Mapping recovery in simple and complex tibial plateau fracture fixation.

AIMS: The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) versus complex (Schatzker V-VI) fractures. PATIENTS AND METHODS: Patients undergoing open reduction and internal fixation (ORIF) for tibial plateau fractures were enrolled into a prospective database. Functional outcome, using the 36-Item Short Form Health Survey Physical Component Summary (SF-36 PCS), was collected at baseline, six months, one year, and five years. The trajectory of recovery for complex fractures (Schatzker V and VI) was compared with simple fractures (Schatzker I to IV). Minimal clinically important difference (MCID) was calculated between timepoints. In all, 182 patients were enrolled: 136 (74.7%) in simple and 46 (25.3%) in complex. There were 103 female patients and 79 male patients with a mean age of 45.8 years (15 to 86). RESULTS: Mean SF-36 PCS improved significantly in both groups from six to 12 months (p < 0.001) and one to five years (simple, p = 0.008; complex, p = 0.007). In both groups, the baseline scores were not reached at five years. The SF-36 PCS was significantly higher in the simple group compared with the complex group at both six months (p = 0.007) and 12 months (p = 0.01), but not at five years (p = 0.17). Between each timepoint, approximately 50% or more of the patients in each group achieved an MCID in their score change, indicating a significant clinical change in condition. The complex group had a much larger drop off in the first six months, with comparable proportions achieving MCID at the subsequent time intervals. CONCLUSION: Tibial plateau fracture recovery was characterized overall by an initial decline in functional outcome from baseline, followed by a steep improvement from six to 12 months, and ongoing recovery up to five years. In simple patterns, patients tended to achieve a higher functional score by six months compared with the complex patterns. However, comparable functional scores between the groups achieved only at the five-year point suggest later recovery in the complex group. Function does not improve to baseline by five years in either group. This information is useful in counselling patients about the course of prospective recovery. Cite this article: Bone Joint J 2019;101-B:1009-1014.

Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study.

One hundred and fifty-two patients who had 154 closed fractures of the shaft of the tibia were prospectively randomized to management with interlocking intramedullary nailing either with or without reaming. Thirteen patients who had been randomized to treatment without reaming were switched to the group that had reaming because of technical reasons; these patients were excluded from the analysis of the results. An additional five patients were lost to follow-up. Thus, seventy-two patients (seventy-three fractures) who had been managed with nailing with reaming and sixty-three patients (sixty-three fractures) who had been managed with nailing without reaming were available for follow-up at an average of twelve months (range, three to thirty-three months) postoperatively. The two groups were similar with regard to demographics and the configurations of the fractures. The average total duration of the procedures performed without reaming was eleven minutes shorter than that of the procedures done with reaming (p = 0.0013). The duration of fluoroscopy was not significantly different between the two groups (p = 0.35, Mann-Whitney test). The average estimated blood loss was identical for the two groups. Seventy fractures (96 per cent) that were treated with nailing with reaming and fifty-six (89 per cent) that were treated with nailing without reaming united without the need for an additional operation (p = 0.19). Because of the small sample size, the study has insufficient power (34.7 per cent) to detect this difference if it is real. There was only one deep infection, which developed after nailing without reaming. The nail fractured after one procedure with reaming. A screw fractured after two procedures with reaming and after ten without reaming (p = 0.012); multiple screws fractured after three procedures in the latter group. Malunion occurred after three nailing procedures with reaming and after two without reaming. Four malunions were of very proximal fractures and one was of a very distal fracture. Seventeen screws and twenty-four nails were removed after nailing with reaming, and twenty screws and nineteen nails were removed after nailing without reaming; neither of these prevalences was significantly different between the two groups (p = 0.27 and 0.89; chi-square test). We concluded that there are no major advantages to nailing without reaming as compared with nailing with reaming for the treatment of closed fractures of the shaft of the tibia. There was a higher prevalence of delayed union and breakage of screws after nailing without reaming.

Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study.

