Femoral neck pseudoarthrosis in a polio patient treated with closed reduction and cell therapy.

Poliomyelitis disease affects the anterior horns cells of the spinal cord and certain motor nuclei of the brain stem. Paralysis type is flaccid and asymmetrical and result in muscular imbalance. Due to this, in case of having a hip muscles involvement, degenerative or posttraumatic, total hip arthroplasty is normally contraindicated because of the excessive risk of hip dislocation. In cases of subcapital femoral neck fractures the femoral head vascularization is a main concern, and in cases of neglected fracture with pseudoarthrosis the vascular status to the head must be investigated prior to further decisions. We report the case of a femoral neck fracture non-union after a missed femoral neck fracture in a polio affected leg treated with cannulated screws and percutaneous autologous injection of processed total nuclear cells (TNC) mixed with putty demineralized bone matrix.

Outcome of femoral fractures care as a measure of trauma care between level I and level II trauma systems in Israel.

BACKGROUND: Our hypothesis in this study was that the outcome of patients with femur fractures would be favorable in a level I trauma center (LITC). METHODS: A prospective multicenter cohort study. 5 LITC and 6 regional (level II) trauma centers (RTCs) were enrolled to participate in the study. A total of 238 patients suffering from a femoral fracture were recruited to the study. 125 patients were treated in LITCs and 113 in RTCs. Data were extracted from the emergency medical services ambulances, emergency department records, patient hospitalization and discharge records, operating room records, and the national trauma registry (for LITCs). A study questionnaire was administered to all participating patients at discharge, 6 weeks and 6 months postoperatively. The following parameters were studied: mechanism of injury, time from injury to the hospital, Injury Severity Score, classification of femoral fracture, additional injuries, medical history, time to surgery, implant type, skill level of the surgical team, type of anesthesia, length of stay and intensive care unit (ICU) stay, postoperative and intraoperative complications and mortality. RESULTS: There was a significant difference in the modality of patient transfer between the 2 study groups-with the LITC receiving more patients transported by helicopters or medical intensive care. Time to surgery from admission was shorter in the LITC. Length of stay, ICU stay, and mortality were similar. In the LITCs, 47% of the procedures were performed by residents without the supervision of an attending surgeon, and in the RTCs 79% of the procedures were performed with an senior orthopaedic surgeon. Intraoperative and immediate complication rates were similar among the 2 groups. CONCLUSIONS: A femoral shaft fracture can be successfully treated in an LITC and RTC in the state of Israel. Both research and policy implementation works are required. Also, a more detailed outcome analysis and triage criteria for emergency are desired. LEVEL OF EVIDENCE: II.

Haptic computer-assisted patient-specific preoperative planning for orthopedic fractures surgery.

PURPOSE: The aim of orthopedic trauma surgery is to restore the anatomy and function of displaced bone fragments to support osteosynthesis. For complex cases, including pelvic bone and multi-fragment femoral neck and distal radius fractures, preoperative planning with a CT scan is indicated. The planning consists of (1) fracture reduction-determining the locations and anatomical sites of origin of the fractured bone fragments and (2) fracture fixation-selecting and placing fixation screws and plates. The current bone fragment manipulation, hardware selection, and positioning processes based on 2D slices and a computer mouse are time-consuming and require a technician. METHODS: We present a novel 3D haptic-based system for patient-specific preoperative planning of orthopedic fracture surgery based on CT scans. The system provides the surgeon with an interactive, intuitive, and comprehensive, planning tool that supports fracture reduction and fixation. Its unique features include: (1) two-hand haptic manipulation of 3D bone fragments and fixation hardware models; (2) 3D stereoscopic visualization and multiple viewing modes; (3) ligaments and pivot motion constraints to facilitate fracture reduction; (4) semiautomatic and automatic fracture reduction modes; and (5) interactive custom fixation plate creation to fit the bone morphology. RESULTS: We evaluate our system with two experimental studies: (1) accuracy and repeatability of manual fracture reduction and (2) accuracy of our automatic virtual bone fracture reduction method. The surgeons achieved a mean accuracy of less than 1 mm for the manual reduction and 1.8 mm (std [Formula: see text] 1.1 mm) for the automatic reduction. CONCLUSION: 3D haptic-based patient-specific preoperative planning of orthopedic fracture surgery from CT scans is useful and accurate and may have significant advantages for evaluating and planning complex fractures surgery.

