabolic deterioration that is observed once the critical delta P threshold is crossed. The type of compartment syndrome should always be considered when interpreting tissue pressure measurements as indications for fasciotomy.

Tibial nonunion treated with direct current, capacitive coupling, or bone graft.

Two hundred seventy-one tibial nonunions of average duration of 23.5 months (range, 9-69 months) were treated with direct current (167 patients), capacitive coupled electrical stimulation (56 patients), or bone graft surgery (48 patients). Logistic regression analysis was used to compare heal rates among the 3 treatment methods, to identify risk factors adversely affecting the heal rate, and to predict the probability of successful healing of a nonunion of any given risk profile treated with each of the 3 forms of therapy. Seven risk factors were identified: duration of nonunion, prior bone graft surgery, prior electrical treatment, open fracture, osteomyelitis, comminuted or oblique fracture, and atrophic nonunion. When no risk factors were present, there were no significant differences among the 3 treatment methods. As progressively more risk factors were present, the predicted heal rates decreased significantly regardless of the treatment method. Some differences among the treatment groups did appear in the heal rates: bone graft surgery yielded a worse heal rate when there was a previous bone graft failure, and capacitive coupling had a worse heal rate in the presence of an atrophic nonunion.

Compartment syndrome of the forearm and hand.

Compartment syndrome in the hand and forearm is a serious and debilitating complication of crush injury. Pain with passive motion is the most reliable physical finding; however, compartment pressure measurement is the only truly reliable method of diagnosis. Immediate and adequate decompression will prevent the development of Volkmann's ischemic contracture and its associated severe loss of function in the affected extremity.

Immediate internal fixation of low-velocity gunshot-related femoral fractures.

Fractures caused by gunshots are increasingly common in urban hospitals and trauma centers. The rising incidence and complexity of these injuries present difficult management problems and health care burdens. In a 3-year period, from 1989 through 1991, 21 patients with femoral shaft fractures from low-velocity bullets were treated with intramedullary fixation within 15 hours of admission. Eighteen patients were available for follow-up. The fractures had healed in all patients. Average hospitalization for an isolated injury was 7 days. There were no complications related to immediate internal fixation. Immediate internal fixation of femoral shaft fractures caused by low-velocity gunshots can be performed in an efficient and cost effective manner.

Quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lower-extremity amputation.

One hundred nine patients with long-bone fracture nonunion, chronic refractory osteomyelitis, and posttraumatic amputation were evaluated to assess the impact of chronic disability on the quality of life. The quality of life parameters were defined by a functional assessment instrument, the Arthritis Impact Measurement Scale (AIMS), and a Psychosocial Adjustment to Illness Scale (PAIS). A spouse PAIS self-report instrument was administered to assess the psychosocial adjustment of spouses or significant others. A final questionnaire was developed to determine the reasons, in order of their importance, for either continuing medical therapy or accepting amputation. The PAIS scores differed significantly between osteomyelitis patients and nonunion or amputation patients. The presence or absence of pain produced significant differences in AIMS and PAIS scores of nonunion and osteomyelitis patients. Subscale analysis of AIMS scores showed significant differences among the three groups with respect to health perception and scale of orthopaedic problem. The osteomyelitis patients were more severely affected than the nonunion or amputation patients. The PAIS was unable to detect any statistically significant differences in psychosocial adjustment of the spouses of patients in each of the three population groups. The most frequent reason for continuing medical and surgical management of nonunion and osteomyelitis was hopeful expectation for cure. The group who chose amputation did so in an attempt to put an end to the need for medical and surgical treatment. Differences in psychosocial and functional ability were related to disease diagnosis, pain, status of fracture healing, and timing of amputation. This study provides further insight into the quality of life experience for patients with long-term orthopaedic problems.

Diagnoses and staging. Osteomyelitis and prosthetic joint infections.