Ninety-one patients who had ninety-four open fractures of the tibial shaft were randomized into two treatment groups. Fifty fractures (nine type-I, eighteen type-II, sixteen type-IIIA, and seven type-IIIB fractures, according to the classification of Gustilo et al.) were treated with nailing after reaming, and forty-four fractures (five type-I, sixteen type-II, nineteen type-IIIA, and four type-IIIB fractures) were treated with nailing without reaming. The average diameter of the nail was 11.5 millimeters (range, nine to fourteen millimeters) in the group treated with reaming and 9.2 millimeters (range, eight to ten millimeters) in the group treated without reaming. Follow-up information was adequate for forty-five patients (forty-seven fractures) who had been managed with reaming and forty patients (forty-one fractures) who had been managed without reaming. No clinically important differences were found between the two groups with regard to the technical aspects of the procedure or the rate of early postoperative complications. The average time to union was thirty weeks (range, thirteen to seventy-two weeks) in the group treated with reaming and twenty-nine weeks (range, thirteen to fifty weeks) in the group treated without reaming. Four (9 per cent) of the fractures treated with reaming and five (12 per cent) of the fractures treated without reaming did not unite (p = 0.73). There were two infections in the group treated with reaming and one in the group treated without reaming. Significantly more screws broke in the group treated without reaming (twelve; 29 per cent) than in the group treated with reaming (four; 9 per cent) (p = 0.014). There was no difference between the two groups with regard to the frequency of broken nails (two nails that had been inserted after reaming broke, compared with one that had been inserted without reaming). The functional outcome, in terms of pain in the knee, range of motion, return to work, and recreational activity, did not differ significantly between the groups. We concluded that the clinical and radiographic results of nailing after reaming are similar to those of nailing without reaming for fixation of open fractures of the tibial shaft, although more screws broke when reaming had not been done.

Reamed nailing of open tibial fractures: does the antibiotic bead pouch reduce the deep infection rate?

Eighty-one open tibial fractures were treated by reamed intramedullary nailing. There were 38 type II, 23 type IIIa and 20 type IIIb injuries. At the end of the nailing procedure the first 26 fractures (15 type II, five type IIIa, and six type IIIb) had antibiotic prophylaxis and delayed closure of the open wound. The subsequent 55 fractures (23 type II, 18 type IIIa, and 14 type IIIb) had identical management but in addition had an antibiotic bead pouch inserted into the open wound following debridement. Three amputations were performed: one (3.8%) in the group treated without a bead pouch and two (3.6%) in the bead pouch group in patients with grade IIIb fractures and severe crushing injuries. Of the remainder, there were four deep infections (16%) in the 25 fractures treated prior to the use of the bead pouch and two (4%) deep infections in the 53 fractures following introduction of the bead pouch. Addition of the bead pouch to the wound management protocol was associated with a worthwhile reduction of deep infection.

Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion.

OBJECTIVES: To evaluate the effectiveness of the use of iliosacral screw fixation in the management of the vertically unstable pelvis. STUDY DESIGN: Retrospective analysis with clinical follow-up of patients to assess functional outcome. METHODS: Thirty-eight vertically unstable pelvic fractures were treated using iliosacral screw fixation. Anterior fixation was by means of plating in sixteen pelves and by external fixation in fifteen pelves. Four pelves had no anterior fixation. Complications were recorded and radiographs were analyzed to classify fractures and identify screw misplacement and malunion. Twenty-six patients had a functional evaluation. RESULTS: Five patients (13 percent) suffered a pulmonary embolus in the early postoperative period, one of which was fatal, a hospital mortality of 2.6 percent. Screw misplacement occurred in five patients but there were no adverse sequelae. In thirty-four cases with radiographic follow-up, malunion was noted in fifteen cases (44 percent). A lower rate of malunion (36 percent) was noted with internal fixation of the anterior lesion. Of twenty-six patients with long-term follow-up, only four (15 percent) had no pain. Sacroiliac fusion for pain was performed in three patients (11 percent). Twelve patients (46 percent) returned to their preinjury occupation, six patients (23 percent) changed occupation, and nine patients (30 percent) had not yet returned to work by last follow-up. CONCLUSIONS: Iliosacral screw fixation is a useful method of fixation in the vertically unstable pelvis but needs to be augmented by rigid anterior fixation to minimize malunion.

