Surgical reconstruction of late pelvic post-traumatic nonunion and malalignment.

We have retrospectively reviewed the clinical and radiological results in 204 consecutive adult patients who had surgical correction of 70 late post-traumatic pelvic nonunions and 134 malalignments. The deformed pelvises were subdivided into united (true), unstable, ununited, and partially stable malalignments with heterotopic bone. The principal complaints were of pain, pelvic instability, sitting imbalance, and apparent limb-length discrepancy. After surgery, 195 patients (96%) achieved a primary union and 144 (71%) had slight, intermittent or no pelvic pain, while pelvic instability was entirely eliminated. Overall, 131 patients (64.2%) were extremely satisfied, 58 (28.4%) were satisfied and 15 (7.4%) were unsatisfied. After reconstruction of the malaligned pelvises, 67 results (50%) were anatomical, 47 (35%) were satisfactory and 20 (15%) were unsatisfactory. For a pelvic nonunion with local osteopenia and malalignment, stabilisation of all three pelvic columns is recommended. True pelvic (united) malunions were the most satisfactorily realigned and had the fewest complications. Ununited and unstable malalignments, especially those with heterotopic bone, had the poorest corrections and the most neurological complications. A therapeutic alternative, by the local resection of a symptomatic bony prominence, and fixation in situ of a posterior pelvic nonunion, gives highly effective symptomatic relief with fewer complications. Despite this, many patients had persistent low back pain.

Primary total hip arthroplasty after acetabular fracture.

In most cases, when THA is performed after an acetabular fracture, it is done to manage secondary degenerative change or, possibly, osteonecrosis of the femoral head. Secondary complicating factors may be encountered during the THA. After initial nonsurgical treatment of an acetabular fracture, an occult or frank acetabular nonunion and malunion are not uncommon and may extend to the residual pelvic ring. After surgical treatment, intrusive hardware, heterotopic bone, dense scar tissue, ischemic muscle or bone, and occult infection are additional hazards that may be encountered. When acute sciatic nerve palsy, whether induced traumatically or iatrogenically, accompanies the initial acetabular injury, the palsy is likely to be exacerbated during a subsequent THA. A careful clinical and radiographic evaluation is needed, along with the formulation of a detailed surgical strategy. The need for specialized arthroplasty instruments, fixation devices, and autograft or, occasionally, allograft has to be identified. When heterotopic bone is evident, an extensile approach may be needed to allow adequate exposure for its complete removal. After a bone defect and/or a nonunion with displacement has been characterized, one or more strategies for obliteration of the defect are considered; these include the use of impaction grafting, a structural graft, a cup inserted with multiple screws, mesh, or a suitable ring or other fixation device. Evaluation of results has shown that, overall, the late outcome of THA after acetabular fracture is inferior to that of arthroplasty performed because of degenerative arthritis. Although open reduction and internal fixation of an acute acetabular fracture was previously hypothesized as an effective way to improve the anticipated late outcome of THA by the elimination of a large fracture gap or the prevention of a potential nonunion, current observations do not support that hypothesis. An initial open reduction may compromise the outcome of a subsequent THA by compromising the blood supply of the acetabulum and by initiating the formation of scar tissue, heterotopic bone, or an occult or frank infection. For a highly selected group of especially severe acetabular fractures, particularly those in elderly patients, THA appears to be a promising therapeutic alternative.

Partial resection of the scapula and a release of the long head of triceps for the management of Sprengel's deformity.

Previous surgical methods to address Sprengel's deformity by an attempted relocation of the scapula have achieved a limited functional improvement. A novel method was devised that includes a partial scapular resection, a removal of any omovertebral communication, and a release of the long head of triceps from the scapula. The results of eight cases are presented in which this method was used on 5 males and 3 females patients (age range, 19 months to 9 years). Early postoperative, active-assisted motion exercises for the patients were encouraged. On average, flexion improved from 100 degrees to 175 degrees and abduction improved from 90 degrees to 150 degrees. In one patient, a second operation was performed to remove an exostosis that followed the primary procedure. Initially, two keloid scars followed the use of a curvilinear incision. However, subsequently, this problem was eliminated by the use of a transverse incision. The new method seems to provide highly favorable functional and cosmetic results with a low morbidity.

A biodialysis system for liver support tested in a porcine hepatic failure model.