The diagnoses of osteomyelitis and prosthetic joint infections are usually made on the basis of clinical, laboratory, and radiographic examination. The diagnostic studies presently employed to diagnosis and assess osteomyelitis and prosthetic joint infections are described. A universally applied classification system for stratifying osteomyelitis and prosthetic joint infection would provide a framework for the evaluation of medical and surgical treatment efficacy. Such a system would enable treatment results to be compared among institutions. Staging systems currently being used are described.

Comparison of the clinical efficacy and tolerance of gentamicin PMMA beads on surgical wire versus combined and systemic therapy for osteomyelitis.

These data do not prove a statistical superiority of conventional antibiotics or Septopal in the treatment of chronic osteomyelitis. This result, however, is complicated by the biased data set represented by the combined treatment. The data do suggest that cost of treatment is considerably less in patients who are treated with local antibiotics (i.e., Septopal) alone. The rate of adverse experiences was directly related to the use of parenteral antibiotics, with higher rates of adverse experiences in the conventional and combined treatment groups. Furthermore, the Cierny-Mader Physiologic Class had the best correlation with outcome, suggesting that host factors are probably of critical importance in inducing remission of chronic osteomyelitis. This protocol was not designed to test the role of debridement in the treatment of osteomyelitis: it was assumed that debridement would be the same in both groups. It is the investigators' strong opinion, however, that adequacy of debridement was an important determinant in quiescence or recurrence in the study patients. Similarly, there was no strict control for adequacy of soft-tissue coverage provided by local or distant tissue transfer. Again, the investigators believe that adequacy, including viability and durability, of soft-tissue covering was an important determinant for the end result in these patients. Other covariants such as smoking, history, nutritional status, and other measures of general health will be added to this model when data are available. This analysis will allow definition of the appropriate clinical situations in which use of Septopal alone or combined with parenteral antibiotic is indicated.

Chronic exertional compartment syndrome: correlation of compartment pressure and muscle ischemia utilizing 31P-NMR spectroscopy.

In the past 5 years, a great deal of time and effort has been expended in an effort to better define clinical, anatomic, and laboratory parameters of CECS. It is now a well-recognized entity and one that can be readily resolved with fasciotomy. But the reasons for predisposition and the pathophysiologic mechanisms remain obscure. It appears, however, that basing the decisions for fasciotomy on clinical characteristics alone leads to overdiagnosis and excessive surgery. In this series, almost 50% of the referred subjects failed to demonstrate adequate laboratory criterion for the diagnosis of CECS. Fasciotomy in these patients may have effected a cure, but the reasons may be unrelated to increased intracompartmental pressure. Furthermore, in the laboratory diagnosis of CECS, the rate of return to resting compartment pressure following exercise seems more accurate than reliance on resting pressure alone. 31P-NMR has proved valuable in the dynamic assessment of muscle ischemia as reflected by relative PCr concentrations. Finally, although a mechanism explaining the source of pain has not been established by this study, it appears that ischemia is not a significant factor.

Compartment syndrome complicating prolonged use of the lithotomy position.

Two patients with three postoperative calf compartment syndromes, which followed prolonged lithotomy positioning, will be presented. Potential physiologic mechanisms are described, and a review of current cases in literature are summated.

Psychosocial, functional, and quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lower extremity amputation.

One hundred nine patients with long-bone fracture nonunion, chronic refractory osteomyelitis, or posttraumatic amputation were evaluated for the impact of chronic disability on quality of life, as measured by the Arthritis Impact Measurement Scale (AIMS) and the Psychosocial Adjustment to Illness Scale (PAIS). A self-administered PAIS for spouses assessed psychosocial adjustment of spouses or significant others. A final questionnaire ranked the reasons for either continuing medical therapy or accepting amputation. The PAIS scores differed significantly between osteomyelitis patients and both nonunion and amputation patients (p less than .05). The presence or absence of pain produced significant differences in AIMS and PAIS scores of nonunion and osteomyelitis patients (p less than .05). Subscale analysis of AIMS scores revealed significant differences among the three groups in health perception and scale of orthopedic problem: osteomyelitis patients were more severely affected than nonunion or amputation patients. The PAIS detected no statistically significant difference in psychosocial adjustment of spouses of patients in the three population groups. The most common reason for continuing medical and surgical management of nonunion and osteomyelitis was expectation for cure. The amputee group chose ablation to avoid further treatment. Differences in psychosocial and functional ability were related to disease diagnosis, pain, status of fracture healing, and timing of amputation.