Psychometric analysis of measuring functional outcomes in tibial plateau fractures using the Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA) and the Western Ontario McMaster Osteoarthritis (WOMAC) questionnaires.

Patients participating in a modern prospective orthopaedic trauma database may be asked to complete many functional outcome measures, adding to the burden of study participation. This prospective study assessed the utility and responsiveness of the generic Short Form 36 (SF-36) and the disease specific Short Musculoskeletal Function Assessment (SMFA) and the Western Ontario McMaster Osteoarthritis (WOMAC) questionnaires in 55 patients treated operatively for tibial plateau fractures with the goal of determining if there was clear benefit of using multiple measures in a lower extremity peri-articular fracture population. There was very good correlation between all three scores at 6 and 12 months, indicating they are measuring similar factors. Responsiveness was assessed using the standard response mean (SRM), proportion of patients attaining the minimal clinically important difference (MCID) between 6 and 12 months, and floor and ceiling effects. The SRM for the SF-36 was statistically higher than the SRM for the SMFA or the WOMAC. Significantly more patients were found to have a MCID between 6 and 12 months post-surgery based on the SF-36 than the other two functional scores. There was no floor effect found on any of the 3 functional scores evaluated; however, a significant ceiling effect was noted with the WOMAC but not with the SF-36 or the SMFA. These results, along with the usefulness of the SF-36 for comparing disease burden across populations, favour the SF-36 as the instrument of choice in assessing functional outcome in patients with tibial plateau fractures.

Modified tension band technique for patella fractures.

The use of tension band wire technique for patella fractures fixation is a well-established technique. However, the standard technique, which involves using two Kirschner wires through the patella, can cause problems with prominent hardware, and difficulty capturing the change to figure of eight wire. Here we describe a modified technique using four Kirschner wires, which allows each wire to be bent, and well-impacted in order to avoid these problems. The basic surgical technique, and our case series are reviewed.

Length of stay, mortality, morbidity and delay to surgery in hip fractures.

Our aim was to determine the effect of delay to surgery on the time to discharge, in-hospital death, the presence of major and minor medical complications and the incidence of pressure sores in patients with a fracture of the hip. All patients admitted to Vancouver General Hospital with this injury between 1998 and 2001 inclusive were identified from our trauma registry. A review of the case notes was performed to determine the delay in time from admission to surgery, age, gender, type of fracture and medical comorbidities. A time-to-event analysis was performed for length of stay. Additionally, a Cox proportional hazards model was used to determine the effect of delay to surgery on the length of stay while controlling for other pertinent confounding factors. Using logistical regression we determined the effect of delay to surgery on in-hospital death, medical complications and the presence of pressure sores, while controlling for confounding factors. Delay to surgery (p = 0.0255), comorbidity (p < 0.0001), age (p < 0.0001) and type of fracture (p = 0.0004) were all significant in the Cox proportional hazards model for increased time to discharge. Delay to surgery was not a significant predictor of in-hospital mortality. However, a delay of more than 24 hours was a significant predictor of a minor medical complication (odds ratio (OR) 1.53, 95% confidence interval (CI) 1.05 to 2.22), while a delay of more than 48 hours was associated with an increased risk of a major medical complication (OR 2.21, 95% CI 1.01 to 4.34), a minor medical complication (OR 2.27, 95% CI 1.38 to 3.72) and of pressure sores (OR 2.29, 95% CI 1.19 to 4.40). Patients with a fracture of the hip should have surgery early to lessen the time to acute-care hospital discharge and to minimise the risk of complications.

The effects of intraoperative positioning on patients undergoing early definitive care for femoral shaft fractures.