Intraoperative 3-dimensional imaging of scaphoid fracture reduction and fixation.

INTRODUCTION: We examined the clinical benefit of two intraoperative three-dimensional imaging modalities for reduction and fixation of scaphoid fractures. HYPOTHESIS: Our hypothesis was that three dimensional imaging will aid in operative care in comparison with standard fluoroscopy. METHODS: In 25 consecutive patients treated for fractures, after satisfactory reduction and fixation was obtained with a single Kirschner wire using fluoroscopy, intraoperative three-dimensional visualization was performed. The quality of fracture reduction, wire position and extrusion of the wire were examined. RESULTS: In two of the 25 cases, after three-dimensional visualization, malreduction of the fracture was seen and the reduction revised. Artifact and the dependency on technologist performance, limited the use of these modalities to locate the wire accurately. DISCUSSION: Diagnosis of malreduction of a scaphoid fracture is possible with 3-dimensional modalities. Utilization of these systems is still limited by technical factors.

Orthogonal double plate fixation for long bone fracture nonunion.

PURPOSE OF THE STUDY: The treatment of long bone diaphyseal fracture-nonunion is challenging. While taking into account biological needs, a stable mechanical environment is pertinent for fracture healing. This work aims at evaluating the surgical management of stubborn ununited fractures using orthogonal double plating of diaphyseal fractures with limited periosteal stripping and soft tissue dissection. PATIENTS AND METHODS: Retrospective analysis in a level I trauma center. Between the years 2007-2009, 22 patients were treated with double plating due to nonunion of long bone fractures. Long bones included three clavicles, six humeri, three femora, seven ulnae, two tibiae and one radius. The mean period between index procedures (if existed) and revision procedures was 53.35 weeks (range 6 months-3 years). The same surgical technique, independent on the anatomical location was utilized. Perioperative intravenous antibiotics were withheld until intraoperative cultures were obtained in all patients. An approach to the fracture site was performed with removal of all previous existing hardware, including aggressive debridement of the nonunion site while keeping stripping to the necessary minimum. After primary plate fixation of the fracture with adequate compression, a second plate, with at least two well spaced screws on each side, was placed at a ninety degree angle to the primary plate. Autologous bone graft or bone graft substitute was placed in most, but not all cases. All procedures and assessment of union were done by fellowship trained trauma surgeons. In the infected cases, culture specific intravenous antibiotics were administered for six weeks. Quality of life measures included DASH score of the upper extremity, lower extremity functional score (LEFS) for the lower extremity and Short From 12 (SF-12) for all patients. RESULTS: Union was achieved in all patients, with an average time to union of 5.8 months (range 2-24 months). One patient healed after a repeat double plating, since the first procedure was unsuccessful. Tissue culture were positive in 11 out of 22 patients. One clavicular plate was removed, due to irritation. No hardware failure was noted in these cases. Mean LEFS was 59%, quick DASH score -18.5 20 and SF-12 MCS and PCS were 50.37 15.22 and 49.96 8.5 receptively. CONCLUSION: Double plating is a biomechanically sound option for treating long bone fracture nonunion with reasonable results, provided adequate biological conditions are met including eradication of infection.

The Stoppa approach for acetabular fracture.