BACKGROUND: A practical liver support system for patients in fulminant hepatic failure (FHF) remains a needed therapeutic modality. A new method of bioartificial liver support, the liver biodialysis system (LBDS), is described. METHODS: Porcine hepatocytes, removed from direct contact with the treated subject's circulation, are in culture in a bioreactor which is combined in a dialysis circuit for patient treatment. The LBDS was tested in a porcine ischaemic hepatic failure model. RESULTS: The viable hepatocyte content of the bioreactor was 2.49 +/- 0.72 x 10(10). Cells remained viable in culture throughout the experiments (30 +/- 3 h) without evidence of immunological damage. A decrease in the degree of accumulation in the blood of ammonia (P < 0.02) and of 14 amino acids (P < 0.001) was achieved by the LBDS. Cerebral perfusion pressure was maintained at significantly higher levels in LBDS-treated animals (P < 0.05). CONCLUSIONS: In the LBDS, hepatocytes in large numbers and satisfactory culture conditions in a bioreactor have sustained viability and function. When combined in a dialysis circuit for the treatment of FHF pigs, immune reactions between the blood and hepatocytes were prevented and beneficial metabolic effects were observed.

Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone.

The incidence of acetabular fractures in the elderly has recently shown a marked increase due to the combination of greater longevity for the population as a whole and a relative decrease in the incidence of alcohol-related trauma in younger adults. The compromised physiologic reserve and the diminished healing capacity of the typical elderly patient have an adverse effect on the potential for a favorable clinical outcome. The presence of osteopenic bone or degenerative arthritis and the effects of previous radiation therapy to the hip and pelvis hamper diagnostic imaging and the utility of some treatment alternatives that were designed primarily for younger patients. The diverse clinical presentations include major polytrauma, minor trauma, and insufficiency fractures. An assessment of the prior health and functional status of the patient is crucial in determining the optimal therapeutic protocol. Treatment options vary according to the clinical presentation and include conservative methods, percutaneous fixation in situ, open reduction, and acute total hip arthroplasty. The feasibility of acute total hip arthroplasty rests on the use of newly developed techniques for minimally invasive stabilization of the acetabular fracture with cables and the application of morselized or structural autograft harvested from the femoral head. Whichever surgical method is chosen, the objective is rapid mobilization of the patient on a walker or crutches. Late complications that may occur after nonoperative or operative treatment include posttraumatic arthritis, nonunion, wound infection, and heterotopic bone formation.

Developments in blood management: the potential therapeutic role for epoetin alfa in orthopedic trauma.

Orthopedic trauma is a major source of morbidity and mortality in the United States and other countries. Major orthopedic trauma often results in significant blood loss, which is the most common cause of shock in the trauma setting. Transfusion of allogeneic blood and blood products may be used to maintain blood pressure but may not be the most effective therapy for the acute anemia that results from trauma-induced hemorrhage. Because acute anemia can interfere with successful and timely rehabilitation of these patients, it is important to be aggressive in treating anemia. One approach is to administer Epoetin alfa to stimulate erythropoiesis. A pilot study is currently in progress to test the efficacy of this approach in major trauma patients.

Positive biochemical effects of a bioartificial liver support system (BALSS) in a porcine fulminant hepatic failure (FHF) model.

This study describes biochemical changes in the plasma and blood of pigs with devascularised livers treated in a bioartificial liver support system (BALSS). Porcine hepatic cells were incubated with collagen-coated dextran microspheres (CDM) for 3 hours and the medium tested to determine cellular metabolic activity. Incubation continued for a further 18 hours during which the hepatic cells attach to the CDM. The CDM-attached cells were inoculated into a hollow fibre bioreactor which was part of an extracorporeal support system. Hepatic cell content of the bioreactor was 6 x 10(9) cells. The system was tested in a controlled trial in pigs prepared in a surgical model of fulminant hepatic failure (FHF). When plasma from FHF pigs was circulated through the device containing hepatic cells, there was significantly less increase in the accumulation of ammonia and most amino acids, together with a decrease in plasma lactate and of one amino acid, compared to control experiments when hepatic cells were excluded. We conclude that primary porcine hepatocytes can contribute beneficial metabolic function in a BALSS.

Stabilization of an acetabular fracture with cables for acute total hip arthroplasty.

A critical stage of total hip arthroplasty for an acute acetabular fracture where extensive comminution, impaction, and osteopenia thwart the application of conventional open or closed methods, especially in the elderly, is stable fixation of the acetabulum. The use of 2-mm braided cables permits effective immobilization of the fracture for use in conjunction with a hybrid arthroplasty. The method is consistent with the use of a conventional arthroplastic incision and is suitable for other applications including the fixation of periprosthetic fractures, bulk allografts, and conventional acetabular fractures.

ABO blood group incompatibility in liver transplantation: a single-centre experience.