OBJECTIVES: To determine if there is a difference in morbidity and mortality in orthopaedic trauma patients with femoral shaft fractures undergoing early definitive care with intramedullary (IM) nails in the supine versus the lateral position. DESIGN: Retrospective cohort study, single centered. SETTING: One level 1 trauma center. PATIENTS: Nine hundred eighty-eight patients representing 1027 femoral shaft fractures treated with IM nails were identified through a prospectively gathered database between 1987 and 2006. INTERVENTION: Antegrade IM nail insertion with reaming of the femoral canal in either the supine or lateral position. OUTCOME MEASURES: Mortality was the primary outcome. Admission to intensive care unit (ICU) was the secondary outcome measure and a surrogate measure of morbidity. Literature review was performed to identify factors shown to contribute to morbidity and mortality in orthopaedic trauma patients. Intraoperative position in either the supine or lateral position was added to this list. Logistic regression analysis was performed to determine the magnitude and effect of the independent variables on each of the study end points. To determine if a more significant trend toward less favorable outcomes was observed with increasing severity of injury, particularly injuries of the chest and thorax, subgroup analysis was performed for all those with a femur fracture and an Injury Severity Score > or =18 and all those with a femur fracture and an Abbreviated Injury Score chest > or =3. RESULTS: Intraoperative position in either the supine or lateral position was not a significant predictor of mortality or ICU admission for the original cohort or the subgroup of Injury Severity Score > or =18. However, for the subgroup of Abbreviated Injury Score chest > or =3, intraoperative positioning in the lateral position had a statistically significant protective effect against ICU admission (P = 0.044). CONCLUSIONS: For polytrauma patients with femoral shaft fractures, surgical stabilization using IM nails inserted with reaming of the femoral canal in the lateral position is not associated with an increased risk of mortality or ICU admission.

Proteoglycans synthesized by cultured mouse osteoblasts.

Proteoglycan synthesis in nonmineralizing osteoblast cultures was investigated. Cultures were labeled with [35S]sulfate or [3H]serine, and proteoglycans were extracted from medium and cell layer with 4 M guanidine HCl. Labeled material was subjected to Sepharose CL-4B and DEAE-Sephacel chromatography and polyacrylamide gel electrophoresis. The size and composition of the glycosaminoglycan chains and the protein core size were determined. Two proteoglycan populations were isolated by Sepharose CL-4B chromatography: a minor excluded species with chondroitin sulfate chains of apparent Mr 25,000 and a smaller population (Kav = 0.43) accounting for 80% of the total labeled material. This small population resolved into two species by polyacrylamide gel electrophoresis. Both species contain dermatan sulfate chains of apparent Mr 40,000 and a core protein with Mr 45,000 on sodium dodecyl sulfate gels. With the exception of their glycosaminoglycan composition these species appear similar to those extracted from bone. In addition, high molecular weight hyaluronic acid and glycosaminoglycan peptides were found in cell extracts.

Glucose and insulin dynamics in the anaesthetized dog: a mathematical modeling study.

A combined circulation and organs model of glucose and insulin dynamics is presented. The model is based on physiological parameters, incorporating blood and plasma flow rates, circulatory paths, intra-and extra-vascular glucose and insulin spaces, as well as the specific organs and tissues involved both with insulin disappearance and with glucose production or uptake. Its simulations readily lend themselves to physiological interpretation. To explore its validity, the model was assigned parameters typical of a 12 kg dog and was arranged to accept known glucose and insulin infusions from four different experiments on such diabetic animals. It predicted the observed glucose and insulin concentrations as well as total uptake rates for both moieties. This confirmed the ability of the model to predict with consistency the group mean outcomes of these four experiments when differing routes (portal or peripheral) of infusion were applied. Excellent agreement for most studies was achieved while the need for including more sophisticated dynamics of glucose transport in the liver or into erythrocytes was identified. The model isolates glucose uptake in the periphery, the liver, the brain and the gut and allows a direct comparison of glucose disposal along various routes. Thus the total amount of glucose uptake by peripheral, insulin-dependent tissues is directly calculated to be 22-28% of an intravenous glucose load, regardless of its route of infusion.

