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.

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.

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.

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.

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.

Use of dual-energy X-ray absorptiometry (DEXA) to follow mineral content changes in small ceramic implants in rats.

Dual energy X-ray absorptiometry (DEXA) imaging was used to quantify bone ingrowth into hydroxyapatite (HA) ceramic implants in rats. HA cylinders implanted in the proximal tibiae were followed for 13 wk. The increase in alkaline phosphatase (ALP) activity within the implants preceded the increase in mineral content as measured non-invasively by the DEXA technique. This was consistent with the timing of ALP activity in respect of mineralization as they occur during fracture healing. The results show that DEXA imaging is useful in measuring bone ingrowth into small ceramic HA implants in vivo, despite the high mineral content background of the implant scaffold.

Split-thickness skin excision in severe open fractures.

Split-thickness skin excision can be used as a one-stage procedure for the accurate diagnosis of flap viability and the immediate treatment of friction-avulsion injuries in severe open fractures. After cleaning the wound, the avulsed flap is temporarily sutured back to its original bed and a split thickness graft is taken from it and meshed to a 1:3 ratio. Surface dermal capillary bleeding then serves as an indicator of viability, clearly displaying a line for the excision of devascularized skin and correlating well with a concomitant fluorescein test. The wounds are re-opened and, after fixation of the fracture, the viable part of the flap is returned to its original bed and the remaining defects are covered with the meshed graft. We have treated 16 patients with extensive degloving injuries in this way, 15 needing only the single surgical procedure. All retained flaps survived, no other donor sites were needed and the split-thickness grafts took with 90% to 100% success.

Osteomyelitis of the pelvis.

Four cases of osteomyelitis of the pelvis are reported to demonstrate the several clinical syndromes to which this disease can give rise. Extensive surgical drainage and antibiotic treatment led to recovery in all cases.

Surgical treatment of fractures of the capitellum in adults: a modified technique.

Five adults with fractures of the capitellum (Hahn-Steinthal type) were treated by a modified improved technique of open reduction and internal fixation in 1988 and 1989. Full range of motion was achieved in all cases at 4 months.

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.

Nonunion of a fracture of the lateral malleolus: a case report and review of the literature.

Nonunion of a fracture of the lateral malleolus is a rare condition. We present a case of established nonunion of a fracture of the lateral malleolus confirmed and treated surgically, using debridement and internal fixation with autologous bone graft. At 5-year follow-up, the fracture was united but the patient still showed clinical signs of reflex sympathetic dystrophy. Male gender, supination fractures, Weber type C fractures, and primary internal fixation are cited as possible risk factors. Prognosis is variable.

The role of intramedullary nailing in modern treatment of open fractures of the tibia and femur.

The increasing incidence of open tibial and femoral fractures causes great suffering by patients and is an enormous economic burden, necessitating improved treatment. The current treatment of these fractures is reviewed, as well as the evolving role of intramedullary nailing in this treatment. Intramedullary nailing seems to give better results than external fixation in Gustilo type I and II fractures, and is at least as good in type III. The introduction of the non-reamed interlocking intramedullary nail may bring about even better outcomes. Any improvements in treatment should be based on thorough understanding of the biology and biomechanics of the injury.

Eosinophilic granuloma of the spine.

Twenty patients treated for eosinophilic granuloma of the spine were studied. Only 40% demonstrated the classical radiographic picture of vertebra plana. In 60% a lytic lesion of the vertebral body or the posterior elements was found. Seven patients underwent surgery; the indications were neurological involvement or failure of the biopsy to disclose the diagnosis. At an average follow-up period of 7 years, 17 patients are well and alive with no residual spinal pain, neurological compromise, recurrent disease, or extraskeletal involvement. Vertebral body collapse underwent some regeneration but did not regain full body height. In several patients this resulted in a local deformity. In patients with unifocal spinal eosinophilic granuloma, watchful observation with no treatment other than spinal support is warranted. In patients with neural involvement or multifocal lesions, a more active treatment, including surgery, may be indicated.

"Krammer splint technique" for immediate measuring of intramedullary nails.

We illustrate a simple and quick method of measuring the length of the intramedullary nail. The method utilizes the intervals between the metal ranks of the Krammer splint, and it has proved especially useful in the care of multitrauma victims.

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.

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.

Midshaft femoral fracture, concomitant ipsilateral hip joint injury, and disruption of the knee extensor mechanism: a unique triad of dashboard injury.

Our experience with 10 patients who suffered midshaft fractures of the femur and injuries to their ipsilateral hips has resulted in a treatment protocol that we believe can avoid unnecessary complications. The surgical protocol is a three-stage procedure based on (1) intramedullary nailing of the femur with interlocking for preserving the anatomic length and rotation of the femur; (2) treatment of the hip joint injury by means of open reduction and internal fixation of the acetabular fracture and/or reduction and fixation of the fractured femoral neck; and (3) repair of the extensor mechanism. Eight patients received this treatment and had fast recoveries. Union of the femoral fracture and full range of motion of the knee joint were observed within 3 months. In contrast, two patients who had received different surgical treatment had incomplete functional recoveries. This study offers a treatment protocol for ipsilateral disruption of the extensor mechanism, hip joint injury, and midshaft fracture of the femur in the multiply injured patient that can achieve full recovery with no complications. This relatively rare combination of injuries is definitely worthy of special attention.