OBJECTIVE: Acetabular fractures pose a great surgical challenge for orthopedic trauma surgeons. We believe that the Stoppa approach with an iliac window extension, previously described as a modified Stoppa approach is adequate for the majority of acetabular fractures excluding those with predominant posterior wall involvement. In this paper we will present our experience in using the Stoppa approach, its indications, preparations, the detailed surgical approach, complications and the different tips used in this relatively modern approach. INDICATIONS: All simple and combined fracture types that involve the anterior column of the pelvis including the quadrilateral plate. CONTRAINDICATIONS: Posterior wall or extensive posterior column involvement. Transverse and T-fractures with mainly posterior displacement. SURGICAL TECHNIQUE: Suprapubic, intrapelvic approach, extending from the symphysis pubis anteriorly to the sacroiliac joint posteriorly. Superficial landmarks are identical to the Pfannenstiel approach, the rectus abdominis muscles are longitudinally dissected, the symphysis pubis is exposed and a sub-periosteal deep surgical dissection is carried out along the anterior column and the quadrilateral plate, and posteriorly toward the greater sciatic notch and the sacroiliac joint. RESULTS: In a 5-year review of 60 acetabular fractures that underwent open reduction and internal fixation using the modified Stoppa approach, there were 36% anterior column fractures, 28% both-column fractures, the rest being anterior column with posterior hemi transverse fractures, transverse and T-fractures. Any extension of the fracture to the iliac wing necessitated an additional lateral window (93% of cases). In cases with posterior displacement, an additional approach was utilized to address a posterior wall fracture. All fractures healed within 12 weeks. Mean Merle d'Aubigné score was 15.22. Postoperative radiological evaluation revealed anatomical reduction in 54% of the patients, satisfactory in 43%, and unsatisfactory in 3% of the patients. Overall there were 15 minor and major complications.

A prospective, randomised study comparing the percutaneous compression plate and the compression hip screw for the treatment of intertrochanteric fractures of the hip.

Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function. The percutaneous compression plate (PCCP) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure. It has several potential mechanical advantages over the conventional compression hip screw (CHS). Our aim in this prospective, randomised, controlled study was to compare the outcome of patients operated on using these two devices. We randomised 104 patients with intertrochanteric fractures (AO/OTA 31.A1-A2) to surgical treatment with either the PCCP or CHS and followed them for one year postoperatively. The mean operating blood loss was 161.0 ml (8 to 450) in the PCCP group and 374.0 ml (11 to 980) in the CHS group (Student's t-test, p < 0.0001). The pain score and ability to bear weight were significantly better in the PCCP group at six weeks post-operatively. Analysis of the radiographs in a proportion of the patients revealed a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients, 18.9%); Fisher's exact test, p < 0.02. The PCCP device was associated with reduced intra-operative blood loss, less postoperative pain and a reduced incidence of collapse of the fracture.

The use of intraoperative three-dimensional imaging (ISO-C-3D) in fixation of intraarticular fractures.

INTRODUCTION: The purpose of this study was to analyse the applicability and advantages of the intraoperative use of a mobile isocentric C-arm with three-dimensional imaging (Siremobil ISO-C-3D) in fixation of intraarticular fractures. METHODS: After the fixation was judged to be satisfactory relying on the images provided by routine fluoroscopy, intraoperative CT visualisation with ISO-C-3D was performed to evaluate the fracture reduction and implant position. Intraoperative revision was performed based on the additional information ISO-C-3D provided beyond routine fluoroscopy. ISO-C-3D was used on a series of 72 closed-intraarticular fractures in 70 patients. Fracture distribution was: calcaneus (25), tibial plateau (17), tibial plafond (12), acetabulum (11), distal radius (3), ankle Weber-C (3) and femoral head (l). The primary outcome measure was revision rate after final ISO-C-3D data acquisition and prior to wound closure. Secondary objectives were to measure the additional time required for ISO-C-3D use and to determine the rate of further re-do surgeries. RESULTS: Eight out of 72 (11%) fracture fixations were judged by the surgeon to require intraoperative revision following ISO-C-3D imaging. Prior to leaving the operating room, the surgeon was satisfied with fracture alignment in all the procedures. The mean additional operative time using ISO-C-3D was 7.5 min (8.2% of the mean total operative time). No patient required re-do surgery. CONCLUSION: : Intraoperative three-dimensional visualisation of intraarticular fractures enables the surgeon to identify inadvertent malreductions or implant malpositions which may be overlooked by routine C-arm fluoroscopy and hence may eliminate the need for re-do procedures. ISO-C-3D adds little operative time and may preclude the need for pre-operative and post-operative CT-scans in selected cases.

Early diagnosis of occult hip fractures MRI versus CT scan.