A prospective assessment of nutritional status and complications in patients with fractures of the hip.

A group of 40 consecutive patients with hip fractures were studied and confirmed to have a high incidence of protein-calorie malnutrition. The prospective nutritional assessment performed for this study included: serum albumin, serum transferrin, anthropometric measurements, skin testing for delayed hypersensitivity, total lymphocyte count, and a 24-h urine collection for metabolic and nitrogen balance determinations. At 3 months after their hip fracture, 37.5% returned to their premorbid ambulatory status; 42.5% sustained a decrement in their ambulatory status or independence; 12.5% died; 7.5% were lost to follow-up. Of the nutritional parameters studied, albumin was significantly associated with mortality (p = 0.004). Considering those patients with an albumin less than 3.0, a mortality rate of 70% was observed in follow-up (maximum of 11 months), compared with a mortality rate of 18% in patients with an albumin greater than or equal to 3.0. It is concluded that the serum albumin has value as a nutritional index without specialized nutritional parameters, and that a more aggressive approach to nutritional support is needed for the hypoalbuminemic patient with a hip fracture, particularly for those with a serum albumin below 3.0.

Treatment of chronic osteomyelitis complicating nonunion and segmental defects of the tibia with open cancellous bone graft, posterolateral bone graft, and soft-tissue transfer.

Forty-two consecutive patients with chronic osteomyelitis complicating persistent tibial nonunion and chronic osteomyelitis complicating tibial fracture with segmental bone loss were treated from January 1979 through December 1986 using a protocol including either open cancellous bone grafting (Friedlaender-Papineau technique), posterolateral bone grafting (Harmon technique), or local or microvascular soft-tissue transfer before cancellous bone grafting. Each patient had undergone surgical debridement and intravenous antibiotic therapy before inclusion in this study. Patients were classified using a staging system which included consideration of anatomic location of the infection within the bone; extent of bone involvement; quality of soft-tissue envelope and vascular integrity; and generalized host status. The overall success rate for arresting the osteomyelitis and healing the nonunion was 62% (26/42). If the six patients who refused additional bone graft surgery, the one patient who represented poor patient selection, and the patient who refused ankle arthrodesis are eliminated, the success rate for healing of the nonunion and resolving the osteomyelitis in this difficult patient population is: open bone cell graft, 66% (12/18); soft-tissue transfer 87.5%, (7/8); and posterolateral bone grafting, 87.5% (7/8). Use of a standardized classification system allows comparison of treatment results. Adequate debridement is crucial in treating osteomyelitis complicating established long bone fractures and nonunions. Determining the extent of debridement has proven to be the single most difficult aspect technically. Patient selection and pretreatment education are crucial. Caring for these patients is not only labor intensive and demanding of personnel and hospital resources, but demanding of the patients as well.

Neutropenia complicating parenteral antibiotic treatment of infected nonunion of the tibia.

Fifty patients with posttraumatic tibial nonunion complicated by chronic refractory osteomyelitis were treated with intravenous antibiotics. Fifteen patients (30%) experienced 18 episodes of leukopenia; seven of these patients became neutropenic and three became severely neutropenic. No patient became neutropenic prior to the 20th day of antibiotic therapy. The classic findings of fever, pruritus, maculopapular rash, and eosinophilia did not correlate with either the onset or the severity of the neutropenia. Neutropenia can develop precipitously. Prevention of neutropenia is difficult in a patient population receiving long-term antibiotic therapy. Regular monitoring of the white blood cell count and differential cell count minimizes the risk of developing prolonged, severe neutropenia with potential complications. No patient in this series had any serious or infectious complication secondary to neutropenia.