Reamed interlocking intramedullary nailing of open fractures of the tibia.

One hundred twelve open tibial fractures were treated by reamed interlocking nailing in 108 patients. There were 31 (28%) Grade I fractures, 38 (34%) Grade II, 23 Grade IIIA (21%), and 20 (18%) Grade IIIB fractures. Early amputation was performed in 2 (10%) Grade IIIB fractures for severe crushing injuries. Compartment syndrome complicated 8 (7%) fractures. Mean time to union was 29 weeks for Grade I fractures, 32 weeks for Grade II, 34 weeks for Grade IIIA, and 39 weeks for Grade IIIB. Nonunion complicated 9 (8%) fractures: 1 (3%) Grade I fracture, 2 (5%) Grade II fractures, 3 (13%) Grade IIIA fractures, and 3 (17%) Grade IIIB fractures. Deep infection complicated 4 Grade II fractures (10%) and 2 (11%) Grade IIIB fractures. Reamed locking intramedullary nailing is a safe and effective technique for management of open tibial fractures.

Fixation of intertrochanteric hip fractures: gamma nail versus dynamic hip screw. A randomized, prospective study.

OBJECTIVE: To compare the efficacy of the gamma nail (GN) to the dynamic hip screw (DHS) in the management of intertrochanteric hip fractures. DESIGN: Randomized, prospective clinical trial with a mean follow-up of 52 weeks (range from 11 to 82 weeks). SETTING: A university teaching hospital. PATIENTS: One hundred and one patients with 102 fractures: 49 fractures were treated with the DHS and 53 fractures were treated with the GN. INTERVENTIONS: Fracture fixation with the DHS or the GN. MAIN OUTCOME MEASURES: Comparison of duration of operation, blood loss, early and late complications, functional outcome and duration of hospital stay. RESULTS: There was no significant difference between the two groups with respect to intraoperative blood loss, days in hospital, time to union and eventual functional outcome. The length of the procedure and fluoroscopy time were longer for the GN group. CONCLUSIONS: Both the GN and the DHS can be used effectively for the treatment of intertrochanteric fractures. In this study the DHS was associated with a lower risk of local complications and should still be considered to be the implant of choice for patients with intertrochanteric fractures.

Range of motion and complications after postburn heterotopic bone excision about the elbow.

OBJECTIVE: To review the results of surgical management of heterotopic ossification about the elbow in burned patients. DESIGN: Retrospective analysis with long-term patient follow-up. MATERIALS AND METHODS: Eleven patients with 16 elbows requiring surgery were admitted between January 1, 1982 and December 31, 1993. A posterior approach to the elbow with release of the encased ulnar nerve +/- anterior transposition and transolecranon osteotomy to access extensive bone formation in the olecranon fossa was employed. Eight patients (11 elbows) were available for long-term follow-up conducted at mean 50 +/- 13 months after surgery. Long-term follow-up consisted of measurement of range of elbow motion, as well as clinical assessment of ulnar nerve function. MAIN RESULTS: For the 11 elbows examined postoperatively, the mean range of motion preoperatively in flexion-extension was 11 degrees +/- 5 degrees compared to 89 degrees +/- 12 degrees postoperatively (p < 0.001). Three patients with poor long-term results had ankylosis of the joint preoperatively. Of four patients with ulnar nerve paresis preoperatively, none had ulnar nerve dysfunction at follow-up. Of 16 elbows operated on, four (25%) had postoperative complications. Two suffered soft-tissue breakdown with hardware exposure requiring abdominal flap closure, one early failure of olecranon fixation, and one late infected hardware. CONCLUSIONS: Surgery for both limited range of motion as well as ulnar nerve compression is effective in cases of heterotopic ossification about the elbows of burned patients. Early operative intervention is indicated in progressive disease, particularly ulnar nerve palsy, if soft-tissue quality is adequate. Complications with 25% of elbows suggest that use of olecranon osteotomy for joint access may warrant review.