OBJECTIVE: We compared Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) in diagnosis of a painful hip in elderly patients after trauma. We report on accuracy, efficiency and benefits. DESIGN: We assessed 13 patients, average age 73 years, after fall with plain X-rays showing no evidence of fracture. There were two groups: Group A (six patients) underwent CT and MRI; Group B underwent MRI only. RESULTS: In Group A where all of the six patients underwent CT and MRI, four of the CT images resulted in misdiagnosis due to inaccuracy. In Group B where all the seven patients underwent only MRI, all the results were accurate and enabled a precise and fast diagnosis. CONCLUSIONS: MRI was found to be a more accurate modality than CT scan for obtaining early diagnosis of occult hip fractures. These results point out the advantage of immediate MRI imaging in patients with occult hip fracture enabling a more effective treatment, a shorter hospitalisation period entailing decreased medical costs.

Delayed reaction to shrapnel retained in soft tissue.

BACKGROUND: Treatment of penetrating injuries to soft tissues does not require surgical excision of shrapnel. Metals usually remain inert and do not cause damage and are therefore left in soft tissue. OBJECTIVE: Characterization of delayed reaction to shrapnel retained for many years in soft tissue. PATIENTS: Four patients sustained penetrating injuries to the limbs with embedded shrapnel. Many years later, they experienced delayed reaction to the metals that required surgery, with very unusual findings. CONCLUSIONS: Although nonsurgical treatment of shrapnel in soft tissues is the treatment of choice in most cases, we need to be aware of the possibility of late complications requiring surgical treatment.

The 1226G (N370S) Gaucher mutation among patients with Legg-Calve-Perthes disease.

Legg-Calve-Perthes disease (LCPD) is an avascular necrosis of the femoral head with an annual incidence of 5-15/100,000. The estimated incidence of Gaucher disease, a lysosomal recessive storage disease, is 1:850, with a carrier rate of 1:17.5 for the 1226G (N370S) mutation among Ashkenazi Jews in whom there is a predilection. Since clinical and radiological findings of avascular hip necrosis due to either Gaucher disease or LCPD may be indistinguishable, misdiagnosis may occur. The purpose of this study was to evaluate the incidence of 1226G Gaucher mutation in a cohort of radiologically confirmed LCPD patients (diagnosed 1986-2000) in Israel. Enzyme assay was performed for confirmation of affected versus carrier status in patients with the 1226G mutation. In all, 78 LCPD patients, 86% males, 51% with severe bone disease, were studied. Family history was negative for Gaucher disease. Ethnic origin was 39% Ashkenazi Jewish, 6% Arab, and 55% other ethnicities. One Ashkenazi Jewish LCPD patient was homozygous for the 1226G mutation, and 4 LCPD patients were carriers: 3 Ashkenazi Jewish and 1 Arab patient. The frequency of the 1226G mutation among the LCPD patients was increased relative to historical Ashkenazi Jewish Israeli controls (P = 0.01). Since Gaucher disease may be misdiagnosed as LCPD, glucocerebrosidase enzyme testing is recommended among Ashkenazi Jewish children diagnosed with LCPD.

The floating hip injury: patterns of injury.

OBJECTIVE: To evaluate the relationship between mechanism of injury, type of femoral fracture and type of acetabular fracture in floating hip injury. DESIGN: Historical retrospective. PATIENTS: Twenty consecutive patients who sustained a floating hip injury, i.e. simultaneous ipsilateral fracture of the acetabulum and the femur. INTERVENTION: Statistical analysis of the correlation between the mechanism of injury and fracture type. RESULTS: Two main patterns of floating hip injury were observed. The first is the posterior type, which occurs due to a longitudinal force along the femur that causes first, a posterior type fracture of the acetabulum and thereafter, a midshaft femoral fracture. The second pattern is the central type, caused by a lateral blow to the greater trochanter, which then causes a central fracture-dislocation of the acetabulum and a proximal fracture of the femur. CONCLUSIONS: This observation explains the biomechanical nature of this injury and has treatment related implications.

Proximal tibial fractures--should we nail them?

Intramedullary nails (IMNs) are the treatment of choice for diaphyseal tibial fractures. Its use has been expanded both distally and proximally to cover metaphyseal fractures at both ends of the tibia. Several authors have stated that IMN use in proximal tibial fractures (extra-articular) can become problematic, leading to a significantly increased rate of malunion. Different strategies for solving this problem have been reported in recent years, but no strategy is fault-free. We review the causes of and solutions for increased malunion following use of IMNs for proximal tibial fractures.