BACKGROUND: For most organ transplantation (Tx), ABO blood group incompatibility (ABOI) is an absolute contraindication because of the high incidence of hyperacute rejection (HAR). While HAR occurs in ABOI liver Tx (LTx), it is known that some liver grafts can be accepted. METHODS: ABO-incompatible (ABOI) liver allografts were used in seven of 355 orthotopic LTx operations performed at our institution over a 10-year period. All seven recipients were in fulminant hepatic failure (FHF) prior to Tx. RESULTS: Following Tx, all grafts functioned immediately. One patient died without recovering consciousness. Six patients recovered consciousness following Tx but three patients subsequently required re-transplantation (with ABO-compatible grafts (ABOC)) because of severe acute rejection (2) and chronic rejection (1). Hyper-acute rejection did not occur. All six patients are now well, with a mean survival of 61.5 months. When compared to 36 other FHF patients who received ABOC grafts, graft survivals were 3/7 (43%) for ABOI versus 23/36 (64%) for ABOC (P = not significant (NS)). Patient survivals were 6/7 (85.7%) for ABOI patients and 23/36 (64%) for ABOC (P = NS). The re-transplantation rate was significantly higher in the ABOI group (P = 0.001). CONCLUSIONS: The results confirm that ABOI liver grafts should be used in urgent circumstances when compatible grafts are not available. Some grafts function indefinitely, while those that fail may function for sufficient time to allow successful retransplantation with ABOC grafts.

[Management of pelvic pseudarthroses and pelvic malunion]. / Das Management von Beckenpseudarthrosen und Beckenfehlstellungen.

Nonunion with or without a late pelvic deformity remains a formidable reconstructive problem [1, 2]. For the present discussion, a nonunion is defined as a failure to achieve a union of a pelvic fracture, within six months after the time of injury, as documented by clinical and radiographic assessment. Most of the cases follow conservative management or the initial application of external fixation of a displaced and unstable injury pattern. While most of the nonunions represent a combination of a significant traumatic event, a smaller subgroup constitute pathological fractures or so-called "insufficiency fractures" of osteopenic bone [3]. By definition, the latter group represents a variety of pathological conditions including senile, post-menopausal and post-irradiation osteopenia or after the harvesting of massive autologous bone graft from the posterior ilium. Active malignancy as a factor is wholly excluded from these cases. The present report is based upon our clinical experience of two hundred cases that were managed during the past twenty year period [4]. The results constitute a summary of the observations whereupon certain recommendations for a therapeutic protocol have evolved. With the unusual nature of this clinical problem and the great diversity of presenting problems, no attempt to randomize the treatment modalities was deemed to be realistic.

Preclinical trial of a bioartificial liver support system in a porcine fulminant hepatic failure model.

BACKGROUND: This study describes the pre-clinical trials of an extracorporeal bioartificial liver support system (BALSS). It includes the biochemical changes which occur in the plasma and blood of pigs with devascularized livers when the plasma is treated in a BALSS, and the testing of the system for presence or absence of infective agents, pyrogens and for toxicity. METHODS: Hepatic cells were prepared from littermate juvenile white landrace pigs with a double-step collagenase digest technique. The cell preparations were incubated with collagen-coated dextran microspheres (CDM) for 3 h and the medium was tested to determine cellular metabolic activity. Incubation continued for a further 20 h during which the hepatic cells attach to the CDM. The CDM-attached cells were inoculated into a hollow fibre bioreactor which was part of an extracorporeal liver support system. RESULTS: Hepatic cell content of the bioreactor was 6 x 10(9) +/- 3 x 10(8) cells, equivalent to those present in half a pig's liver. The system was tested in a controlled trial with the plasma of pigs with fulminant hepatic failure (FHF) due to devascularized livers. When plasma from FHF pigs was circulated through the device there was significantly less of an increase in the accumulation of ammonia, lactate and most amino acids when hepatic cells were included in the circuit compared with those in control experiments when they were excluded. Similar changes occurred in procine blood. There were few infections diagnosed and an absence of pyrogens, endotoxins and toxicity in the bioreactor contents or in the terminating reservoir or animal blood samples. CONCLUSIONS: We believe that the results, demonstrating function of the porcine hepatic cells in the circuit, together with low risks, justify a clinical trial of use of the BALSS in Australia.

The evaluation of the isolated perfused liver as a model for the assessment of liver preservation.

An ex vivo isolated perfused porcine liver model was tested to assess its suitability for rapid, reliable and relatively cheap testing of organ preservation solutions for liver transplantation. The model consists of a machine driven recirculating system incorporating an organ chamber, blood pump and membrane oxygenator. Autologous blood was used for perfusion for a period of 2 h at a temperature of 37 degrees C. The model was tested with five groups of livers which had sustained varying degrees of injury ranging from minimally damaged to those known to be incapable of sustaining life when used for liver transplantation. The groups of livers were: (i) controls; (ii) preserved in University of Wisconsin solution (UW) for 6 h; (iii) preserved in an albumin-based extracellular fluid (ALB) for 6 h; (iv) preserved in UW for 18 h; and (v) preserved in ALB for 18 h. Bile production was found to be a reliable parameter of preservation damage. Changes in perfusate levels of aspartate aminotransferase, potassium, glucose and calcium also occurred in relationship to preservation damage. In contrast, weight gain of the liver, sequestration of the white cells and platelets in the liver, urea production and oxygen consumption were unreliable predictors of liver damage. Histology of biopsy specimens revealed apparently well preserved livers in all cases after preservation but before perfusion, but serious abnormalities after perfusion in long preserved livers, with features in these suggestive of damage to the sinusoidal endothelium. We believe that the model is a worthwhile adjunct to research into liver preservation.

Intraoperative somatosensory evoked potential monitoring of pelvic and acetabular fractures.

The efficacy of intraoperative somatosensory evoked potential (SSEP) monitoring was evaluated in the surgical management of 82 patients with pelvic and acetabular fractures. The injuries consisted of 45 acetabular fractures, 30 pelvic ring disruptions, and seven combined injuries. Preoperative neurological deficits were recorded in 34% of the study group (29% of those with an acetabular fracture and 47% of those with a pelvic ring injury). Three patients sustained an iatrogenic sciatic nerve injury during the study period (all of which were documented in the first 40 cases). Two patients sustained an exacerbation of an existing sciatic nerve injury. In the group of pelvic fractures, hazardous parts of the exposure, reduction, and fixation were identified by the SSEP monitoring. Removal of the provocative stimulus by the surgeon led to reversal of the SSEP abnormalities, and none of this group of patients sustained an iatrogenic injury. When the intraoperative SSEP changes were noted during an acetabular fracture fixation, immediate attempts were made to relieve the excessive tension on the sciatic nerve by replacing or removing a retractor, flexing the knee, extending the hip, or dividing the femoral insertion of the gluteus maximus. None of the SSEP changes were associated with the lacerative injury to the sciatic nerve. For the method to be clinically effective in reducing the incidence of neurological deficit, even subtle changes in the SSEP tracing must be recognized immediately by the neurophysiologist so that a corresponding corrective measure can be rapidly undertaken by the surgeon to remove the offending stimulus.

Treatment of chronic infected hip arthroplasty wounds by radical debridement and obliteration with pedicled and free muscle flaps.

Nine patients with extensive wounds of the hip joint due to chronic infection following total hip arthroplasty or internal fixation of fractures of the femoral head and neck have been treated by serial radical debridements to remove infected bone, contaminated remnants of bone cement, and the surrounding fibrotic soft tissues. The resultant deep cavity extending down to the acetabulum has then been obliterated with either pedicled muscle flaps or free muscle flaps. Subcutaneous or transpelvic transposition of rectus abdominis muscle flaps is preferred for smaller defects, but only the free latissimus dorsi muscle flap provides sufficient volume of tissue to obliterate the more extensive hip defects. Systemic antibiotics have been continued only for a short-term course of 14 days postoperatively. There has been no recurrence of infection, with follow-up ranging between 6 months and 3 1/4 years. One patient has undergone reimplantation of a second custom hip prosthesis into the vascularized bed of a free latissimus dorsi muscle flap.

Arthrodesis of the ankle and subtalar joints.

The late reconstruction of a complex nonunion of the distal tibial metaphysis, the ankle, or the subtalar joint was undertaken in five patients through a posterior surgical approach and the application of a blade plate into the os calcis. This technique was preferred as a salvage operation when the surrounding soft tissue envelope was compromised by the initial injury, previous surgical procedures, or infection. Each of the cases was notable for a segmental bone loss, an infected nonunion, or a collapse of the talar body. In the presence of a major soft tissue defect, the internal fixation was accompanied by the application of a microvascular free flap. The postoperative assessment of the posterior arthrodesis with the blade plate fixation was at an average of 33 months. Using a modification of the Boston Children's Hospital ankle scoring system, a preoperative and postoperative assessment was made. The criteria included an objective rating system based on the intensity of pain, the cessation of drainage, the degree of independent ambulation, and the roentgenographic documentation of union. The average preoperative score was 13 (range, 8-16). After arthrodesis, the average score was 44 (range, 40-48), with three patients rated excellent and two rated good.