Retrograde nailing of femoral fractures distal to previous osteosynthesis.

As the proportion of elderly in the population grows, the incidence of femoral fractures distal to previous proximal osteosynthesis is increasing. When the gap between two rigid load-bearing fixations consists of osteopenic bone, the risk of further fractures increases. Herein the authors describe a load-sharing device that stabilizes the fracture and eliminates the osteopenic gap, allowing early mobilization and rapid return to the preinjury level of activity.

Gerdy's tubercle osteotomy for the treatment of coronal fractures of the lateral femoral condyle.

Coronal fractures of the femoral condyle (Hoffa fractures) are intraarticular fractures that are commonly treated surgically by open reduction and internal fixation. Surgical fixation is demanding because anatomic reduction is mandatory and adequate exposure is often difficult. Herein we describe a new technique that permits excellent visualization and fixation of lateral Hoffa fractures based on osteotomy of Gerdy's tubercle and reflection of the attached iliotibial band.

Surgical treatment of intercondylar fractures of the humerus in adults.

The rarity, complexity, and intra-articular involvement of intercondylar fractures, along with the osteopenic nature of the elbow joint, make surgical repair of these fractures a difficult and challenging task. When the procedure is properly executed, open reduction and internal fixation can promote proper reduction of the articular fragments and allow early range-of-motion exercises, which are so important for good functional results. We report the results of 30 such fractures treated surgically with good or excellent results. The pros and cons of the transolecranon approach are discussed, along with the options of fracture fixation and importance of early postoperative mobilization.

The "rubber band technique": a simple method for closing large skin defects.

Traditional methods of obtaining definitive soft-tissue cover in open wounds after high-energy trauma necessitate repeated surgical procedures and sophisticated soft-tissue reconstructions. A simple one-stage technique to treat skin loss in severe open fractures is described. The "rubber band technique" enables postoperative exposure and drainage of the fracture site. The wound closes gradually by facilitated mobilization of skin in response to continuous tension from the rubber band. This technique may prevent the need for additional procedures. Continuous drainage is achieved. When deep infection is suspected, removal of the elastic rubber band permits sufficient exposure of the deep tissues. The "rubber band technique" has proved to be a safe, simple, and efficient method for treating extensive soft-tissue loss in open fractures and after incisions for open reduction or fasciotomy.

The "crushed open pelvis" in children.

A retrospective analysis was performed in order to review the outcome of open pelvic fractures in children. Medical records, radiographs and CT scans of 15 children with open pelvic fractures admitted to our trauma centre between 1983 and 1995 were reviewed. The minimal follow-up on the survivors was two years. Out of 15 open pelvic fractures ten were vertically unstable. The mechanism of injury was auto-pedestrian collision in 93% (n = 14) of the cases. 86% (n = 13) of the fractures were a result of a "run-over" mechanism, 40% (n = 6) were caused by heavy duty vehicles. All children had injuries in the proximity of the pelvis. Despite the severity of trauma, we found mortality to be 20% (n = 3). Sepsis and deep infection originating from anorectal and genitourinary excretions were found to be the most frequent complications. The improvement in surgical techniques of the pelvis influenced the orthopaedic treatment in these 15 children. External fixation of the pelvis is not always sufficient and to achieve better stabilization of the pelvis, open reduction and internal fixation should be considered. In order to minimize complications, aggressive intervention is needed including irrigation, debridement, intravenous antibiotics, diverging colostomies and cystostomies and fracture fixation. The coordination between trauma teams of different disciplines throughout all stages of the treatment is crucial to achieving better results.

Combined injuries to the lower limbs.

Several patterns of severe lower limb injuries are presented. They all indicate high energy trauma and affect the immediate care of the patient. The improvement of evacuation systems and resuscitating methods in intensive care create many reconstruction challenges for the orthopaedic surgeon. Awareness of the different combinations which are presented can serve as a tool that may be helpful in these demanding injuries. Guidelines for management of combined injuries are essential to improve the outcome of these life-threatening situations.